The standardized exploration of the radial nerve during humeral shaft fixation reduces the incidence of iatrogenic palsy.

BACKGROUND: The purpose of this study is to determine if a standardized protocol for radial nerve handling during humeral shaft repair reduces the incidence of iatrogenic nerve palsy post operatively. METHODS: Seventy-three patients were identified who underwent acute or reconstructive humeral shaft repair with radial nerve exploration as part of the primary procedure for either humeral shaft fracture or nonunion. All patients exhibited intact radial nerve function pre-operatively. A retrospective chart review and analysis identified patients who developed a secondary radial nerve palsy post-operatively. In each case, the radial nerve was identified and mobilized for protection, regardless of whether the implant necessitated the extensile exposure. RESULTS: Fractures were classified according to AO/OTA guidelines and included 23 Type 12A, 11 Type 12B, and 3 Type 12C. Eight patients had periprosthetic fractures and 28 fractures could not be classified. All patients in the cohort were fixed with locking plates. Surgery was indicated for 36 patients with humeral nonunions and 37 patients with acute humeral shaft fractures. Of the 73 patients, 2 (2.7%) developed radial nerve palsy following surgery, one from the posterior approach and one from the anterolateral approach. Both patients exhibited complete recovery of radial nerve function by 6-month follow-up. No significant differences (p > 0.05) were found in any demographic or surgical details between those with and without radial nerve injury. CONCLUSIONS: Nerve exploration identification and protection leads to a low incidence of transient radial nerve palsy compared to the rate reported in the current literature (2.7% compared to 6-24%). Thus, radial nerve exploration and mobilization should be considered when approaching the humeral shaft for acute fracture and nonunion repairs. LEVEL OF EVIDENCE: Level III.

The sensitivity of acute flaccid paralysis surveillance - the case of South Sudan: retrospective secondary analysis of AFP surveillance data 2014-2019.

Introduction: South Sudan has made quite impressive progress in interrupting wild poliovirus and maintaining a polio-free status since the last case was reported in 2009. South Sudan introduced different complementary strategies to enhance acute flaccid paralysis (AFP) surveillance. Hence, the objective of this study is to evaluate the sensitivity of the surveillance system using the WHO recommended surveillance standard and highlight the progress and challenges over the years. Methods: we conducted a retrospective, descriptive, quantitative study design and used the available secondary AFP surveillance database. Results: the overall non-polio AFP rate was 6.2/100,000 children under 15 years old in the study period. The stool adequacy was maintained well above the certification level of surveillance. The two main surveillance performance indicators were met at the national level throughout the study period. In contrast, only five out of ten states persistently attained and maintained the two main surveillance performance indicators throughout the study period, while in 2019 all states achieved except for Jonglei state. During the analysis period, no wild poliovirus was isolated except two circulating Vaccine Derived Poliovirus Type 2 (cVDPV2) cases in 2014 and one Immunodeficiency Vaccine Derived Poliovirus Type 2 (iVDPV2) case in 2015. However, on average, three cases were classified as polio compatible with each year of the study. Conclusion: South Sudan met the two key surveillance performance indicators and had a sensitive AFP surveillance system during the period studied. We recommend intensifying surveillance activities in the former conflict-affected states and counties to maintain polio-free status.

Risk Factors and Prevention of C5 Palsy After Anterior Cervical Decompression and Fusion: Similarity of the Pathomechanism With That After a Posterior Approach.

STUDY DESIGN: This was a retrospective study. OBJECTIVE: The objective of this study was to review clinical and imaging findings after anterior cervical decompression and fusion, as a basis for prevention of C5 palsy. SUMMARY OF BACKGROUND DATA: C5 palsy is a common postoperative complication in spine surgery, but the mechanistic basis for this condition is unknown. MATERIALS AND METHODS: The subjects were 239 patients with cervical myelopathy who underwent anterior cervical decompression and fusion including at C4-C5 disk level at our hospital from 2001 to 2018. Twelve of these patients (5.0%) had C5 palsy postoperatively. Clinical features and imaging findings were compared in patients with and without C5 palsy. RESULTS: In patients with C5 palsy, the sagittal alignment of the cervical spine was kyphotic, the width of the C5 intervertebral foramen was narrower, and the lateral decompressed line was wider beyond the medial part of the Luschka joint. Age, sex, disease, the number of fused segments, decompression width, and anterior shift of the spinal cord did not differ significantly between patients with and without C5 palsy. CONCLUSIONS: These results indicate that the pathomechanism of C5 palsy may be dependent on the location of the lateral decompression line, especially in patients with cervical kyphosis and a narrow C5 intervertebral foramen. Excessive lateral decompression beyond the Luchka joint might lead to C5 root kinking between the intervertebral foramen and posterior edge of vertebra. This pathomechanism may be similar in anterior and posterior approaches. To prevent C5 palsy, the medial line of the Luschka joint should be confirmed intraoperatively and decompression should be performed within the Luschka joints. Alternatively, medial foraminotomy should be used in cases needing wide decompression, such as those with massive ossification of the posterior longitudinal ligament, lateral osteophytes, and symptomatic foraminal stenosis. LEVEL OF EVIDENCE: Level III.

Critical points and effectiveness of prophylactic C4/5 foraminotomy to prevent C5 palsy after posterior cervical spine surgery.

OBJECTIVE: The aim of this study was to clarify the cut-off values of the spinal canal parameters as risk factors for C5 palsy after posterior cervical spine surgery with and without foraminotomy. METHODS: One hundred three consecutive patients (67 males, 36 females; mean age = 66 years, age range = 27-87 years) with cervical myelopathy who underwent posterior cervical spine surgery at our institution were retrospectively reviewed and included in the study. The first consecutive 69 patients who underwent posterior cervical spine surgery with prophylactic bilateral C4/5 foraminotomy were designated as the F (+) group. The subsequent 34 consecutive patients who underwent posterior cervical spine surgery without prophylactic bilateral C4/5 foraminotomy were designated as the F (-) group. All patients were then divided into four subgroups. In the F (+) group, patients with C5 palsy were designated as the F (+) P (+) subgroup (n = 13), while those without C5 palsy were designated as the F (+) P (-) subgroup (n = 56). In the F (-) group, patients with C5 palsy were designated as the F (-) P (+) subgroup (n = 5), while those without C5 palsy were designated as the F (-)P(-) subgroup (n = 29). Receiver operating characteristic curves were used to investigate the cut-off values of the spinal canal parameters for the development of postoperative C5 palsy. The assessed spinal parameters were the gutter positions (GP), laminar inclination angles (LIA), and postoperative cross-sectional areas (CSA) of the dural sac. The risk ratios (RR) of the spinal canal parameters as risk factors for C5 palsy were evaluated. RESULTS: The incidence of C5 palsy was similar between the F (+) group (18.8%) and the F (-) group (14.7%). The cut-off values for each spinal canal parameter in the F (+) group (GP: 0.82-0.84, LIA: 58.9-62.4°, and CSA: 189.5-200 mm2 ) were similar to those in the F (-) group (0.81-0.89, 61.7-62.5°, and 197.5-199.5 mm2, respectively). In the RR results for C5 palsy, the LIA was highest in both groups. The F (+) P (-) subgroup had significantly larger mean CSA at C4/5 and C5/6 (202.3 mm2 and 200.9 mm2, respectively) than the F (-)P(-) subgroup (177.3 mm2 and 178.9 mm2, respectively) (P = 0.0181 and P = 0.0277, respectively). Prophylactic C4/5 foraminotomy did not specifically prevent postoperative C5 palsy due to foraminal stenosis at C4/5. CONCLUSION: C4/5 foraminotomy should not be recommended for avoidance of C5 palsy. Although the bony spinal parameters were similar between the F (+) and F (-) groups, the CSA in the F (+) group was significantly than that in the F (-) group in the patients without C5 palsy.

[Effect of prophylactic C 4, 5 foraminal dilatation in posterior cervical open-door surgery on postoperative C 5 nerve root palsy syndrome].

OBJECTIVE: To investigate the effect of prophylactic C 4, 5 foraminal dilatation in posterior cervical open-door surgery on postoperative C 5 nerve root palsy syndrome. METHODS: The clinical data of patients with cervical spondylotic myelopathy (cervical spinal cord compression segments were more than 3) who met the selection criteria between March 2016 and March 2019 were retrospectively analyzed. Among them, 40 patients underwent prophylactic C 4, 5 foraminal dilatation in posterior cervical open-door surgery (observation group) and 40 patients underwent simple posterior cervical open-door surgery (control group). There was no significant difference between the two groups ( P>0.05) in gender, age, disease duration, Nurick grade of spinal cord symptoms, and preoperative diameter of C 4, 5 intervertebral foramen, Japanese Orthopaedic Association (JOA) score, and visual analogue scale (VAS) score. The occurrence of C 5 nerve root paralysis syndrome was recorded and compared between the two groups, including incidence, paralysis time, recovery time, and spinal cord drift. VAS and JOA scores were used to evaluate the improvement of pain and function before operation and at 12 months after operation. RESULTS: The incisions of the two groups healed by first intention, and there was no early postoperative complications such as cerebrospinal fluid leakage. Patients of both groups were followed up 12-23 months, with an average of 17.97 months. C 5 nerve root paralysis syndrome occurred in 8 cases in the observation group (3 cases on the right and 5 cases on the left) and 2 cases in the control group (both on the right). There was significant difference of the incidence (20% vs. 5%) between the two groups ( χ 2=4.114, P=0.043). Except for 1 case in the observation group who developed C 5 nerve root palsy syndrome at 5 days after operation, the rest patients all developed at 1 day after operation; the recovery time of the observation group and the control group were (3.87±2.85) months and (2.50±0.70) months respectively, showing no significant difference between the two groups ( t=-0.649, P=0.104). At 12 months after operation, the JOA score and VAS score of cervical spine in the two groups significantly improved when compared with those before operation ( P<0.05); there was no significant difference in the difference of the cervical spine JOA score and VAS score between at 12 months after operation and before operation and the degree of spinal cord drift between the two groups ( P>0.05). CONCLUSION: Prophylactic C 4, 5 foraminal dilatation can not effectively prevent and reduce the occurrence of postoperative C 5 root palsy, on the contrary, it may increase its incidence, so the clinical application of this procedure requires caution.

Beneficial Effects of Cyclic Ether 2-Butoxytetrahydrofuran from Sea Cucumber Holothuria scabra against Aß Aggregate Toxicity in Transgenic Caenorhabditis elegans and Potential Chemical Interaction.

The pathological finding of amyloid-ß (Aß) aggregates is thought to be a leading cause of untreated Alzheimer's disease (AD). In this study, we isolated 2-butoxytetrahydrofuran (2-BTHF), a small cyclic ether, from Holothuria scabra and demonstrated its therapeutic potential against AD through the attenuation of Aß aggregation in a transgenic Caenorhabditis elegans model. Our results revealed that amongst the five H. scabra isolated compounds, 2-BTHF was shown to be the most effective in suppressing worm paralysis caused by Aß toxicity and in expressing strong neuroprotection in CL4176 and CL2355 strains, respectively. An immunoblot analysis showed that CL4176 and CL2006 treated with 2-BTHF showed no effect on the level of Aß monomers but significantly reduced the toxic oligomeric form and the amount of 1,4-bis(3-carboxy-hydroxy-phenylethenyl)-benzene (X-34)-positive fibril deposits. This concurrently occurred with a reduction of reactive oxygen species (ROS) in the treated CL4176 worms. Mechanistically, heat shock factor 1 (HSF-1) (at residues histidine 63 (HIS63) and glutamine 72 (GLN72)) was shown to be 2-BTHF's potential target that might contribute to an increased expression of autophagy-related genes required for the breakdown of the Aß aggregate, thus attenuating its toxicity. In conclusion, 2-BTHF from H. scabra could protect C. elegans from Aß toxicity by suppressing its aggregation via an HSF-1-regulated autophagic pathway and has been implicated as a potential drug for AD.

Can prophylactic C4/5 foraminotomy prevent C5 palsy after cervical laminoplasty with and without posterior instrumented fusion with maximal expansion?

OBJECTIVE: To prospectively examine whether laminoplasty with maximal expansion induces C5 palsy, even with prophylactic bilateral C4/5 foraminotomy. METHODS: Thirty-five consecutive patients with cervical myelopathy underwent laminoplasty (n = 19: LP group) or posterior decompression and fusion (n = 16: PDF group) with maximal expansion. Prophylactic bilateral C4/5 foraminotomy was performed alternately in consecutive five patients undergoing each type of surgery. In each type of surgery, the first and third consecutive five patients did not undergo foraminotomy (NF subgroup: 20 patients), while the second and fourth consecutive five patients underwent foraminotomy (F subgroup: 15 patients). The widths between the gutters was equivalent to the diameter of the spinal canal, and an inclination angle of the lamina of approximately 90° was created during laminoplasty. The incidence and severity of postoperative C5 palsy were investigated. Patients with a manual muscle testing score for the deltoid muscle and/or biceps brachii muscle of ≤ 2 were diagnosed with severe palsy. RESULTS: The respective incidences of C5 palsy in the F and NF subgroups were 33% and 20% in the LP group and 50% and 20% in the PDF group. Severe palsy occurred in 67% and 0% of patients who had developed palsy in F and NF subgroups, respectively, in the LP group, and in 100% of patients in the PDF group. Furthermore, 40% of the patients with severe palsy took more than 6 months to recover. CONCLUSIONS: Laminoplasty with maximal expansion induced C5 palsy in both the LP and PDF groups, even with the addition of prophylactic bilateral C4/5 foraminotomy.

Hesperidin improves motor disability in rat spinal cord injury through anti-inflammatory and antioxidant mechanism via Nrf-2/HO-1 pathway.

Spinal cord injury (SCI) is associated with inflammation with concurrent oxidative stress and glial activation. The aim of this study was to evaluate whether hesperidin, a representative flavonoid in citrus fruits, ameliorates SCI-induced motor dysfunction and neuro-pathologic degeneration in rat model. Rats received hesperidin (100 mg/kg body weight/daily, oral administration) from 7 days prior to SCI to 7 days post SCI. Behavioral test was done on rats with SCI until 6 weeks. For the study of inflammatory molecules in SCI rats with hesperidin treatment, rats were sacrificed at day 4 post SCI, and spinal cords were collected and studied histopathologically. Behavioral tests on hind-limbs of rats with SCI revealed that treatment of hesperidin in rats with SCI significantly ameliorate the hind-limb paralysis beginning at day 21 post SCI. Hesperidin treatment in rats with SCI reduced the neuropathological changes (e.g., hemorrhage, inflammatory cell infiltration, and tissue loss) and pro-inflammatory cytokines including tumor necrotic factor-α and interleukin-1ß. In addition, oxidative stress related molecules including superoxide dismutase, catalase, nuclear factor erythroid 2-related factor-2 and heme oxygenase-1 were also increased by hesperidin treatment. Furthermore, Fe2+, bilirubin and p38 mitogen activated protein kinase, these by-product of heme catabolism in serum and spinal cord of rats with hesperidin-treatment groups were significantly increased compared with those of vehicle-treatment group. Collectively, this study implies that hesperidin accelerates recovery of locomotor function and tissue repair of damaged spinal cord, with concurrent upregulation of heme oxygenase-1 as far as rat SCI model is concerned.

Strengthening acute flaccid paralysis surveillance post Ebola virus disease outbreak 2015 - 2017: the Liberia experience.

INTRODUCTION: Liberia remains at high risk of poliovirus outbreaks due to importation. The country maintained certification level acute flaccid paralysis (AFP) surveillance indicators each year until 2014 due to Ebola outbreak. During this time, there was a significant drop in non-polio AFP rate to (1.2/100,000 population under 15 years) in 2015 from 2.9/100, 000 population in 2013, due to a variety of reasons including suspension on shipment of acute flaccid paralysis stool specimen to the polio regional lab in Abidjan, refocusing of surveillance officers attention solely on Ebola virus disease (EVD) surveillance, inactivation of national polio expert committee (NPEC) and National Certification Committee (NCC). The Ministry of Health (MOH) supported by partners worked to restore AFP surveillance post EVD outbreak and ensure that Liberia maintains its polio free certification. METHODS: We conducted a desk review to summarize key activities conducted to restore acute flaccid paralysis (AFP) surveillance based on World Health Organization (WHO) AFP surveillance guidelines for Africa region. We also reviewed AFP surveillance indicators and introduction of new technologies. Data sources were from program reports, scientific and gray literature, AFP database, auto visual AFP detection and reporting (AVADAR) and ONA Servers. Data analysis was done using Microsoft excel and access spread sheets, ONA software and Geographic Information System (Arc GIS). RESULTS: AFP surveillance indicators improved with a rebound of non-polio AFP rate (NPAFP) rate from 1.2/100, 000 population under 15 years in 2015 to 4.3 in 2017. The stool adequacy rate at the national level also improved from 79% in 2016 to 82% in 2017, meeting the global target. The percentage of counties meeting the two critical AFP surveillance indicators NPAFP rate and stool adequacy improved from 47% in 2016 to 67% in 2017.The Last polio case reported in Liberia was in late 2010. CONCLUSION: There was significant improvement in the key AFP surveillance indicators such as NPAFP rate and stool adequacy with a 3.5 fold increase in NPAFP from 2014 to 2017. By 2017, the stool adequacy rate was up to target levels compared to 2016, which was below target level of 80%. The number of counties meeting target for the two critical AFP surveillance indicators also increased by 20% points between 2016 and 2017. Similarly there was approximately two-fold increase in the oral polio vaccines (OPV) coverage for the reported AFP cases between 2015 and 2017. Strategies employed to address gaps in AFP surveillance included enhanced active case search for AFP, re-instatement of laboratory testing, supportive supervision in addition to facilitating enhanced community engagement in surveillance activities. New technologies such as AVADAR Pilot, electronic integrated supportive supervision (ISS) and electronic surveillance (eSurv) tools were introduced to improve real time AFP case reporting. However, there remain residual gaps in AFP surveillance in the country especially at the sub-national level. Similarly, the newly introduced technologies will require continued funding and capacity building for MOH staff to ensure sustainability of the initiatives.

Inhibition of amyloid-induced toxicity by ergothioneine in a transgenic Caenorhabditis elegans model.

The abnormal accumulation of ß-amyloid peptide (Aß) is recognized as a central component in the pathogenesis of Alzheimer disease. While many aspects of Aß-mediated neurotoxicity remain elusive, Aß has been associated with numerous underlying pathologies, including oxidative and nitrosative stress, inflammation, metal ion imbalance, mitochondrial dysfunction, and even tau pathology. Ergothioneine (ET), a naturally occurring thiol/thione-derivative of histidine, has demonstrated antioxidant and neuroprotective properties against various oxidative and neurotoxic stressors. This study investigates ET's potential to counteract Aß-toxicity in transgenic Caenorhabditis elegans overexpressing a human Aß peptide. The accumulation of Aß in this model leads to paralysis and premature death. We show that ET dose-dependently reduces Aß-oligomerization and extends the lifespan and healthspan of the nematodes.

Limited laminectomy and foraminal decompression combined with internal fixation for treating multi-segment cervical spondylotic myelopathy: Does it effectively improve neurological function and prevent C5 palsy?

Laminectomy is an effective surgical treatment for multi-segment cervical spondylotic myelopathy (M-CSM) but usually results in C5 palsy. Some surgical techniques to restore the spinal sequence, increase the intervertebral foramen diameter, and limit the spinal cord drift distance have been proposed; however, it is unclear whether these procedures can avoid this complication.To investigate the clinical efficacy of limited laminectomy and foraminal decompression with fixation (LLFDF) for improving neurological recovery and preventing C5 palsy.A total of 71 patients with M-CSM were retrospectively analyzed. Thirty-nine of them were treated with LLFDF (group A) and 32 with normal laminectomy with fixation (NLF; group B) after 3 months of formal conservative treatment. Pre- and postoperative neurological function, spinal cord drift distance, cervical curvature index (CCI), and number of C5 palsy cases were recorded and analyzed.There was no significant intergroup difference in the surgical time or intraoperative blood loss (P >.05). The laminectomy widths in groups A and B were 16.7 ±â€Š2.6 mm and 21.8 ±â€Š2.9 mm, respectively (P <.01), while the spinal cord drift distances were 2.3 ±â€Š0.4 mm and 3.6 ±â€Š0.7 mm, respectively (P <.01). The mean Japanese Orthopedic Association score of both groups increased significantly after surgery (P <.01), and no significant difference was noted at any observation time points (P >.05). Both groups demonstrated significant CCI improvements after surgery compared with those before surgery (P <.01). There were 2 cases of C5 palsy in group A (5.1%) and 8 cases in group B (25.0%), and the difference was significant (P <.05).LLFDF can relieve spinal compression and considerably promote neurological recovery. Moreover, it restricts excessive spinal cord back drifting and decreases the incidence of C5 palsy.

Lonicera japonica extends lifespan and healthspan in Caenorhabditis elegans.

Lonicera japonica (LJ) is widely used as the local medicine to improve body and prevent ills in China, but mechanisms of its healthy beneficial effects remain largely unclear. Here, we evaluated the anti-aging and healthspan promoting activities of 75% ethanol extract of LJ (LJ-E) in the animal model Caenorhabditis elegans. Our results showed that LJ-E (500 µg/mL) treatment enhanced the mean lifespan of worms by over 21.87% and significantly improved age-associated physiological functions in C. elegans. The 500 µg/mL concentration of LJ-E enhanced the survival rates under oxidative and thermal stresses, and decreased reactive oxygen species (ROS) levels and fat accumulation in the worms. Gene-specific mutant studies showed that LJ-E-mediated lifespan extension was dependent on mev-1, daf-2, daf-16, and hsf-1, but not eat-2 genes. LJ-E could upregulate stress-inducible genes, viz., hsp-16.2, sod-3 and mtl-1. Moreover, we found that the D1086.10 protein interacted with superoxide dismutase (SOD)-3 by functional protein association networks analysis according to RNA-sequencing results. It was confirmed that D1086.10 was needed to promote longevity, and positively regulated expression of sod-3 by using D1086.10 mutants. Furthermore, LJ-E significantly delayed amyloid ß-protein induced paralysis in CL4176 strain. Given the important role of autophagy in aging and protein homeostasis, we observed that LJ-E could remarkably increase the mRNA expression of autophagy gene bec-1 in CL4176 strain, and decrease expression of autophagy substrate p62 protein by more than 40.0% in BC12921 strain. Finally, we found that combination composed of three major compounds (54 µg/mL chlorogenic acid, 15 µg/mL 1,5-dicaffeoylquinic acid and 7.5 µg/mL 1,3-dicaffeoylquinic acid) of 500 µg/mL LJ-E could significantly delay paralysis in CL4176 worms caused by Aß toxicity, comparable to that of LJ-E. Overall, our study may have important implications in using Lonicera japonica to promote healthy aging and have a potency to design therapeutics for age-related diseases.

Arthroscopic Superior Capsule Reconstruction Can Eliminate Pseudoparalysis in Patients With Irreparable Rotator Cuff Tears.

BACKGROUND: Patients with pseudoparalysis and irreparable rotator cuff tears have very poor function. The authors developed a superior capsule reconstruction (SCR) technique for irreparable rotator cuff tears that restores shoulder stability and muscle balance, improving shoulder function and relieving pain. PURPOSE: To evaluate whether arthroscopic SCR reversed preoperative pseudoparalysis in patients with irreparable rotator cuff tears. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: One hundred consecutive patients with irreparable rotator cuff tears underwent arthroscopic SCR with fascia lata autografts; 7 patients with deltoid weakness from cervical or axillary nerve palsy and 5 with severe presurgical shoulder stiffness were excluded. The remaining 88 were allocated to 3 groups according to their preoperative active shoulder elevation: no pseudoparalysis (45 patients; mean age, 66.2 years; mean tear size, 3.5 cm), moderate pseudoparalysis (28 patients, 68.3 years, 3.5 cm), and severe pseudoparalysis (15 patients, 62.3 years, 4.9 cm). Clinical outcome, active shoulder range of motion, acromiohumeral distance, and healing rate were compared between patients with and without pseudoparalysis, as well as before surgery and at final follow-up (35-110 months). RESULTS: American Shoulder and Elbow Surgeons score, active elevation, active external rotation, and acromiohumeral distance increased significantly after arthroscopic SCR among all patients. Graft healing rates did not differ among the groups ( P = .73): 98% (44 of 45) for no pseudoparalysis, 96% (27 of 28) for moderate pseudoparalysis, and 87% (13 of 15) for severe pseudoparalysis. Pseudoparalysis was reversed in 96% (27 of 28) of patients with preoperative moderate pseudoparalysis and 93% (14 of 15) with preoperative severe pseudoparalysis. Both patients with residual pseudoparalysis postoperatively (1 of 28 with preoperative moderate pseudoparalysis, 1 of 15 with preoperative severe pseudoparalysis) had graft tears. CONCLUSION: Arthroscopic SCR restored superior glenohumeral stability and improved shoulder function among patients with or without pseudoparalysis who had previously irreparable rotator cuff tears. In the absence of postoperative graft tear, arthroscopic SCR reversed preoperative pseudoparalysis. Graft healing rates after arthroscopic SCR did not differ between patients with and without pseudoparalysis.

Operative technique for benign submandibular gland mass without identifying the mandibular branch of the facial nerve.

OBJECTIVE: The marginal mandibular branch of the facial nerve must be protected during surgery for benign diseases of submandibular gland. Methods for protecting the marginal mandibular branch include the nerve identification method and the non-identification method. METHODS: We performed submandibular gland surgery in 138 patients with benign submandibular gland diseases using the non-identification method to preserve the marginal mandibular branch. In brief, the submandibular gland capsule is incised at the inferior border of the gland and detached along the gland parenchyma. The nerve is protected by this procedure without the need for identification. RESULTS: Among 138 patients who underwent this surgical procedure, only 7 patients developed transient paralysis of the lower lip. CONCLUSION: This method of resecting the submandibular gland without identifying the marginal mandibular branch is an effective procedure associated with a low incidence of transient paralysis. Moreover, no patient developed paralysis due to procedural errors.

Introduction of Inactivated Poliovirus Vaccine and Impact on Vaccine-Associated Paralytic Poliomyelitis - Beijing, China, 2014-2016.

When included in a sequential polio vaccination schedule, inactivated polio vaccine (IPV) reduces the risk for vaccine-associated paralytic poliomyelitis (VAPP), a rare adverse event associated with receipt of oral poliovirus vaccine (OPV). During January 2014, the World Health Organization (WHO) recommended introduction of at least 1 IPV dose into routine immunization schedules in OPV-using countries (1). The Polio Eradication and Endgame Strategic Plan 2013-2018 recommended completion of IPV introduction in 2015 and globally synchronized withdrawal of OPV type 2 in 2016 (2). Introduction of 1 dose of IPV into Beijing's Expanded Program on Immunization (EPI) on December 5, 2014 represented China's first province-wide IPV introduction. Coverage with the first dose of polio vaccine was maintained from 96.2% to 96.9%, similar to coverage with the first dose of diphtheria and tetanus toxoids and pertussis vaccine (DTP) (96.5%-97.2%); the polio vaccine dropout rate (the percentage of children who received the first dose of polio vaccine but failed to complete the series) was 1.0% in 2015 and 0.4% in 2016. The use of 3 doses of private-sector IPV per child decreased from 18.1% in 2014, to 17.4% in 2015, and to 14.8% in 2016. No cases of VAPP were identified during 2014-2016. Successful introduction of IPV into the public sector EPI program was attributed to comprehensive planning, preparation, implementation, robust surveillance for adverse events after immunization (AEFI), and monitoring of vaccination coverage. This evaluation provided information that helped contribute to the expansion of IPV use in China and in other OPV-using countries.

Status of surveillance and routine immunization performances in Amhara Region, Ethiopia: findings from in-depth peer review.

INTRODUCTION: Trend analyses of non-polio AFP and stool adequacy rates in Amhara Region showed optimal performance over the years. However, sub regional gaps continue to persist in certain zones where the reasons for low performance were not well documented. The objective of this study was to assess the performance of the disease surveillance and immunization system in Amhara Region, Ethiopia with emphasis on low performing woredas and zones. METHODS: A descriptive cross-sectional study was conducted from July 2-10, 2015 to assess the structure, core and support surveillance functions in five zones and two town administrations that were purposively sampled based on differing performances, geographic location, and history of vaccine preventable disease outbreaks among others. RESULTS: Of the 82 sites reviewed, 71 (87%) have a designated surveillance focal person. Less than half 36(44%) of these focal persons have written terms of reference. Twenty-six (93%) of the health offices had a written surveillance work plan for the fiscal year. Only 17 (81%) of woreda health offices and town administrations had prioritized active surveillance sites into high, medium and low during the last 12 months. Only 4(17%) had independent active case search visits to these sites as per the priority. Seventy-eight (95%) and seventy-seven (94%) sites have a designated immunization focal person and updated EPI performance monitoring charts, respectively. There had been vaccine stock out in the 3 months before assessment in 28 (34%) of the sites. CONCLUSION: Though there is an existence of well-organized surveillance network with adoption of the integrated disease surveillance and response, gaps exist in following the standard guidelines and operation procedures. Improvements needed in reporting site priority setting and regular visiting for active case search, outbreak investigation and management, vaccine supply and overall documentations.

Does Surgical Intervention or Timing of Surgery Have an Effect on Neurological Recovery in the Setting of a Thoracolumbar Burst Fracture?

Traumatic thoracolumbar burst fractures are one of the most common forms of spinal trauma with the majority occurring at the junctional area where mechanical load is maximal (AOSpine Thoracolumbar Spine Injury Classification System Subtype A3 or A4). Burst fractures entail the involvement of the middle column, and therefore, they are typically associated with bone fragment in the spinal canal, which may cause compression of the spinal cord, conus medullaris, cauda equina, or a combination of these. Fortunately, approximately half of the patients with thoracolumbar burst fractures are neurologically intact due to the wide canal diameter. Recent evidences have revealed that functional outcomes in the long term may be equivalent between operative and nonoperative management for neurologically intact thoracolumbar burst fractures. Nevertheless, consensus has not been met regarding the optimal treatment strategy for those with neurological deficits. The present review article summarizes the contemporary evidences to discuss the role of nonoperative management in the presence of neurological deficits and the optimal timing of decompression surgery for neurological recovery. In summary, although operative management is generally recommended for thoracolumbar fracture with significant neurological deficits, the evidence is weak, and nonoperative management can also be an option for those with solitary radicular symptoms. With regards to timing of operative management, high-quality studies comparing early and delayed intervention are lacking. Extrapolating from the evidence in cervical spine injury leads to an assumption that early intervention would also be beneficial for neurological recovery, but further studies are warranted to answer these questions.

Do Formal Laminectomy and Timing of Decompression for Patients With Sacral Fracture and Neurologic Deficit Affect Outcome?

OBJECTIVES: To identify whether formal sacral decompression provides improvement in outcome for patients with neurologic deficit after sacral fracture compared with patients treated with indirect decompression and whether the timing of surgical decompression influences neurologic outcome? DATA SOURCES: MEDLINE was searched via PubMed using combinations of the following search terms: "Sacral fracture," "Traumatic Sacral fracture," "Sacral fracture decompression," "Sacral fracture time to decompression," "Sacral Decompression." Only clinical studies on human subjects and in the English language were included. STUDY SELECTION: Studies that did not provide sufficient detail to confirm the nature of the sacral injury, treatment rendered, and neurologic outcome were excluded. Studies using subjects less than 18 years of age, cadavers, nonhuman subjects, or laboratory simulations were excluded. All other relevant studies were reviewed in detail. DATA EXTRACTION: All studies were assigned a level of evidence using the grading tool described by the Centre for Evidence-Based Medicine and all studies were analyzed for bias. Both cohorts in articles comparing 2 groups of patients treated differently were included in the appropriate group. Early decompression was defined as before 72 hours. DATA SYNTHESIS: The effect of decompression technique and timing of decompression surgery on partial and complete neurologic recovery was estimated using a generalized linear mixed model to implement a logistic regression with a study-level random effect. CONCLUSIONS: There was no benefit to early decompression within 72 hours and no difference between formal laminectomy and indirect decompression with respect to neurologic recovery.

Cervical laminectomy of limited width prevents postoperative C5 palsy: a multivariate analysis of 263 muscle-preserving posterior decompression cases.

PURPOSE: Between 2006 and 2010, we performed wide laminectomy (wide LAM) alone, with decompression performed between the bilateral medial margin of the zygapophyseal joints, or double-door laminoplasty (DL) combined with wide LAM for cervical compressive myelopathy (CCM). From 2010, instead of wide LAM and DL, we began to perform narrow LAM, where the laminectomy width was no more than 2-3 mm wider than the spinal cord width (SW). This study aimed to elucidate the risk factors for C5 palsy by reviewing surgical outcomes. METHODS: The clinical features and radiological findings of 263 CCM patients with or without C5 palsy were compared. Risk factors for C5 palsy were assessed using logistic regression analysis. The decompression width (DW) was defined as the laminectomy width or the width between the bilateral medial margins of the bony gutters in DL. RESULTS: Narrow LAM reduced the incidence of C5 palsy from 9.2 to 1.2%. DL was performed more frequently in the C5 palsy group. The difference between the DW and the SW (DW - SW) was significantly greater in the C5 palsy group. Posterior spinal cord shift, aging, and the number of consecutive laminae surgically treated were significantly higher in the C5 palsy group. The diameter of the foramen (DF) at C4/5 was significantly smaller in the C5 palsy patients. The logistic regression analysis revealed that DL, DW - SW, DF, and aging were risk factors for C5 palsy. CONCLUSIONS: Cervical laminectomy of limited width prevented postoperative C5 palsy without compromising the functional recovery.

The Accuracy of Multimodality Intraoperative Neuromonitoring to Predict Postoperative Neurologic Deficits Following Cervical Laminoplasty.

BACKGROUND: Intraoperative neuromonitoring (IONM) has been reported to be sensitive and specific in the detection of neurologic injury during spinal surgery. The purpose of this study was to clarify the incidence of C5 palsy using multimodality IONM and to compare the accuracy of multimodality IONM to predict postoperative C5 palsy with isolated transcranial motor evoked potentials (MEPs). METHODS: We retrospectively reviewed 135 consecutive patients at a single institution with cervical spondylotic myelopathy who underwent open door laminoplasty using MEPs combined with somatosensory evoked potentials and free-running electromyography. RESULTS: Multimodality IONM was obtained in 131 cases. Ossification of the posterior longitudinal ligament was present in 19 patients (14.1%). Postoperative C5 palsy occurred in 3 patients (2.2%). Significant MEP alerts occurred in 12 patients. Significant somatosensory evoked potential change was not observed. To predict acute-onset C5 palsy, MEP alerts in the deltoid or biceps had 100% sensitivity and 98.4% specificity. Transient or persistent MEP alerts in the deltoid or biceps had same positive predictive value with sensitivity of 50.0% and specificity 99.2%. CONCLUSIONS: Incidence of any neurologic deficit, including C5 palsy, during laminoplasty while using multimodality IONM was relatively low. MEP alerts in the deltoids or biceps had 100% sensitivity and 98.4% specificity for predicting a postoperative deficit. Somatosensory evoked potentials did not appear to be helpful in predicting postoperative deficits.