Laminoplasty with selective fusion at unstable segment versus laminectomy with fusion for multilevel cervical myelopathy: a case‐control study

Background Segmental cervical instability is a risk factor for the progression of osteophytic bone spurs and development of myelopathy, and is treated as a relative contraindication of cervical laminoplasty. The aim of this study was to compare laminoplasty with selective fixation (LPSF) versus laminectomy with fusion (LCF) in patients with multilevel cervical myelopathy accompanied by segmental instability. Methods A case-control study was conducted by reviewing data from 63 patients who underwent LPSF (n = 30) or LCF (n = 33). Cervical alignment, range of motion (ROM), neurologic status and axial symptom severity pre-operation, 3-days after operation, and at the final follow-up (minimum 24 months) were measured and compared between groups. Results Postoperation, patients in the LPSF group lost 31.1 ± 17.3 % of cervical lordosis and 43.2 ± 10.9 % cervical ROM while patients in the LCF group lost 5.7 ± 8.2 % and 67.9 ± 15.5 %, respectively. Both LPSF and LCF groups significantly improved neurologic status and axial symptom severity at the final follow-up with similar between-group results(P > 0.05). Blood loss, operation time, hospital stay, and medical cost in the LPSF group were significantly less than in the LCF group(P < 0.05). Conclusions In 2 years of clinical observation, LPSF was effective in maintaining the stability of the cervical spine with less sacrifice of mobility and surgical trauma for multilevel myelopathy with segmental instability compared to LCF.

Brain Arteriovenous Malformations: Impact of Neurologic Status, Bleeding, and Type of Treatment on Final Outcome

Background Well-designed studies assessing the treatment outcome of brain arteriovenous malformations (AVMs) are infrequent and have not consistently included all of the available treatment modalities, making their results not completely generalizable. Moreover, the predictors of poor outcome are not well defined. Methods We performed an observational retrospective study of AVM patients. We included patients with clinical, radiologic, and outcome data, with a minimum follow-up of 1 year. Neurologic outcome was documented using the modified Rankin Scale (mRS) at the AVM diagnosis and 30 days after the treatment. Results There were 117 patients, with equal male/female proportion. The mean follow-up time was 51 months. Treatment distribution in the Spetzler–Martin grades I–III was as follows: 52 (54.6%) surgery, 31 (32.35%) radiosurgery, 2 (0.02%) embolization, and 11 (12%) conservative follow-up. Treatment distribution in Spetzler–Martin grades IV and V was as follows: 4 (20%) surgery, 7 (35%) radiosurgery, and 10 (45%) conservative follow-up. Poor neurologic outcome (mRS ≥ 3) was significantly associated with poor clinical status at diagnosis (Glasgow Coma Scale [GCS] score< 14; odds ratio [OR]: 0.20; 95% confidence interval [CI]: 0.001–0.396; p = 0.010). The rupture of the AVM was associated with poor neurologic outcome. The Lawton–Young Supplementary scale (LYSS) proved to be the most effective in predicting poor outcome. The existence of seizures, treatment-related complications, and conservative treatment was associated with the worsening of the mRS score, whereas the existence of hemorrhage was associated with the likelihood of disability. Conclusion Our results suggest that poor neurologic status at diagnosis, AVM rupture, and conservative treatment were associated with worse outcome. Hemorrhage as initial presentation is related to disability, not with mRS worsening. The LYSS appeared to be the best method to predict outcome.

SURGICAL TREATMENT OF PATIENTS WITH MALIGNANT TUMOR LESIONS OF THE SPINE

Introduction: The problem of diagnostics and treatment of oncological diseases is one of the most urgent challenges of the public health system. Despite successful achievements over the past years, surgical treatment of spinal tumors is becoming more demanded due to the increasing number of cases with complexities and long duration of the disease. The research found out developing compression of the spinal cord at 10% of patients with spinal spread. Still, the patients suffering spinal tumors are associated with high mortality rates. Aim: To analyze the results of clinical treatment of spinal tumors at patients who have received specialized orthopedic aid. Methods and materials: From 2014 to 2019, patients with spinal neoformations (N=240) received surgical treatment at Traumatology Unit of North-Western State Medical University named after I.I. Mechnikov. We assessed categories of sex, age, histologic type and location of tumors, pain severity (BAIII), neurologic status (Frankel scale), life span (from operation to death or the latest check-up). Results: The choice of the treatment method depended on the pathology of the spinal tumor. Analysis of the material found: spinal lesion is caused by secondary tumors, mainly; spinal spread results in chest lesions. Positive dynamics of the neurologic status was observed at patients of B,C,D,E groups (Frankel scale) after the surgery. All the patients, having received puncture vertebroplasty, experienced the regression of pain severity. Conclusion: Vertebroplasty is an efficient treatment of pain severity at patients with symptomatic and aggressive haemangeoma and pathologic fractures of vertebral bodies during the neoplastic process. We should apply surgical treatment for patients with spinal cord compression as earlier as possible to prevent from the development of sever neurologic disorders and pain management. The main method of treatment is decompressing and stabilizing interventions from the posterior approach.

Promising candidates for extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest

Precise criteria for extracorporeal cardiopulmonary resuscitation (ECPR) are still lacking in patients with out-of-hospital cardiac arrest (OHCA). We aimed to investigate whether adopting our hypothesized criteria for ECPR to patients with refractory OHCA could benefit. This before-after study compared 4.5 years after implementation of ECPR for refractory OHCA patients who met our criteria (Jan, 2015 to May, 2019) and 4 years of undergoing conventional CPR (CCPR) prior to ECPR with patients who met the criteria (Jan, 2011 to Jan, 2014) in the emergency department. The primary and secondary outcomes were good neurologic outcome at 6-months and 1-month respectively, defined as 1 or 2 on the Cerebral Performance Category score. A total of 70 patients (40 with CCPR and 30 with ECPR) were included. For a good neurologic status at 6-months and 1-month, patients with ECPR (33.3%, 26.7%) were superior to those with CCPR (5.0%, 5.0%) (all Ps < 0.05). Among patients with ECPR, a group with a good neurologic status showed shorter low-flow time, longer extracorporeal membrane oxygenation duration and hospital stays, and lower epinephrine doses used (all Ps < 0.05). The application of the detailed indication before initiating ECPR appears to increase a good neurologic outcome rate.

Abstract 201: Bougie-Assisted Endotracheal Intubation in the Pragmatic Airway Resuscitation Trial

Objective: Paramedics often perform endotracheal intubation (ETI) in the management of out-of-hospital cardiac arrest (OHCA). While ETI assisted by use of the gum elastic Bougie has been associated with improved first-pass intubation success in the emergency department, its influence upon out-of-hospital cardiac arrest (OHCA) ETI is unknown. We compared success rates and outcomes between Bougie-assisted and standard ETI in the Pragmatic Airway Resuscitation Trial (PART). Methods: We conducted a secondary analysis of PART, a clinical trial comparing initial-ETI vs. initial-laryngeal tube airway management strategies in adult OHCA. We included only patients receiving initial ETI attempts. The primary exposure was Bougie-assisted vs. standard ETI. The primary outcome was first-pass ETI success. Secondary outcomes included overall ETI success, time to successful ETI, 72-hour survival, hospital survival and hospital survival with favorable neurologic status. We assessed the associations between Bougie-assistance and ETI outcomes using Generalized Estimating Equations and Cox Regression, adjusting for for age, sex, race, witnessed arrest, bystander CPR and initial rhythm. Results: Of the 3,004 patients enrolled in PART, 1,227 received initial ETI, including 440 Bougie-assisted and 787 standard ETI. First-pass ETI success did not differ between Bougie-assisted and standard ETI (53.1% vs. 42.8%; adjusted OR 1.12, 95% CI: 0.97 to 1.39). Overall ETI success was slightly higher for Bougie-assisted ETI (56.2% vs. 49.1%; adjusted OR 1.19, 95% CI: 1.01 to 1.32). Time to ETI was longer for Bougie-assisted than standard ETI (median 13 vs. 11 min; adjusted HR 0.63, 95% CI: 0.45 to 0.90). While survival to hospital discharge was lower for Bougie-assisted than standard ETI (3.6% vs. 7.5%; adjusted OR 0.94, 95% CI: 0.92 to 0.96), there were no differences in 72-hour survival or hospital survival with favorable neurologic status. Conclusion: In the PART trial, Bougie assistance resulted in slightly higher overall ETI success but with longer airway placement time. Bougie assistance was not associated with first-pass ETI success. The association between Bougie-assisted ETI and OHCA survival was unclear. The role of Bougie-assisted ETI in OHCA is uncertain.

The Neurological Exam of a Comatose Patient: An Essential Practical Guide

A thorough examination of a comatose patient is essential given the spectrum of clinical diagnoses. The most immediate threat to patients is airway, breathing and circulation. All attending physician should employ a structured and focused approach in dealing with a comatose patient. It is important to recognise the urgent steps needed at the time to prevent further deterioration, followed by the final diagnosis of patient’s neurologic status. Here we provide the essential practical guide to the neurological exam of a comatose patient that would assist to determine the aetiology, location and nature of the neurological lesion.