Changes in Function and Muscle Strength of Encephalitis Survivors After Inpatient Rehabilitation

Objective To investigate the clinical demographics and rehabilitative assessments of encephalitis survivors admitted to a rehabilitation center, and to confirm the effects of inpatient rehabilitation manifested by changes in muscle strength and function after hospitalization.Methods Data of encephalitis survivors who received rehabilitation at our institution from August 2009 to August 2019 were reviewed. Medical charts were retrospectively reviewed, and motor, functional, and cognitive assessments were collected. Manual muscle testing (MMT), Fugl-Meyer Assessment (FMA), Berg Balance Scale (BBS), Functional Ambulation Category (FAC), Korean version of Modified Barthel Index (K-MBI), grip strength, Box and Block Test (BBT), and Korean version of Mini-Mental State Examination (K-MMSE) were performed, and the results upon admission and discharge were compared and analyzed.Results Most of the patients with encephalitis admitted to our institution had viral or autoimmune etiologies. The assessment results of 18 encephalitis patients upon admission and discharge were compared. The total K-MBI score, FAC, grip strength, and BBT significantly improved, but not the MMT and FMA. Subgroup analysis was performed for viral and autoimmune encephalitis, which are the main causes of the disease, but there was no difference in items with significant changes before and after hospitalization.Conclusion Encephalitis survivors showed a significant improvement in functional assessment scale during their hospital stay through rehabilitation, without significant changes in motor strength. Hence, we can conclude that encephalitis survivors benefit from inpatient rehabilitation, targeting functional gains in activities of daily living training more than motor strength.

Clinical Outcome in Cerebral Vasospasm Patients Treated with and without Intra-Arterial Nimodipine Infusion

Background Cerebral vasospasm (CV) after aneurysmal subarachnoid hemorrhage (aSAH) is still a problem. Hypertension, hypervolemia, and hemodilution (triple-H) therapy and oral nimodipine only a modest effect on patients. Intra-arterial treatment, including nimodipine, has been studied, but only as retrospective and single-arm prospective studies. We compared the outcomes between CV patients who received an adjunct intra-arterial nimodipine infusion (IANI) and those who received the standard medical treatment alone in a prospective randomized controlled trial. Methods In this study, patients between the age of 18 and 80 years, who underwent angiography within 14 days after aneurysm obliteration, were recruited and randomized to receive adjunct IANI or not, if they were identified with angiographic vasospasm. All the angiographic and neurologic data were recorded and analyzed during their admission, at the discharge date, and during the 6-month follow-up period. Results From June 2016 to December 2018, we enrolled 68 patients who were randomized into two groups, 36 in the intervention group and 32 in the control group. The patients' characteristics, aneurysm data, and modalities of treatment were similar between the two groups. Within 24 hours after IANI, Glasgow Coma Scale (GCS) score and motor strength revealed a significant improvement of 33.33 and 38.89%, respectively, in the intervention group versus 12.5 and 9.38%, respectively, in the control group. At discharge, the intervention group still had significant motor improvement (58.33 vs. 21.88%; p = 0.002). Conclusion IANI could be considered an effective treatment for CV without significant complications. This is the first RCT demonstrating statistically significant motor strength improvement within 24 hours and at discharge.

Primary Graviceptive System and Astasia: Case Report and Literature Review

Purpose of ReviewAstasia refers to the inability to maintain upright posture during standing, despite having full motor strength. However, the pathophysiology and neural pathways of astasia remains unclear.Recent FindingsWe analyzed 26, including ours, non-psychogenic astasia patients in English literature. Seventy-three percent of them were man, 73% were associated with other neurologic symptoms and 62% of reported lesions were at right side. Contralateral lateropulsion was very common followed by retropulsion while describing astasia. Infarction (54%) was the most commonly reported cause. Thalamus (65%) was the most commonly reported location. Infarction being the mostly likely to recover (mean:10.6 days), while lesions at brainstem had longer time to recover (mean: 61.6 days).SummaryThe underlying interrupted pathway may be the primary graviceptive system, which composed of at least five unilateral and contralateral projection fibers from vestibular nuclei to thalamic nuclei, and thalamo-cortical projections including subcortical white matter tracts and cortical areas.

Transforaminal Percutaneous Endoscopic Discectomy in the Treatment of Adolescent Lumbar Disc Herniations With Posterior Ring Apophysis Separation

Objective: To assess the efficacy of transforaminal percutaneous endoscopic discectomy in the treatment of adolescent lumbar disc herniations with posterior ring apophysis separation Methods: Overall 23 cases of adolescent lumbar disc herniations with posterior ring apophysis separation were treated with the procedure of transforaminal percutaneous endoscopic discectomy between January 2016 and December 2019. Preoperative and postoperative (6 week, 6 month and 12 month) clinical outcome data (back and leg VAS and Macnab criteria) were collected along with clinical assessments of motor strength (graded 0-5).Results All patients were discharged to home on the same day of surgery. The average leg Visual Analog Scale improved from 8.7 ± 1.5 to 2.0± 0.5 (p < 0.005). Fifteen patients had excellent outcomes, six had good outcomes, two had fair outcomes, and no had poor outcomes, according to the Macnab criteria. Ten of eleven patients had excellent or good outcomes, for an overall success rate of 91.3%. No patients required reoperation. There were no incidental durotomies, infections, vascular or visceral injuries. There was 1 complication, a case of leg numbness caused by ganglion injury. The numbness improved after 3 weeks. After 2 months, it was obvious that the total area of numbness in the legs had become smaller. At last follow-up, the patient had no pain, and only a few areas with numbness remained and did not affect the patient’s activities of daily living. Conclusion:Transforaminal percutaneous endoscopic discectomy achieve satisfactory results for adolescent lumbar disc herniations with posterior ring apophysis separation.

Increased Asymmetry of Trunk, Pelvis, and Hip Motion during Gait in Ambulatory Children with Spina Bifida

Spina bifida (SB) is caused by incomplete neural tube closure and results in multiple impairments, including muscle weakness. The severity of muscle weakness depends on the neurologic lesion level. Though typically symmetric, there can be asymmetries in neurologic lesion level, motor strength, skeletal structures, and body composition that affect patients’ gait and function. Using body segment and joint motion obtained through 3D computerized motion analysis, we evaluated asymmetry and range of motion at the hip, pelvis, and trunk in the frontal and transverse planes during gait in 57 ambulatory children with SB and 48 typically developing controls. Asymmetry and range of hip, pelvis, and trunk motion in the frontal and transverse planes were significantly greater for patients with mid-lumbar and higher level lesions compared with those having sacral/low-lumbar level lesions and controls without disability (p ≤ 0.01). Crutch use decreased asymmetry of trunk rotation in mid-lumbar level patients from 10.5° to 2.6° (p ≤ 0.01). Patients with asymmetric involvement (sacral level on one side and L3-4 on the other) functioned similarly to sacral level patients, suggesting that they may be better categorized using their stronger side rather than their weaker side as is traditional. The information gained from this study may be useful to clinicians when assessing bracing and assistive device needs for patients with asymmetric SB involvement.

Roles of preoperative and early postoperative electrodiagnosis in brachial plexus injury patients undergoing nerve transfer operations: retrospective feasibility study

Objective The purpose of this retrospective observational study was to assess the feasibility of electrodiagnostic parameters, perioperatively, and to discover optimal values as prognostic factors for patients with brachial plexus injury undergoing nerve transfer operations. Methods We retrospectively reviewed the records of 11 patients who underwent nerve transfer surgery. The patients underwent perioperative electrodiagnosis (EDX) before and approximately 6 months after surgery. We evaluated the compound muscle action potential (CMAP) ratio, motor unit recruitment, and their interval changes. To evaluate motor strength, we used the Medical Research Council (MRC) grade, 6 and 12 months after surgery. We evaluated the relationships between improved CMAP ratio, and motor unit recruitment and MRC grade changes 6 and 12 months postoperatively. Results All parameters increased significantly after surgery. The CMAP ratio improvement 6 months after surgery correlated with the MRC grade change from baseline to 12 months, with a correlation coefficient of 0.813. Conclusion EDX parameters improved significantly postoperatively, and the CMAP ratio improvement 6 months after surgery correlated with the clinical outcomes at 1 year. The results of perioperative EDX might help establish long-term treatment plans for patients who undergo nerve transfer surgery.

A developing brain abscess as acute stroke mimic: presentation of case and review of literature

Whether brain abscess is a cause, or a complication of stroke has been a question that elicited differing opinions. We report a case of a child who initially presented with hemiparesis and seizures. Initial brain tomography did not show hemorrhage or infarction. He was managed as a case of childhood stroke. The neurologic manifestations gradually improved until the 17th day of hospitalization when regression of the motor strength and anisocoria occurred. A repeat brain tomography showed multiple masses and vasogenic edema consistent with brain abscess.

Endoscopic Endonasal Transclival Odontoidectomy for Basilar Invagination: Operative Video and Technical Nuances

Basilar invagination is a congenital or acquired craniovertebral junction abnormality where the tip of the odontoid process projects through the foramen magnum which can cause severe symptomatic compression of the brainstem and spinal cord. If left untreated, patients can develop progressive quadriparesis. Traditionally, basilar invagination can be treated with cervical traction and posterior stabilization. However, in irreducible cases, anterior decompression via a transoral or endonasal approach may be necessary. In this operative video, we demonstrate an endoscopic endonasal transclival approach for odontoidectomy to successfully treat a 37-year-old female with severe basilar invagination causing symptomatic compression on the cervicomedullary junction resulting in unsteady gait and motor weakness. The patient had Klippel–Feil syndrome where the C1 arch was assimilated to the foramen magnum and transclival drilling was needed to adequately access the odontoid process for removal. A second-stage posterior occipitocervical stabilization and fusion was performed the following day. Immediate postoperative imaging showed excellent decompression of the cervicomedullary junction. Postoperatively, the patient had significant improvement in gait and motor strength in all extremities, and was ambulating independently without assistance at 1 year after surgery. The endoscopic endonasal transclival odontoidectomy is a useful strategy to treat severe irreducible basilar invagination causing symptomatic neural compression. The surgical technique and nuances are described in a step-by-step fashion in this illustrative operative video.The link to the video can be found at: https://youtu.be/HL4K7KqJEJM.

Dexmedetomidine as an adjunct to local anesthetics in nerve block relieved pain more effectively after TKA: a meta-analysis of randomized controlled trials

Background Dexmedetomidine has shown potential in pain control in patients undergoing total knee arthroplasty (TKA). However, the combination of nerve block and dexmedetomidine may be a preferred alternative for postoperative analgesia after TKA. The aim of this study was to perform a meta-analysis on existing randomized controlled trials (RCTs) to determine the efficacy and safety of dexmedetomidine as an adjunct to local anesthetics in nerve block after TKA. Methods A literature survey was conducted in the databases of PubMed, Embase, Cochrane Library, Web of science, and ScienceDirect for the RCTs completed before February 1st, 2020 that met pre-specified inclusion criteria. The primary outcomes included the pain scores, duration of analgesia, opioid consumption within 24 h postoperatively, and the level of patient satisfaction. The secondary outcomes included the motor strength, degree of sedation, postoperative nausea and vomiting, and other related complications. The methodological quality was assessed by the Cochrane risk of bias tool. Results The initial literature search yielded 143 studies, out of which seven studies met the inclusion criteria. The pooled data indicated that dexmedetomidine combined with local anesthetics in nerve block in TKA decreased the postoperative pain scores at rest as well as at motion (SMD = − 1.01 [95% CI − 1.29 to − 0.72], p < 0.01; SMD = − 1.01 [− 1.25 to − 0.77], p < 0.01) respectively, decreased the total opioid consumption within 24 h (SMD = − 0.63 [− 0.86 to − 0.40], p < 0.01), prolonged the duration of analgesia (SMD = 0.90 [0.64 to 1.17], p < 0.01), improved motor strength (SMD = 0.23 [0.01 to 0.45], p = 0.04), improved the degree of sedation (SMD = 0.94 [0.70 to 1.18], p < 0.01), and increased the level of patient satisfaction (SMD = 0.88 [0.60 to 1.17], p < 0.01) without increasing nausea and vomiting (RD = − 0.05 [− 0.11 to 0.01], p = 0.14), as well as other complications (RD = − 0.01 [− 0.08 to 0.07], p = 0.89), compared with local anesthetics alone. Conclusions It is effective and safe for dexmedetomidine as an adjunct to local anesthetics in nerve block in TKA to relieve postoperative pain, decrease total opioid consumption, prolong analgesic duration, and increase patient satisfaction without increasing related complications. Based on the quality of evidence, this meta-analysis recommends that dexmedetomidine can be used in a regular treatment regimen and as an adjunct addition to local anesthetics in nerve block for patients undergoing TKA. Registration This meta-analysis was prospectively registered on PROSPERO (International prospective register of systematic reviews) and the registering number was CRD42020169171.