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In a trial comparing decompressive craniectomy with medical therapy in patients with traumatic brain injury and raised intracranial pressure refractory to medical therapy, decompressive craniectomy resulted in lower mortality and higher rates of vegetative state and severe disability. After traumatic brain injury (TBI), intracranial pressure can be elevated owing to a mass effect from intracranial hematomas, contusions, diffuse brain swelling, or hydrocephalus. 1 Intracranial hypertension can lead to brain ischemia by reducing the cerebral perfusion pressure. 2 Intracranial hypertension after TBI is associated with an increased risk of death in most studies. 3 , 4 The monitoring of intracranial pressure and the administration of interventions to lower intracranial pressure are routinely used in patients with TBI, despite the lack of level 1 evidence. 5 Decompressive craniectomy is a surgical procedure in which a large section of the skull is removed and the underlying . . .

Background The surgical management of cervical brachialgia utilising anterior cervical discectomy and fusion (ACDF) or posterior cervical foraminotomy (PCF) is a controversial area in spinal surgery. Previous studies are limited by utilisation of non-validated outcome measures and, importantly, absence of pre-operative analysis to ensure both groups are matched. The authors aimed to compare the effectiveness of ACDF and PCF using validated outcome measures. To our knowledge, it is the first study in the literature to do this. Methods The authors conducted a 5-year retrospective review (2008–2013) of outcomes following both the above procedures and also compared the effectiveness of both techniques. Patients with myelopathy and large central discs were excluded. The main outcome variables measured were the neck disability index (NDI) and visual analogue scores (VAS) for neck and arm pain pre-operatively and again at 2-year follow-up. The Wilcoxon signed-rank test and Student t -tests were used to test differences. Results A total of 150 ACDFs and 51 PCFs were performed for brachialgia. There was no differences in the pre-operative NDI, VAS neck and arm scores between both groups ( p  > 0.05). As expected, both ACDF and PCF delivered statistically significant improvement in NDI, VAS-neck and VAS-arm scores. The degree of improvement of NDI, VAS-neck and VAS-arm were the same between both groups of patients ( p  > 0.05) with a trend favouring the PCF group. In the ACDF group, two (1.3 %) patients needed repeat ACDF due to adjacent segment disease. One patient (0.7 %) needed further decompression via a foraminotomy. In the PCF group one (2.0 %) patient needed ACDF due to persistent brachialgia. Conclusions We found both interventions delivered similar improvements in the VAS and NDI scores in patients. Both techniques may be appropriately utilised when treating a patient with cervical brachialgia.

Bacterial and viral infectious triggers are linked to spondyloarthritis (SpA) including psoriatic arthritis (PsA) development, likely dendritic cell activation. We investigated spinal entheseal plasmacytoid dendritic cells (pDCs) toll-like receptor (TLR)-7 and 9 activation and therapeutic modulation, including JAK inhibition. We also investigated if COVID-19 infection, a potent TLR-7 stimulator triggered PsA flares. Normal entheseal pDCs were characterized and stimulated with imiquimod and CpG oligodeoxynucleotides (ODN) to evaluate TNF and IFNα production. NanoString gene expression assay of total pDCs RNA was performed pre- and post- ODN stimulation. Pharmacological inhibition of induced IFNα protein was performed with Tofacitinib and PDE4 inhibition. The impact of SARS-CoV2 viral infection on PsA flares was evaluated. CD45+HLA-DR+CD123+CD303+CD11c- entheseal pDCs were more numerous than blood pDCs (1.9 ± 0.8% vs 0.2 ± 0.07% of CD45+ cells, p=0.008) and showed inducible IFNα and TNF protein following ODN/imiquimod stimulation and were the sole entheseal IFNα producers. NanoString data identified 11 significantly upregulated differentially expressed genes (DEGs) including TNF in stimulated pDCs. Canonical pathway analysis revealed activation of dendritic cell maturation, NF-κB signaling, toll-like receptor signaling and JAK/STAT signaling pathways following ODN stimulation. Both tofacitinib and PDE4i strongly attenuated ODN induced IFNα. DAPSA scores elevations occurred in 18 PsA cases with SARS-CoV2 infection (9.7 ± 4 pre-infection and 35.3 ± 7.5 during infection). Entheseal pDCs link microbes to TNF/IFNα production. SARS-CoV-2 infection is associated with PsA Flares and JAK inhibition suppressed activated entheseal plasmacytoid dendritic Type-1 interferon responses as pointers towards a novel mechanism of PsA and SpA-related arthropathy.

An early-stage, multi-centre, prospective, randomised control trial with five-year follow-up was approved by Health Research Authority to compare the efficacy of a minimally invasive, laterally implanted interspinous fixation device (IFD) to open direct surgical decompression in treating lumbar spinal stenosis (LSS). Two-year results are presented. Forty-eight participants were randomly assigned to IFD or decompression. Primary study endpoints included changes from baseline at 8-weeks, 6, 12 and 24-months follow-ups for leg pain (visual analogue scale, VAS), back pain (VAS), disability (Oswestry Disability Index, ODI), LSS physical function (Zurich Claudication Questionnaire), distance walked in five minutes and number of repetitions of sitting-to-standing in one minute. Secondary study endpoints included patient and clinician global impression of change, adverse events, reoperations, operating parameters, and fusion rate. Both treatment groups demonstrated statistically significant improvements in mean leg pain, back pain, ODI disability, LSS physical function, walking distance and sitting-to-standing repetitions compared to baseline over 24 months. Mean reduction of ODI from baseline levels was between 35% and 56% for IFD (p<0.002), and 49% to 55% for decompression (p<0.001) for all follow-up time points. Mean reduction of IFD group leg pain was between 57% and 78% for all time points (p<0.001), with 72% to 94% of participants having at least 30% reduction of leg pain from 8-weeks through 24-months. Walking distance for the IFD group increased from 66% to 94% and sitting-to-standing repetitions increased from 44% to 64% for all follow-up time points. Blood loss was 88% less in the IFD group (p=0.024) and operating time parameters strongly favoured IFD compared to decompression (p<0.001). An 89% fusion rate was assessed in a subset of IFD participants. There were no intraoperative device issues or re-operations in the IFD group, and only one healed and non-symptomatic spinous process fracture observed within 24 months. Despite a low number of participants in the IFD group, the study demonstrated successful two-year safety and clinical outcomes for the IFD with significant operation-related advantages compared to surgical decompression.

Abstract BACKGROUND: Artificial cervical disk replacements are commonly used to treat radiculomyelopathy caused by degenerative disk disease. However, long-term disk mobility and an effect on adjacent segment disease have yet to be demonstrated. We report improvements in clinical outcome after disk replacement but also demonstrate potential limitations. OBJECTIVE: To review clinical and radiological outcomes after diskectomy and disk replacement with the Porous Coated Motion (PCM) artificial cervical disk. METHODS: A retrospective review was done of consecutive patients who underwent 1- or 2-level PCM disk replacements. The following criteria were studied: arm pain, neck pain, Neck Disability Index and Short Form-36 questionnaires, and flexion-extension radiographs up to 2 years after surgery. RESULTS: Eighty PCM artificial disks were implanted in 53 patients. Only 17 disks (21%) maintained physiological movement, and complete fusion was seen in 18.8%. One disk replacement was revised because of anterior displacement. There were no complications of infection, cerebrospinal fluid leak, dysphagia, or hoarse voice. Arm and neck pain improved significantly after diskectomy, but Neck Disability Index questionnaires demonstrated a slight improvement that was not sustained by 2 years. Short Form-36 scores demonstrated a trend toward better outcome with time, but it was significant only for the mental domain. CONCLUSION: Clinical improvement was seen after PCM disk replacement, but adequate range of movement was sustained in only 21% of disk replacements over time. Unclear long-term results of this and other disk replacements suggest caution in adopting these new devices as the gold standard.

BackgroundSpine pedicle screw insertion is technically demanding, with potentially serious risks if screws are misplaced, and an established learning curve of approximately 70 screws placed before there is a significant reduction in screw misplacement. Despite this most units continue to teach screw insertion for the first time in live surgery, both in the UK and worldwide. This study was a single blinded comparison of cadaver types to simulate screw insertion.MethodologyThree cadaver types – Thiel, Crosado and Formaldehyde were positioned prone and a posterior approach to the spine performed. The spines were all exposed by a single surgeon. Experienced spinal surgeons placed screws in each cadaver type sequentially and gave feedback on the tissue quality and feel using a modified Likert scale.ResultsThiel cadavers rated most highly for soft tissue feel and appearance with a median score of 6. Crosado cadavers rated most highly for bony properties, with a median score of 6. Formaldehyde cadavers rated poorly for soft tissue feel, appearance and bony qualities with median scores of 2, 2.5 and 3.5 respectively.ConclusionsThere is a strong argument that pedicle screw insertion should be taught away from the operating theatre but this will have significant cost implications. Cadaveric screw simulation offers the most realistic simulation, with Thiel and Crosado cadavers both rating highly for their properties. Further work is now needed on a larger scale to further explore this valuable resource in surgical training.ReferencesBergeson RK, Schwend RM, DeLucia T, Silva SR, Smith JE, Avilucea FR. How accurately do novice surgeons place thoracic pedicle screws with the free hand technique? Spine 2008;33(15):E501–7Gonzalvo A, Fitt G, Liew S, et al. The learning curve of pedicle screw placement: how many screws are enough? Spine 2009;34(21):E761–5Gautschi OP, Schatlo B, Schaller K, Tessitore E. Clinically relevant complications related to pedicle screw placement in thoracolumbar surgery and their management: a literature review of 35,630 pedicle screws. Neurosurg Focus 2011;31(4):E8

Case report. To report an unusual case of cauda equina syndrome following penetrating injury to the lumbar spine by wooden fragments and to stress the importance of early magnetic resonance imaging (MRI) in similar cases. A 22-year-old girl accidentally landed on wooden bannister and sustained a laceration to her back. She complained of back pain but had fully intact neurological function. The laceration in her back was explored and four large wooden pieces were removed. However 72 h later, she developed cauda equina syndrome. MRI demonstrated the presence of a foreign body between second and third lumbar spinal levels following which she underwent emergency decompressive laminectomy and the removal of the multiple wooden fragments that had penetrated the dura. Post-operatively motor function in her lower limbs returned to normal but she continued to require a catheter for incontinence. At review 6 months later, she was mobilising independently but the incontinence remained unchanged. There are no reported cases in the literature of wooden fragments penetrating the dura from the back with or without the progression to cauda equina syndrome. The need for a high degree of suspicion and an early MRI scan to localise any embedded wooden fragments that may be separate from the site of laceration is emphasized even if initial neurology is intact.

Revised UK guidelines from the National Institute for Health and Clinical Excellence (NICE) for the management of acute head injury address the initial management and triage/ Evidence has also shown that even patients who have sustained a minor head injury have difficulty reintegrating into society.5 Thus, management of head injury is an important topic. The principles for the triage of patients with head injuries were set out in the Royal College of Surgeons' report in 2005.11 This report and the Scottish Intercollegiate Guidelines Network6 were largely based on clinical risk factors and the presence of a skull fracture radiograph.15 This approach resulted in about 5% of patients (about 50000 patients per year in the UK) with head injury proceeding to a CT scan.

Background and purposeAnterior lumbar approaches are recommended for clinical conditions that require interbody stability, spinal deformity corrections or a large fusion area. Anterior lumbar interbody fusion in lateral decubitus position (LatALIF) has gained progressive interest in the last years.The study aims to describe the current habit, the perception of safety and the perceptions of need of vascular surgeons according to experienced spine surgeons by comparing LatALIF to the standard L5-S1 supine ALIF (SupALIF).MethodsA two-round Delphi method study was conducted to assess the consensus, within expert spine surgeons, regarding the perception of safety, the preoperative planning, the complications management and the need for vascular surgeons by performing anterior approaches (SupALIF vs LatALIF).ResultsA total of 14 experts voluntary were involved in the survey. From 82 sentences voted in the first round, a consensus was reached for 38 items. This included the feasibility of safe LatALIF without systematic involvement of vascular surgeon for routine cases (while for revision cases the involvement of the vascular surgeon is an appropriate option) and the appropriateness of standard MRI to evaluate the accessibility of the vascular window. Thirteen sentences reached the final consensus in the second round, whereas no consensus was reached for the remaining 20 statements.ConclusionsThe Delphi study collected the consensus on several points, such as the consolidated required experience on anterior approaches, the accurate study of vascular anatomy with MRI, the management of complications and the significant reduction of the surgical times of the LatALIF if compared to SupALIF in combined procedures. Furthermore, the study group agrees that LatALIF can be performed without the need for a vascular surgeon in routine cases.

Post-traumatic epilepsy (PTE) is a recurrent seizure disorder secondary to brain injury following head trauma. PTE is not a homogeneous condition and can appear several years after the head injury. The mechanism by which trauma to the brain tissue leads to recurrent seizures is unknown. Cortical lesions seem important in the genesis of the epileptic activity, and early seizures are likely to have a different pathogenesis than late seizures. Anti-epileptic drugs available for treatment are phenytoin, sodium valproate, and carbamazepine. Newer anti-epileptics are helpful, particularly in patients with associated post-traumatic stress disorders; however, no randomized controlled studies are available to prove that one of these drugs is better than the other. Current evidence is that the treatment of early post-traumatic seizures does not influence the incidence of post-traumatic epilepsy. Routine preventive anticonvulsants are not indicated for patients with head injuries, and treatment in the acute phase does not reduce death or disability rates.