Association Between Preoperative Midline Shift Growing Rate and Outcomes of Decompressive Craniectomy in Patients with Malignant Middle Cerebral Artery Infarction

Background: Whether preoperative midline shift and its growing rate are associated with outcomes of decompressive craniectomy in patients with malignant middle cerebral artery infarction is unknown. Methods: We retrospectively included patients: 1) who underwent decompressive craniectomy for malignant middle cerebral artery infarction in West China Hospital from August 2010 to December 2, 2018) who had at least two brain computed tomography scans before decompressive craniectomy. Midline shift was measured on the first and last preoperative computed tomography scans. Midline shift growing rate was calculated by dividing Δmidline shift value using Δ time. The primary outcome was inadequate decompression of the mass effect. Secondary outcomes were 3 month death and unfavorable outcomes. Results: Sixty-one patients (mean age 53.7 years, 57.4% (35/61) male) were included. Median time from onset to decompressive craniectomy was 51.8 h (interquartile range: 39.7-77.8). Rates of inadequate decompression, 3 month death, 3 month modified Rankin Scale 5-6 and 4-6 were 50.8% (31/61), 50.9% (29/57), 64.9% (37/57) and 84.2% (48/57), respectively. The inadequate decompression group had a higher midline shift growing rate than the adequate decompression group (median: 2.7 mm/8 h vs. 1.4 mm/8 h, P=0.041). No intergroup difference of 3 month outcomes was found in terms of preoperative midline shift growing rate. Conclusion: Higher preoperative midline shift growing rate was associated with inadequate decompression of decompressive craniectomy in patients with malignant middle cerebral artery infarction.

Spinal Cord Segmentation in Ultrasound Medical Imagery

In this paper, we study and evaluate the task of semantic segmentation of the spinal cord in ultrasound medical imagery. This task is useful for neurosurgeons to analyze the spinal cord movement during and after the laminectomy surgical operation. Laminectomy is performed on patients that suffer from an abnormal pressure made on the spinal cord. The surgeon operates by cutting the bones of the laminae and the intervening ligaments to relieve this pressure. During the surgery, ultrasound waves can pass through the laminectomy area to give real-time exploitable images of the spinal cord. The surgeon uses them to confirm spinal cord decompression or, occasionally, to assess a tumor adjacent to the spinal cord. The Freely pulsating spinal cord is a sign of adequate decompression. To evaluate the semantic segmentation approaches chosen in this study, we constructed two datasets using images collected from 10 different patients performing the laminectomy surgery. We found that the best solution for this task is Fully Convolutional DenseNets if the spinal cord is already in the train set. If the spinal cord does not exist in the train set, U-Net is the best. We also studied the effect of integrating inside both models some deep learning components like Atrous Spatial Pyramid Pooling (ASPP) and Depthwise Separable Convolution (DSC). We added a post-processing step and detailed the configurations to set for both models.

Vertebral artery mobilization for C1–2 reduction and fixation

Craniocervical instability due to chronic atlantoaxial dissociation presents the challenge of providing adequate decompression, reduction, and fixation to promote long-term stability while avoiding iatrogenic vertebral artery dissection or entrapment. The authors present one patient with chronic atlantoaxial dissociation and basilar invagination treated via Goel’s technique and with bilateral vertebral artery mobilization. There was substantial decompression and reduction postoperatively and the patient was discharged with a stable examination. Vertebral artery mobilization at the C1–2 junction can be safely performed via a standard midline suboccipital incision and dissection without vertebral artery injury.The video can be found here: https://youtu.be/VS1Mt1dBLO4.

Acute traumatic thoracolumbar paraspinal compartment syndrome: case report

Although compartment syndrome can occur in any compartment in the body, it rarely occurs in the paraspinal musculature and has therefore only been reported in a few case reports. Despite its rare occurrence, acute paraspinal compartment syndrome has been shown to occur secondary to reperfusion injury and traumatic and atraumatic causes. Diagnosis can be based on clinical examination findings, MRI or CT studies, or through direct measurement of intramuscular pressures. Conservative management should only be used in the setting of chronic presentation. Operative decompression via fasciotomy in cases of acute presentation may improve the patient’s symptoms and outcomes. When treating acute paraspinal compartment syndrome via surgical decompression, an important aspect is the anatomical consideration. Although grouped under one name, each paraspinal muscle is enclosed within its own fascial compartment, all of which must be addressed to achieve an adequate decompression. The authors present the case of a 43-year-old female patient who presented to the emergency department with increasing low-back and flank pain after a fall. Associated sensory deficits in a cutaneous distribution combined with imaging and clinical findings contributed to the diagnosis of acute traumatic paraspinal compartment syndrome. The authors discuss this case and describe their surgical technique for managing acute paraspinal compartment syndrome.

Divergence insufficiency alleviated by posterior fossa decompression with duraplasty in a patient with Chiari type 1.5 malformation

The authors present a case of Chiari type 1.5 malformation with the uncommon presenting symptoms of esotropia and diplopia due to divergence insufficiency in a 12-year-old girl. Imaging at initial diagnosis revealed cerebellar herniation with extension of the tonsils to the C2 vertebral body, a retroflexed odontoid, and a small cervical syrinx. The patient was initially treated with an uncomplicated Chiari malformation decompression without dural opening. Repeat imaging revealed an adequate decompression. Three months postoperatively the patient’s diplopia recurred and she underwent repeat posterior fossa decompression with dural opening and duraplasty. Following repeat decompression with dural opening and duraplasty, the patient’s diplopia had not recurred by the 2-year follow-up.https://thejns.org/doi/abs/10.3171/2018.5.PEDS1886

A study of effect of tarsal tunnel decompression on sensory improvement in diabetic foot: a prospective randomized control trial

Background: In India approximately, 45000 legs are amputated every year and almost 75% of these amputations are carried out in neuropathic feet which are potentially preventable. Diabetic peripheral nerves are at risk of entrapment neuropathies focally, where these nerves are contained in a closed space. The aim of the study was to find out the effect of decompression of compressed posterior tibial nerve and its branches at tarsal tunnel in restoration of sensation in diabetic foot.Methods: A total of 70 diabetic patients with ulcer foot in one limb (test limb) and with no ulcer on the other limb (control limb) were selected for study. The test limb was subjected to tarsal tunnel release. Sensory recovery was evaluated in the ulcer limb and compared with normal limb in same patient and results were evaluated statistically for significance.Results: Present study shows that following tarsal tunnel decompression surgery on test limb, 65 patients (93%) had sensory gain and 5 patients (7%) had documented no sensory gain on test limb, with statistical significance. After de-compressive surgery on the test limb, 69 patients (98.6%) were documented to have resolving of Tinel sign in the test limb with sensory improvement, suggesting adequate decompression and 1 patient (1.4%) was documented to have persistent Tinel sign suggesting possibility of inadequate decompression with no recovery of sensation, with statistical significance.Conclusions: Present study reveals that decompression of tarsal tunnel in diabetic ulcer foot patients leads to definite improvement in sensation of foot which will prevent further ulcer formation and resultant complications ending in amputations.

Surgical treatment of cervical subaxial intraspinal extradural cysts using a full-endoscopic uniportal posterior approach

Purpose: Symptomatic intraspinal extradural cysts of the cervical subaxial spine are rare, but usually require surgery. Conventional posterior decompression is the gold standard. However, there is increasing experience with endoscopic surgical techniques. The purpose of the study is to evaluate the technical implementation and outcomes of a full-endoscopic uniportal technique via the posterior approach in patients with symptomatic intraspinal extradural cysts of the cervical subaxial spine. Methods: Seven consecutive patients with a subaxial location of symptomatic intraspinal extradural cysts were decompressed in a full-endoscopic uniportal technique via the posterior approach between 2009 and 2015. Imaging and clinical data were collected in follow-up examinations for 18 months. Results: In all cases, the cyst was completely removed and adequate decompression was achieved using the full-endoscopic uniportal technique. One patient developed a dural leak that was sutured and covered intraoperatively. No other complications requiring treatment were observed. All patients had a good clinical outcome with stable regression of the radicular and central nerve pain or neurological deficits. The imaging follow-up showed sufficient decompression in all cases. No evidence was found of increasing instability during the follow-up period. Conclusion: The full-endoscopic uniportal operation with a posterior approach allows the resection of the cyst and can minimize trauma and destabilization and has technical benefits and a low complication rate. It is an alternative surgical method that can offer advantages and is considered by the authors to be the surgical technique of choice for cervical subaxial intraspinal extradural cysts.

Peroneal nerve decompression

Peroneal neuropathy is a common pathology encountered by neurosurgeons. Symptoms include pain, numbness, and foot drop. When secondary to compression of the nerve at the fibular head, peroneal (fibular) nerve release is a low-risk procedure that can provide excellent results with pain relief and return of function. In this video, the authors highlight key operative techniques to ensure adequate decompression of the nerve while protecting the 3 major branches, including the superficial peroneal nerve, deep peroneal nerve, and recurrent genicular (articular) branches. Key steps include positioning, circumferential nerve dissection, fascial opening, isolation of the major branches, and closure.The video can be found here: https://youtu.be/0y9oE8w1FIU.

PARTICULARITIES IN TREATMENT OF ESOPHAGEAL PERFORATION AFTER CERVICAL SPINE FUSION EXPERIENCE OF TREATMENT OF 24 PATIENTS

The aim of the study is to specify the causes, peculiarities of the damage and the tactics of treating patients with clinically significant damages to the esophagus after the anterior cervical fusion or in combination with it.Material and methods: medical treatment of 24 patients in Sklifosovsky Emergency Research Institute with the damage to the esophagus after the front access surgery of the cervical spine during the period of 2003-2016 was analyzed.Results: we succeeded to restore or save the support ability of the spine for all patients and at the same time to take away the infected transplants, and, if necessary, to make adequate decompression of neurovascular entities of the spine column and fixation of the verbal-motor segment. 21 patients underwent conserving surgery in the cervical esophagus with its suturing with the double-row suture. 2 patients had failure of seams in the esophagus and they underwent a repeated surgery of suturing its defect. 2 patients underwent organodetrital surgeries. One patient died. Conclusion: damages to the esophagus after anterior cervical fusion or in combination with it are rare complications. That is why it is impossible to gain much experience in treating of such patients in only one clinic. In this case all publications on this topic are of great interest. Due to unsatisfactory results of the conservative therapy we should consider surgical treatment in general hospitals with the participation of a multidisciplinary brigade the golden standard.