Reoperation in Spinal Dysraphism: Does it Help in Reversing the Neurological Deficits?

ABSTRACT Aims: After initial primary repair by inexperienced hands for the spectrum of pathological conditions in spinal dysraphism (SD), a few percentage of patients present with recurrent symptoms and worsening neurological status especially when primarily pathology is not identified and dealt properly. When the primary intradural tethering element is left untouched, worsening of symptoms is common. In this retrospective study, we tried to analyze the symptomatology, functional outcome at 1–2 months after the second surgery and associated complications. Subjects and Methods: All patients underwent second surgery at author’s institution. Pre and post-operative data were evaluated using Necker –Enfants Malades (NEM) neurological and modified Hoffer ambulatory scale. Results: The main presenting complaints were bladder incontinence and limb weakness. Preoperative mean scores for motor and bladder were 3.56 and 2.78 out of 5, 2.67 out of 4, and 2.11 out of 3 for bowel and sensory function, respectively. Postoperative mean score for motor, sensory, bladder, and bowel function revealed good neurological improvement. Statistically neurological improvement in bladder and bowel function was significant. More than 60% of patients had normal ambulation at follow-up. Conclusions: Patients presenting with recurrent symptoms in an operated case of SD need to be investigated, cause of recurrence has to be identified, and if needed repeat surgery is recommended at the earliest. Long-standing neurological deficits can potentially improve, especially bladder and bowel function which gives a good quality of life to the patients. Furthermore, we want to stress the fact that since it is an intradural pathology, these cases should be operated by experienced neurosurgeons, and this fact should be made aware among referring doctors.

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AWAKE CRANIOTOMY FOR BRAIN TUMORS NEAR ELOQUENT CORTEX

Neurosurgery ◽

10.1227/01.neu.0000342405.80881.81 ◽

2009 ◽

Vol 64 (5) ◽

pp. 836-846 ◽

Cited By ~ 135

Author(s):

Stefan S. Kim ◽

Ian E. McCutcheon ◽

Dima Suki ◽

Jeffrey S. Weinberg ◽

Raymond Sawaya ◽

...

Keyword(s):

Surgical Resection ◽

Neurological Status ◽

Extent Of Resection ◽

Sensory Function ◽

Neurological Deficits ◽

Cortical Mapping ◽

Eloquent Areas ◽

Eloquent Cortex ◽

Low Incidence ◽

Intraoperative Localization

Abstract OBJECTIVE Intraoperative localization of cortical areas for motor and language function has been advocated to minimize postoperative neurological deficits. We report herein the results of a retrospective study of cortical mapping and subsequent clinical outcomes in a large series of patients. METHODS Patients with intracerebral tumors near and/or within eloquent cortices (n = 309) were clinically evaluated before surgery, immediately after, and 1 month and 3 months after surgery. Craniotomy was tailored to encompass tumor plus adjacent areas presumed to contain eloquent cortex. Intraoperative cortical stimulation for language, motor, and/or sensory function was performed in all patients to safely maximize surgical resection. RESULTS A gross total resection (≥95%) was obtained in 64%, and a resection of 85% or more was obtained in 77% of the procedures. Eloquent areas were identified in 65% of cases, and in that group, worsened neurological deficits were observed in 21% of patients, whereas only 9% with negative mapping sustained such deficits (P < 0.01). Intraoperative neurological deficits occurred in 64 patients (21%); of these, 25 (39%) experienced worsened neurological outcome at 1 month, whereas only 27 of 245 patients (11%) without intraoperative changes had such outcomes (P < 0.001). At 1 month, 83% overall showed improved or stable neurological status, whereas 17% had new or worse deficits; however, at 3 months, 7% of patients had a persistent neurological deficit. Extent of resection less than 95% also predicted worsening of neurological status (P < 0.025). CONCLUSION Negative mapping of eloquent areas provides a safe margin for surgical resection with a low incidence of neurological deficits. However, identification of eloquent areas not only failed to eliminate but rather increased the risk of postoperative deficits, likely indicating close proximity of functional cortex to tumor.

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101 Case report: to stent, or not to stent? The pale cast of evidence-based practice in acute stroke

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp-2019-anzan.89 ◽

2019 ◽

Vol 90 (e7) ◽

pp. A33.1-A33

Author(s):

Chris Blair ◽

Kartik Bhatia ◽

David Brunacci ◽

John Worthington ◽

Rebekah Ahmed

Keyword(s):

Blood Pressure ◽

Acute Stroke ◽

Evidence Based Practice ◽

Blood Pressure Monitoring ◽

Neurological Deficits ◽

Evidence Based ◽

Limb Weakness ◽

Vasopressor Support ◽

Course Of Action ◽

The Right

IntroductionWith approximately 200 procedures performed in the last year at our centre, worthwhile clinical lessons continue to emerge in the practice of endovascular clot retrieval (ECR) for acute stroke. This case demonstrates the value of considered clinical appraisal in a dynamic, information-rich setting. A 68 year-old man with established vertebrobasilar atherosclerotic disease developed capricious, blood pressure-sensitive neurological deficits after successful ECR for a basilar artery stroke, inviting the possibility of further intervention in the form of intracranial stenting. We avoided pursuing this course of action in favour of a more measured approach, entailing the provision of vasopressor support over the following week.MethodFollowing ECR, our patient was admitted to the intensive care unit for continuous blood pressure monitoring and close observation of his neurological deficits with serial NIHSS (National Institutes of Health Stroke Scale) scoring. Systolic blood pressures were maintained between 140–160 mmHg using vasopressor support, with the aim of allowing time for recovery of vascular autoregulation and collateralization.ResultsOver six days, the patient developed moderate left upper and lower limb weakness. An MRI performed on Day 5 revealed limited interval infarction of the right hemipons and cerebellum, with complete re-occlusion of the mid-basilar arterial segment. He left the ICU with a NIHSS score of 7, and was living independently at 90-day follow-up (Modified Rankin Score 1).ConclusionThe ultimately favourable net outcome for our patient clearly illustrates the imperative to remain within the boundaries of evidence-based practice in this bold and rapidly evolving discipline.

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Cervical neuromyelitis optica with thoracic ependymoma

Surgical Neurology International ◽

10.25259/sni_677_2021 ◽

2021 ◽

Vol 12 ◽

pp. 396

Author(s):

Yeow Leng Tan ◽

Minghe Moses Koh

Keyword(s):

Neuromyelitis Optica ◽

Spinal Cord Tumor ◽

Neurological Deficits ◽

High Signal ◽

Positive Serology ◽

Limb Weakness ◽

Intramedullary Spinal Cord ◽

Critical Studies ◽

Spinal Ependymoma ◽

Abnormal Visual

Background: The occurrence of cervical neuromyelitis optica (NMO) in a patient with a thoracic ependymoma is uncommon. Here, we present a patient with a spinal ependymoma who developed the new onset of NMO 2 months later. Case Description: A 66-year-old male presented with right lower limb weakness. The magnetic resonance (MR) revealed an intramedullary spinal cord tumor at the T2-T4 level. It was surgically excised and proved pathologically to be an ependymoma. 2 months later, the patient presented with an acute partial quadriparesis and a high signal intensity cord lesion at the C2-C3 level attributed to seropositive NMO (i.e. additional diagnostic studies confirmed this diagnosis). Conclusion: Patients with intramedullary thoracic ependymomas may also develop NMO resulting in recurrent/ new neurological deficits. Critical studies utilized to diagnose NMO include brain and spine MRs showing unique intramedullary brain/cord lesions, aquaporin-4 positive serology, and classical abnormal visual studies. If the diagnosis of NMO is established, multiple additional medical therapies are warranted.

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Craniotomy for Fenestration of Multiloculated Hydrocephalus in Pediatric Patients

Operative Neurosurgery ◽

10.1227/01.neu.0000163489.75279.8c ◽

2005 ◽

Vol 57 (suppl_1) ◽

pp. 100-106 ◽

Cited By ~ 10

Author(s):

David I. Sandberg ◽

J. Gordon McComb ◽

Mark D. Krieger

Keyword(s):

Pediatric Patients ◽

Neurological Status ◽

Neurological Deficits ◽

Ventricular Catheter ◽

Shunt System ◽

Neurological Outcomes ◽

Multiloculated Hydrocephalus ◽

Before And After ◽

Posterior Parietal ◽

Ventricular Catheters

Abstract OBJECTIVE: To assess the treatment of progressive multiloculated hydrocephalus by craniotomy for microsurgical fenestration of cerebrospinal fluid (CSF) compartments to minimize the number of ventricular catheters. METHODS: We studied 33 pediatric patients who underwent craniotomies for fenestration of progressive multiloculated hydrocephalus between 1989 and 2003. In 20 of 33 patients, hydrocephalus was attributed to intraventricular hemorrhage associated with prematurity. Twenty-three of 33 patients had previous central nervous system infections. Craniotomy was typically performed via a posterior parietal approach. Communication between bilateral supratentorial loculated compartments and posterior fossa compartments was achieved. Surgical and neurological outcomes were assessed. RESULTS: Fenestration of loculated CSF spaces was performed successfully in all patients. No new neurological deficits were noted after surgery, and no patients required intraoperative blood transfusions. CSF infections within 3 months after surgery occurred in 4 of 33 patients. Over a median follow-up period of 3.7 years (range, 1.5 mo to 8.7 yr), 19 of 33 patients required additional fenestration procedures. The number of repeat fenestration procedures ranged from one to six, and a total of 47 additional fenestrations were performed in these 19 patients. The majority of patients (n = 25) ultimately required shunt systems with only one ventricular catheter. The neurological status of these patients was extremely poor both before and after surgery. Twenty-nine of 33 patients were severely delayed, and four were mildly delayed. CONCLUSION: Fenestration of multiloculated CSF compartments can enable most patients to function with a single ventricular catheter shunt system. Neurological status remains poor in this patient population.

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Tethered cord syndrome in children with anorectal malformations

Journal of Neurosurgery ◽

10.3171/jns.2000.92.4.0626 ◽

2000 ◽

Vol 92 (4) ◽

pp. 626-630 ◽

Cited By ~ 15

Author(s):

Natarajan Muthukumar ◽

Bhuvaneswari Subramaniam ◽

Thangaraj Gnanaseelan ◽

Ramesh Rathinam ◽

Appaswamy Thiruthavadoss

Keyword(s):

Tethered Cord ◽

Anorectal Malformations ◽

Neurological Deficits ◽

Radiographic Evidence ◽

Content Type ◽

X Ray ◽

Neurological Improvement ◽

Intraspinal Anomalies ◽

Bone Abnormalities ◽

Fine Print

Object. Anorectal malformations are known to be associated with neurological deficits, which may contribute to the disability suffered by patients with these malformations. This study was undertaken to determine the incidence and pattern of sacral abnormalities in children with anorectal malformations, the incidence and nature of the neurological deficits, and the incidence and nature of operable intraspinal abnormalities in patients with this condition.Methods. Neurological evaluation was performed in 81 children with anorectal malformations. Plain x-ray films were obtained to identify the presence of sacral abnormalities. The patients with neurological deficits were evaluated for the presence of operable intraspinal anomalies, and when such anomalies were identified, correction of the same was undertaken. In 21% of these children radiographic evidence of sacral abnormalities was shown. Fifteen percent of patients harbored neurological deficits, and 10% harbored operable intraspinal anomalies. In addition, one patient had split notochord syndrome. Patients with operable intraspinal anomalies underwent surgical correction, with resultant neurological improvement.Conclusions. Bone abnormalities of the sacrum, neurological deficits, and operable intraspinal lesions are not uncommon in children with anorectal malformations. Because the neurological deficits can contribute to the disability suffered by these individuals, we recommend routine screening of patients with anorectal malformations and neurological deficits and/or sacral abnormalities for the early identification and treatment of potentially correctable intraspinal lesions.

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Olfactory Mucosal Auto-transplantation in Spinal Cord Injury: A Clinical Trial, Saudi Arabia

Journal of Spine Practice (JSP) ◽

10.18502/jsp.v1i1.9771 ◽

2021 ◽

pp. 11

Author(s):

Ahmad Najib Ashraf ◽

Abdulaziz Shebreen

Keyword(s):

Clinical Trial ◽

Spinal Cord ◽

Spinal Cord Injury ◽

Sensory Function ◽

Cell Transplant ◽

Loss Of Function ◽

Neurological Improvement ◽

Cord Injury ◽

Distinctive Property ◽

Independent Life

Introduction: Spinal cord injury (SCI) results in loss of nervous tissue and consequently loss of motor and sensory function. Despite significant improvements in the early medical and surgical management of SCI, there is no effective treatment available that restores the injury-induced loss of function to a degree that an independent life can be guaranteed. Restoration of function and reversal of paralysis following SCI is among the most daunting challenges in all of neuroscience research. Methodology: We decided to study the outcomes in chronic SCI (CSCI) after autologous olfactory mucosal transplantation into the spinal cord following detethering of the cord. The human surgical procedure of autologous olfactory mucosal transplantation was first developed by Carlos Lima and his colleagues. These investigators provided guidance for the surgical procedures in this study and the procedures on the first six participants were performed in their presence. Result: Patients were screened at different centers in the kingdom. A stringent inclusion and exclusion criteria were applied. Patients for this clinical trial were selected from individuals that suffered an SCI at least 12 months before their assessment and were chronically paraplegic or tetraplegic. The final twenty participants were selected after screening more than 125 patients. While some of them were rejected for medical reasons, some refused to participate upon receiving a full briefing and some of them were unable to fulfill the required psychosocial criteria. Conclusion: The details of the patients and the changes observed in their conditions post olfactory mucosal auto-transplantation will be discussed in detail in oral presentation with graphic results with marked significant improvement in motor and sensory levels of SCI patients as compared to before transplantation of olfactory mucosa. Olfactory unsheathing cells (OECs) are glia cells and continuous axon extension and successful topographic targeting of the olfactory receptor neurons responsible for the sense of smell (olfaction). Due to this distinctive property, OECs have been trialed in human cell transplant therapies to assist in the repair of central nervous system injuries, particularly those of the spinal cord. Although many studies have reported neurological improvement, therapy remains inconsistent and requires further improvement.

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Continuous Incremental Heavy Halo Traction Combined with Posterior-only Approach for Severe Cervical Kyphosis with Neurofibromatosis-1.

10.21203/rs.2.15877/v1 ◽

2019 ◽

Author(s):

Chaofeng Guo ◽

Hongqi Zhang ◽

Zhenhai Zhou ◽

Jinyang Liu ◽

Ang Deng

Keyword(s):

Posterior Instrumentation ◽

Neurological Status ◽

Neurofibromatosis 1 ◽

Neurological Deficits ◽

Cervical Kyphosis ◽

Kyphosis Correction ◽

Halo Traction ◽

Key Words Neurofibromatosis ◽

Correction Result

Abstract Background Surgical management of cervical kyphosis in patients with NF-1 is a challenging task. Presently, anterior-only (AO), posterior-only (PO) and combined anterior-posterior (AP) spinal fusion are common surgical strategies. However, the choice of surgical strategy and application of Halo traction remain controversial. Few studies have shown and recommended posterior-only approach for cervical kyphosis correction in patients with NF-1. The aim of this study is to evaluate the safety and the effectiveness of Continuous-Incremental-Heavy Halo Traction (CIH-HT) combined with posterior-only approach for treatment of cervical kyphosis with NF-1. Methods 19 patients with severe cervical kyphosis due to NF-1 were reviewed retrospectively between January 2010 and April 2017. All the cases underwent CIH-HT combined with posterior instrumentation and fusion surgery. Correction result, neurologic status and complications were analyzed. Results In this study, cervical kyphosis Cobb angle decreased from initial 63.0 ± 21.0 degrees to postoperative 10.8 ± 4.0 degrees(P＜0.01),with total correction rate of 92%, which consist of 44% from CIH-HT and 48% from surgical correction. JOA scores were improved from preoperative 13.6±1.6 to postoperative 16.0±1.0(P＜0.01). Neurological status was also improved. There was no correction loss and the neurological status was stable in mean 3.7 years follow-up. The incidence of complications was 36.8% (7/19). Six patients underwent local complications and one patient underwent a second surgery. Conclusion CIH-HT combined PO approach is safe and effective method for cervical kyphosis correction in patients with NF-1. A satisfied correction result, and successful bone fusion can be achieved via this procedure, even improvement of neurological deficits can also be obtained. Our study suggested that CIH-HT combined PO approach is another consideration for cervical kyphosis correction in patients with NF-1. Key words : Neurofibromatosis-1; Cervical kyphosis; Continuous-Incremental-Heavy Halo Traction; posterior-only approach;

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Postoperative ischemic changes following brain metastasis resection as measured by diffusion-weighted magnetic resonance imaging

Journal of Neurosurgery ◽

10.3171/2013.9.jns13596 ◽

2013 ◽

Vol 119 (6) ◽

pp. 1395-1400 ◽

Cited By ~ 17

Author(s):

Jens Gempt ◽

Julia Gerhardt ◽

Vivien Toth ◽

Stefanie Hüttinger ◽

Yu-Mi Ryang ◽

...

Keyword(s):

Brain Metastasis ◽

Brain Metastases ◽

Neurological Deficit ◽

Karnofsky Performance Status ◽

Performance Status ◽

Neurological Status ◽

Neurological Deficits ◽

Brain Irradiation ◽

Diffusion Weighted ◽

The Mean

Object Brain metastases occur in 10% to 40% of patients harboring cancer. In cases of neurosurgical metastasis resection, all postoperative neurological deterioration should be avoided. Reasons for postoperative deficits can be direct tissue damage due to resection, hemorrhage, venous congestive infarcts, or arterial ischemic events leading to tissue infarction. The aim of this study was to evaluate whether postoperative ischemic infarctions occur in surgery for brain metastasis and to determine their influence on new postoperative neurological deficits. Methods Patients who underwent resection of brain metastases and had preoperative and early postoperative (within 48 hours) MRI scans, including diffusion-weighted imaging sequences and apparent diffusion coefficient maps, between January 2009 and May 2012 were included in this study. Clinical and histopathological data (histopathological results, pre- and postoperative neurological status, and previous tumor-specific therapy) were recorded. Results One hundred twenty-two patients (56 male, 66 female) who underwent resection of brain metastases were included. The patients' mean age was 60 years (range 21–89 years). The mean time span from initial tumor diagnosis to resection of brain metastasis was 44 months (range 0–338 months). The mean preoperative Karnofsky Performance Status was 80% (exact mean 76% ± 17% [SD]), and the mean postoperative value was 80% (exact mean 78% ± 17%). Twelve (9.8%) of the 122 patients had postoperative permanent worsening of a neurological deficit or a new permanent neurological deficit; 44 (36.1%) of the 122 patients had postoperative ischemic lesions. When comparing patients with and without previous brain irradiation, 53.8% of patients with previous brain irradiation had ischemic lesions on postoperative imaging compared with 31.3% of patients without previous brain irradiation (p = 0.033). There was a significant association between ischemia and postoperative neurological status deterioration (transient or permanent); 13 (29.5%) of 44 patients with ischemic lesions had deterioration of their neurological status compared with 7 (9%) of the 78 patients who did not have ischemic lesions (p = 0.003). Conclusions This study demonstrates a high prevalence of vascular incidents in patients undergoing resection for metastatic brain disease. Patients harboring postoperative ischemic lesions detected by MRI have a higher rate of neurological deficits (transient or permanent). Patients who had previous irradiation therapy are at higher risk of developing postoperative ischemic lesions. A large number of postoperative neurological deficits are caused by ischemic incidents.

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Spinal meningiomas: Clinical and therapeutic tonsiderations

Open Medicine ◽

10.2478/s11536-008-0045-7 ◽

2008 ◽

Vol 3 (3) ◽

pp. 322-326

Author(s):

Johannes Schröder ◽

Bernhard Fischer ◽

Stefan Palkovic ◽

Hansdetlef Wassmann

Keyword(s):

Spinal Canal ◽

Thoracolumbar Spine ◽

Cauda Equina ◽

Complete Removal ◽

Neurological Status ◽

Neurological Deficits ◽

Before And After ◽

Patient Will ◽

Spinal Meningiomas ◽

The Mean

AbstractMeningiomas of the spinal canal are rare, in contrast to their cranial counterparts. This study reports on the dominant features of spinal meningiomas before and after treatment. We treated 30 patients (23 female) with meningiomas of the spinal canal from 1992 to 2003. The mean age was 68 (range: 43–91). Upon admission, 26 patients presented with a marked neurological deficit (11 paraparesis, 9 motor weakness, 4 myelopathic ataxia, 1 quadriplegia, and 1 cauda equina syndrome). Two patients had sensory deficits, and two had pain only. The distribution of the tumors was as follows: 8 cases were cranio-cervical, 1 case was cervical, 6 cases were at the cervico-thoracic junction, 9 cases were of the thoracic spine, 5 cases were of the thoracolumbar spine, and 1 case was of the lumbar spine. Five cases also had intracranial manifestations. The mean interval between the onset of the first symptoms and treatment was 12 months. All cases were treated via (hemi)-laminectomy for complete removal of the tumor and occasionally via duraplasty. After a mean follow-up of 3 years, symptoms had improved by 3 points (on a 5-point scale) in 3 cases, by 2 points in 7 cases, and by 1 point in 12 cases; 7 cases were unchanged, and 1 case had worsened by 1 point. We observed 3 local recurrences. One case developed manifestations at a different site. Spinal meningiomas are often diagnosed late, after they have already caused major neurological deficits. Nevertheless, owing to their benign character, the outcome is favorable when treated appropriately. The outcome depends above all on the initial neurological status. The worse the deficit is, the less probable it is that the patient will recover neurologically.

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Effects of profound hypotension on cerebral blood flow during surgery for intracranial aneurysms

Journal of Neurosurgery ◽

10.3171/jns.1981.55.6.0857 ◽

1981 ◽

Vol 55 (6) ◽

pp. 857-864 ◽

Cited By ~ 76

Author(s):

J. Keith Farrar ◽

Francis W. Gamache ◽

Gary G. Ferguson ◽

John Barker ◽

George P. Varkey ◽

...

Keyword(s):

Blood Flow ◽

Cerebral Blood Flow ◽

Neurological Status ◽

Neurological Deficits ◽

Arterial Spasm ◽

Arterial Blood ◽

Flow Disturbances ◽

Group I ◽

Increased Risk ◽

Profound Hypotension

✓ The progression of changes in cerebral blood flow (CBF) and neurological status were measured in 12 patients in whom profound hypotension (mean arterial blood pressure (MABP): 30 to 40 mm Hg) was used during intracranial aneurysm surgery. Nine patients (Group I) showed autoregulation of CBF to an MABP of 40 to 50 mm Hg during surgery. None of these patients had arterial spasm preoperatively. Postoperatively, mild flow disturbances were noted at the site of retraction. Three Group I patients developed arterial spasm postoperatively, but there was no associated neurological deterioration. The remaining three patients (Group II) had impaired autoregulation during surgery, and CBF decreased by 35% to 65% at an MABP of 50 mm Hg. Two of these patients had angiography immediately before surgery, and both showed moderate to severe arterial spasm. Relatively severe flow disturbances were noted postoperatively at the site of retraction, and two patients developed ischemic deficits of late onset. Brain retractor pressure and the degree and duration of hypotension were equivalent in the two patient groups. There was no correlation between intraoperative reductions in CBF (to as low as 20 ml/100 gm/min in the unretracted hemisphere) and immediate postoperative neurological deficits. The use of halothane and mannitol and the relatively short duration of the flow reductions were suggested as factors contributing to the protection from ischemia that was observed. Arterial spasm was found to produce hemodynamic instability and reduced CBF, although neurological status was unaffected in the majority of patients. Patients with impaired autoregulation during surgery were at increased risk of delayed ischemic complications postoperatively, and showed characteristic flow disturbances at all three stages of their clinical course.

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