Re-Admissions of 'Unknown' Traumatic Brain Injury Patients - Inadequacy of Rehabilitative Services in a Developing Country.

BACKGROUND: In neurosurgical practice, continuous care after discharge and the ability to detect subtle indicators of clinical deterioration are mandatory to prevent the progression of a disease. The care of 'unknown' patients discharged to rehabilitation homes may not have this privilege, especially in resource-poor countries such as India. OBJECTIVE: We have attempted to study the causes and outcomes of re-admissions of 'unknown' patients with previous traumatic brain injury (TBI) to estimate the quality of nursing care in our rehabilitation centers. MATERIAL AND METHODS: The electronic hospital records of all consecutive 'unknown' TBI patients with unplanned re-admissions at our institute from January 2014 to December 2018 were retrospectively reviewed and analyzed for the factors determining the risk and outcomes of re-admission. RESULTS: Out of 245 patients sent to rehabilitation homes at discharge, 47 patients (19.18%) were re-admitted. A total of 33 patients (70%) were re-admitted between 1 month and 1 year. Out of these, 38 patients (80.9%) were re-admitted because of preventable causes. Fifteen patients (31.9%) died during the hospital stay. The rest of the 32 (68%) patients were discharged after the management of the concerned condition with an average hospital stay of 9 ± 11.1 days. The average Glasgow coma scale (GCS) at re-admission of the patients who died was 6 (range 3-11). Two patients were brought in the brain dead status, whereas 20 patients (42.6%) had a GCS of 5 or below at the time of re-admission. The risk of mortality among patients with non-preventable causes was 88.9% (8/9) compared to preventable causes 18.4% (7/38). However, preventable causes for re-admission are much more common, resulting in nearly a similar overall contribution to mortality. CONCLUSIONS: There is a high rate of mortality and morbidity in 'unknown' patients with TBI because of poor post-discharge care in developing countries. Because preventable causes are the major contributor to re-admissions, the re-admission rate is a good indicator of a lack of adequate rehabilitative services. The need for improving the post-discharge management of 'unknown' patients with TBI in resource-poor countries cannot be over-emphasized.

Single-Stage Posterior Only Approach for Unilateral Atlantoaxial Spondyloptosis with type-II odontoid Fracture in Pediatric Patients.

Objective: When there is a complete slippage of facet joints of C1 over C2 such that there is no contact between the articulating surfaces of C1 and C2, the condition is known as atlantoaxial spondyloptosis (AAS). AAS represents an extremely rare manifestation of atlantoaxial instability. This study was performed to highlight the presentation, radiological features, and management of unilateral AAS in pediatric patients. Material and Methods: We retrospectively identified four pediatric patients with AAS from our hospital records in the last 6 years (2014-2019). Results: Among the four patients with unilateral AAS, three were posttraumic and one was diagnosed with craniovertebral junction tuberculosis (CVJ TB). All the patients had a varying degree of spastic quadriparesis on presentation. One patient with CVJ TB presented with neck tilt. All patients with traumatic unilateral AAS were associated with an odontoid fracture. These patients underwent C1-C2 fixation with complete reduction of spondyloptosis using the techniques of joint manipulation and joint remodeling with a posterior only approach. Complete reduction of AAS in patients with trauma was also associated with the realignment of the odontoid fracture. All patients improved neurologically after surgery and achieved excellent correction of the deformity on a follow-up imaging. Conclusion: Pediatric unilateral AAS is an extremely rare phenomenon. A single-stage posterior approach with C1-C2 fixation is a feasible technique for the treatment of this seemingly difficult to correct deformity in pediatric patients and the clinical outcomes are excellent.

Management of Pediatric and Adolescent Traumatic Thoracolumbar Spondyloptosis.

Background: Complete subluxation of >100% of one vertebral body with respect to the adjacent vertebra is defined as spondyloptosis. It is the severest form of injury caused by high-energy trauma. Pediatric patients with a traumatic spine injury, particularly spondyloptosis are surgically demanding as reduction and achieving realignment of the spinal column requires diligent planning and execution. Objective: To enlighten readers about this rare but severest form of thoracolumbar spine injury and its management. Methods: Retrospective analysis of patients treated here with spondyloptosis between 2008 and 2016 was done. Results: Seven children, ranging from 9 to 18 years (mean years) age were included in the study. Five patients had spondyloptosis at thoracolumbar junction and one each in the lumbar and thoracic spine. All patients underwent single-stage posterior surgical reduction and fixation except one patient who refused surgery. Intraoperatively, cord transection was seen in five patients while dura was intact in one patient. The mean follow-up period was 17 months (1-36 months) during which one patient expired due to complications arising from bedsores. All patients remained American Spinal Injury Association (ASIA) A neurologically. Conclusions: Traumatic spondyloptosis is a challenging proposition to treat and the aim of surgery is to stabilize the spine. Rehabilitation remains the most crucial but the neglected part and dearth of proper rehabilitation centers inflict high mortality and morbidity in developing countries.

Use of Intraoperative Imaging to Preserve C1-C2 Mobility in Complex Atlas-Hangman Fractures.

Background: Combination fractures of the C1-C2 complex especially atlas and hangman are relatively uncommon and management usually compromises C1-C2 mobility. Objective: To evaluate the treatment of combined C1- hangman's fracture with and without intraoperative O- arm based navigation system, and its outcome in terms of preserving C1-C2 mobility. Methods: This was a case series of patients with combined C1 and hangman's fracture, managed at a tertiary care hospital during February 2009 to December 2016. Neurological function assessed with American Spine Injury Association (ASIA) impairment scale. Radiological fusion of the operated segment assessed with computed tomographic scan, criteria used for successful fusion included formation of callus across the fracture. Preservation of rotational motion between C1 and C2 was assessed by cervical flexion rotation (CFR) test. Results: We included 10 patients (male/female: 9/1; mean 47.7 ± 17.5 years) in our study. Operative intervention was performed in 9 patients. We used intraoperative computed tomogram (CT) scan with navigation in 5 patients. The mean follow-up period was 28.7 months (range 6 to 70 months). Neurological recovery occurred in all 4 patients with preoperative neurological deficits. Radiological fusion occurred in all cases. Rotation at C1-2 was preserved in all 5 cases operated under O-arm guidance and in one patient with type 1 fracture who was managed conservatively. Conclusions: The goals in treating these complex fractures are to achieve early maximum stability and preserving maximum range of motion. These are often competing phenomena, which can be achieved by using intra operative CT scan and navigation system.

Orbital roof intradiploic meningioma in a 16-year-old girl.

Primary intraosseous or ectopic meningioma of the skull is a rare tumor accounting for about 1% of meningioma. Intradiploic meningioma is an extremely rare type of extraneuraxial meningiomas. Intradiploic meningioma of the orbit is extremely rare, and <8 such cases are reported till date in western literature occurring in the pediatric age group. Here the authors present a case of 16-year-old female, who presented with progressive proptosis, with normal vision and was managed successfully surgically. Clinical features, pathophysiology, and surgical management of this rare entity are discussed in the context of pertinent literature.

Hospital acquired infections: preventable cause of mortality in spinal cord injury patients.

BACKGROUND: There is an alarming rate of morbidity and mortality observed in the trauma victims who suffer spinal cord injuries (SCI). Such patients are admitted immediately and stay for longer periods of time and thus are at risk of acquiring nosocomial infections. AIMS: The aim of this study is to analyze the primary cause of mortality in SCI patients. DESIGN: Retrospective study. MATERIALS AND METHODS: We conducted a retrospective 4 year analysis of the postmortem data of 341 patients who died after sustaining SCI at a tertiary care apex trauma center of India. Epidemiological data of patients including the type of trauma, duration of hospital stay, cause of death and microbiological data were recorded. RESULTS: On autopsy, out of 341 patients, the main cause of death in the SCI patients was ascertained to be infection/septicemia in 180 (52.7%) patients, the rest 161 (47.2%) died due to severe primary injury. Respiratory tract infections (36.4%) were predominant followed by urinary tract infections (32.2%), blood stream infections (22.2%), wound infections (7.1%) and meningitis reported in only 5 (2.1%) cases. Acinetobacter sp (40%) was the predominant organism isolated, followed by Pseudomonas sp (16.3%), Klebsiella sp (15.1%), Candida sp (7.8%), Escherichia coli (6.9%), Staphylococcus aureus (6.9%), Proteus sp (3.3%), Enterobacter sp and Burkholderia sp (two cases each) and Stenotrophomonas sp (one case). A high level of multidrug resistance was observed. CONCLUSIONS: Hospital acquired infections (HAI) are leading cause of loss of young lives in trauma patients; hence efforts should be made to prevent HAIs.