Peridural scar and its relation to clinical outcome: a randomised study on surgically treated lumbar disc herniation patients

A prospective randomised 2-year follow-up study on patients undergoing lumbar disc herniation surgery. The objective was to investigate the relationship between peridural scarring and clinical outcome, the scar development 6 and 24 months postoperatively by using MRI, and if ADCON-L (a bioresorbable carbohydrate polymer gel) has an effect on scar size and/or improve patients’ outcome after lumbar disc herniation surgery. The association between peridural scarring and recurrent pain after lumbar disc herniation surgery is debated. Numerous materials have been used in attempts to prevent or reduce postoperative peridural scarring; however, there are conflicting data regarding the clinical effects. The study included 119 patients whose mean age was 39 years (18–66); 51 (47%) were women. Sixty patients (56%) were perioperatively randomised to receive ADCON-L, and 48 (44%) served as controls. All patients underwent MRI at 6 and 24 months postoperatively, and an independent radiologist graded the size, location and development of the scar, by using a previously described scoring system. Pre- and 2-year postoperatively patients graded their leg pain on a visual analogue scale (VAS). At the 2-year follow-up patients rated their satisfaction with treatment (subjective outcome) and were evaluated by an independent neurologist (objective outcome), using MacNab score. There was no relationship between size or localisation of the scar and any of the clinical outcomes (VAS, subjective and objective outcome). The scar size decreased between 6 and 24 months in 49%, was unchanged in 42% and increased in 9% of the patients. Patients treated with ADCON-L did not demonstrate any adverse effects, nor did they demonstrate less scarring or better clinical outcome than control patients. No significant association between the presence of extensive peridural scar or localisation of scar formation and clinical outcome could be detected in the present study. Further, no positive or negative effects of ADCON-L used in disc herniation surgery could be seen.     

Serum levels of S100B,S100A1B and S100BB are all related to outcome after severe traumatic brain injury

Summary Objectives. S100B is an established marker of brain damage. Used in the context as a biochemical marker, S100B denotes a measurement of all S100 proteins, including at least one S100B monomer, i.e. the sum of the two dimers S100A1B and S100BB. Almost all published studies are based on this “sum concentration”. However, the brain specificity of S100B has been questioned and increased serum levels have also been reported after trauma without head injury. Since the S100B monomer dominates in the brain, we hypothesised that the S100BB dimer should be better related to outcome after severe traumatic brain injury than S100A1B or the “sum concentration”. Methods. Daily serum samples were collected from 59 patients with severe traumatic brain injury. Three different ELISA methods were used for measurements of S100B, S100A1B and S100BB respectively. Outcome was assessed after one year and categorised according to the Glasgow Outcome Scale. Results. Serum levels of S100B, S100A1B and S100BB followed the same temporal course, with early maximum and rapidly decreasing values over the first days after the trauma. Maximum serum concentrations of each of the parameters were increased in the patient group with an unfavourable outcome compared with those with a favourable outcome (p = 0.01, 0.006 and 0.004, respectively). Conclusion. Both S100A1B and S100BB were related to outcome after severe traumatic brain injury. Even though this study is small, it seems unlikely that separate analyses of the dimers are of any advantage compared with measuring S100B alone. Correspondence: Dr. Karin Nylén, Department of Neurology, Sahlgrenska University Hospital, SE-413 45 G?teborg, Sweden.     

Correlation between clinical outcome of surgically treated clubfeet and different radiological parameters

The goal of this study was to determine the relationship between the clinical outcome of surgically treated clubfeet and several radiological parameters. The talocalcaneal angle, talocalcaneal index, talo-first metatarsal angle and the calcaneo-first metatarsal angle were measured on anteroposterior and lateral radiographs of 54 children with 70 idiopathic clubfeet treated surgically between 2000 and 2004. Their age at surgery ranged from 4 to 23 months. These radiological parameters were compared with the clinical results. Follow-up was conducted after 24 to 69 months following surgery. Using the functional rating system of Laaveg and Ponseti, results were graded as excellent in 28.6% (20 feet), good in 40% (28 feet), fair in 17.1% (12 feet) and poor in 14.3% (10 feet). There was a statistically significant correlation between the clinical results and two angles: the talo-first metatarsal angle on the anteroposterior radiograph and the calcaneao-first metatarsal angle on the lateral radiograph. These two angles should be considered when designing an evaluation system of clubfeet.     

Neurological outcome in surgically treated patients with incomplete closed traumatic cervical spinal cord injury

Study design:Retrospective study based on a reference paper. Neurological outcome in patients who were managed surgically with closed traumatic cervical spine injury was evaluated using the ASIA motor scoring system and Frankel grading.Objectives:To assess the accuracy of motor charting and Frankel grading as tools to evaluate neurological outcome in closed traumatic cervical spine injury, and also to evaluate how the surgically treated patients fared in their neurological recovery by measurement tools as in the reference paper.Setting:National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK.Method:Fifty-seven patients were admitted within 2 days of the injury with closed traumatic cervical spine injuries (1997-2004). Thirty-seven (65%) met the inclusion criteria as per the referenced paper, that is, were treated surgically, were Frankel grade B and above and had at least 12 months follow up. The remaining 20 patients were not included as they did not meet the inclusion criteria. The breakdown of the 20 patients is given in Table 1. The mean recovery percentage (MRP) and mean deficit percentage (MDP) were calculated as per the referenced paper.Results:An evaluation of 37 patients surgically treated, who had follow up of at least 12 months, showed that preservation of pin prick below the level of lesion, and preservation of anal tone and perianal sensation were good prognostic indicators. There was no correlation between degree of encroachment of canal or the degree of kyphosis to MDP or MRP. The mean time from injury to mobilization was 7.6 days in 25 out of 37 patients. Twelve of the 37 patients had prolonged immobilization because of ITU stay or because they were initially treated conservatively. Three out of the 37 patients developed DVT/PE. Mean hospital stay was 6.4 months.Conclusion:The neurological outcome in surgically treated patients is comparable to the conservatively treated patients. The Frankel grading and ASIA motor charting combined is a powerful tool in assessing the neurological outcome in closed traumatic cervical spinal injured patients. Until now there has been no evidence to suggest that the obvious advantages of surgical management of closed cervical spine injuries (better alignment, easier manual handling and early mobilization) is traded for poorer neurological outcome.Spinal Cord (2008) 46, 603-607; doi:10.1038/sc.2008.29; published online 13 May 2008.     

Early cardiorespiratory findings after severe blunt thoracic trauma and their relation to outcome.

This study examined the initial haemodynamic and oxygen transport patterns in 24 patients with severe blunt thoracic trauma in whom immediate monitoring with femoral and pulmonary artery catheters was required after admission to the intensive care unit. All patients required mechanical ventilation and were studied before receiving inhalational anaesthesia and within 12 h of injury. Two groups of patients were identified; nine patients (group 1) had an impaired left ventricular stroke work index (LVSWI) and 15 patients had a normal LVSWI (group 2). There were no significant differences in the abbreviated injury scale score for the chest, the total injury severity score, or the mean ages of the two groups. There were significant differences in stroke volume index, 32 versus 56 ml m-2 (P less than 0.001), and cardiac index, 3.2 versus 5.3 l min-1 m-2 (P less than 0.001), and therefore in oxygen delivery, 469 versus 852 ml min-1 m-2 (P less than 0.001), despite apparently adequate volume expansion using the same protocol and clinical criteria in both groups. Oxygen consumption was not significantly different in the two groups, 135 versus 157 ml min-1 m-2, because of a higher oxygen extraction ratio in group 1, 29 versus 19 per cent (P less than 0.001), and hence lower mixed venous oxygen saturation, 73 versus 82 per cent (P less than 0.02). Seven patients in group 1 died (78 per cent) compared with two in group 2 (13 per cent). Early depression of cardiac function is associated with poor outcome in patients with thoracic trauma, and measurements of oxygen transport variables may influence resuscitation and the timing of surgical procedures.     

Management and outcomes in 353 surgically treated sciatic nerve lesions

OBJECT: This is a retrospective analysis of 353 surgically treated sciatic nerve lesions in which injury mechanisms, location, time to surgical repair, surgical techniques, and functional outcomes are reported. Results are presented to provide guidelines for management of these injuries. METHODS: One hundred seventy-five patients with buttock-level and 178 with thigh-level sciatic nerve injury were surgically treated at the Louisiana State University Health Sciences Center between 1968 and 1999. Buttock-level injury mechanisms included injection in 64 patients, hip fracture/dislocation in 26, contusion in 22, compression in 19, gunshot wound (GSW) in 17, hip arthroplasty in 15, and laceration in 12; at the thigh level, GSW was the cause in 62 patients, femoral fracture in 34, laceration in 32, contusion in 28, compression in 12, and iatrogenic injury in 10. Patients with sciatic nerve divisions in which positive intraoperative nerve action potentials (NAPs) were found underwent neurolysis and attained at least Grade 3 functional outcomes in 108 (87%) of 124 and in 91 (96%) of 95 buttock- and thigh-level tibial divisions, respectively, compared with 84 (71%) of 119 and 75 (79%) of 95, respectively, in the peroneal divisions. For suture repair, recovery to at least Grade 3 occurred in eight (73%) of 11 buttock-level and in 27 (93%) of 29 thigh-level tibial division injuries, and in three (30%) of 10 buttock-level and 20 (69%) of 29 thigh-level peroneal division lesions. For graft repair, good recovery occurred in 21 (62%) of 34 and in 43 (80%) of 54 buttock- and thigh-level tibial divisions, respectively, even in proximal repairs requiring long grafts, and in only nine (24%) of 37 and 22 (45%) of 49 buttock- and thigh-level peroneal division lesions, respectively. CONCLUSIONS: Surgical exploration and neurolysis after positive NAP readings, or repair with sutures or grafts after negative NAP results are worthwhile in selected cases.     

Significance of serial S100b and NSE serum measurements in surgically treated patients with spondylotic cervical myelopathy

Background  

Predicting functional outcome following surgery performed for spinal cord compression is still a considerable problem. Recent observations, though, strongly suggest that with serial measurements of serum S100b, this might be possible in patients with subacute spinal cord compression. The aim of this study was to examine whether this potential significance of S100b applies as well to patients with spondylotic cervical myelopathy. A further purpose was to assess the value of NSE in this regard, another biochemical marker widely used to monitor cerebral lesions.     

Muscle energy stores in relation to clinical findings and outcome in acute arterial ischaemia of the lower leg

Forty-two patients (mean age 79 years) with acute ischaemia of one leg were evaluated in a prospective study. Forty-nine percent of the patients suffered from embolism, 29% from thrombosis while the etiology was uncertain in 22%. In 30 of the ischaemic legs and in 21 contralateral non-ischaemic legs the muscle energy metabolic status (ATP, ADP, AMP, ECP, PC, Cr and lactate) from the gastrocnemius muscle was measured and compared to values obtained from 24 healthy age-matched controls. There was a high degree of energy metabolic impairment in the ischaemic legs. Furthermore, the contralateral non-ischaemic legs were also energy depleted in comparison with those of the healthy controls. Legs with thrombosis were more energy-deprived than legs with embolism. Clinical evaluation of the degree of ischaemia and the level of occlusion correlated with energy metabolic parameters but the duration of ischaemia did not. The degree of metabolic impairment had no prognostic implication for the clinical outcome.     

SIOOB protein and its clinical effect on craniocerebra injury

Objective： To explore the role of S100B protein in the early diagnosis, treatment, and prognosis judgement of craniocerebral injury.
Methods： In this study, we reviewed the domestic and foreign research reports about the relationship between S100B protein and craniocerebral injury.
Results： The concentration of S100B protein had a different increase based on the degree of injury in early stage after craniocerebral injury, and the increasing degree of S100B protein showed a positive correlation with the grading of pathogenetic condition and prognosis of craniocerebral injury.
Conclusions： S100B protein may be taken as a specific index of early diagnosis, grading of pathogenetic condition, and prognosis judgement after craniocerebral injury. To grasp and regulate the mechanism of neurotoxicity and to elucidate the therapeutic effect of S100B protein will be a research direction in clinical treatment of craniocerebral injury.     

Correlation of clinical and pathological features in surgically treated craniopharyngiomas

Surgical specimens of 104 craniopharyngiomas from 93 patients were reviewed and characterized histopathologically. They were found to have either a classic adamantinous or a squamous papillary structure. The clinical features of each group were then assessed. The frequently solid (50%), always uncalcified squamous papillary tumor type was found in one-third of the adult patients (greater than or equal to 20 years) but did not occur in children. It was associated with a good functional postoperative outcome (84.6%). There have been no cases of tumor recurrence in the squamous papillary group. However, in the group with the adamantinous type of craniopharyngioma, the recurrence rate was 13% in adult patients and 9% in children. When compared to the adult adamantinous cases, the incidence of visual deficits was lower in the squamous papillary group (75% vs. 84%) but the incidence of endocrine abnormalities was higher (75% vs. 52%). Thus, the preoperative, operative, and postoperative features of the two types of craniopharyngioma were found to be distinctly different in adults and children.     

Infantile craniosynostosis: Clinical,radiological, and surgical considerations based on 100 surgically treated cases

Summary One hundred children affected by craniosynostosis were operated on from January 1952 to February 1977.Forty-six patients were operated on within the first year of life, and only 9 after six years of age.In 27 cases only one cranial suture was synostotic (mostly the coronal: 15 cases). In 36 cases two sutures were involved (mostly coronal plus sagittal: 25 cases). In 28 cases all the cranial sutures were involved. Also included in this series are seven cases of Crouzon's, one of Apert's, and one of Carpenter's syndromes. The clinical, radiological, and surgical features of this condition are discussed, and the long-term results are reported.     

CT复查结果与腰椎管狭窄症疗效的关系

目的：评价腰椎管狭窄症术后的临床表现、CT检查结果以及两者之间的内在联系。方法：对102例患者行术后CT检查,根据检查结果将其分为无狭窄、中央性狭窄、侧方性狭窄和混合性狭窄4组。术后腰椎不稳通过动力性X线摄片观察分析,手术效果由临床检查评价。结果：CT检查显示102例中术后有狭窄者为66例,占65％。各组间术后临床表现、疼痛程度以及影像学不稳等无明显差异。结论：腰椎管狭窄症术后影像学狭窄现象较普遍,但该狭窄与术后临床效果并无明显关系。     

The influence of perioperative soft tissue complications on the clinical outcome in surgically treated ankle fractures.

The influence of perioperative soft tissue complications on the functional outcome after open reduction and internal fixation of closed ankle fractures was investigated. Eighty-eight consecutive patients were followed 3.7 years (SD +/- 0.6) after the injury. Two major and 21 minor soft tissue complications were registered. Average dorsal extension was 29.9 degrees (range four to 54, SD +/- 9.5) of the fractured ankles and 37.2 degrees (range eight to 60, SD +/- 9.1) of the non-fractured ankles. The average subjective functional score was 84.6 (range 40 to 100, SD +/- 14.9). A significant difference was found with respect to the subjective functional score (p = 0.048, Kruskal-Wallis test) but not with respect to dorsal extension (0.358, Kruskal-Wallis test) when comparing groups of minor, major and no soft tissue complications. This study suggests that major soft tissue complications have a negative effect on the long-term functional outcome after surgical repair of an ankle fracture. Minor soft tissue complications, primary skin problems, the timing of primary surgery and fracture types according to AO/ASIF have no or minor influence on the long-term functional result. This study confirms previous reports that the presence of osteoarthritis is frequently associated with a reduced functional outcome.     

GFAP versus S100B in serum after traumatic brain injury: relationship to brain damage and outcome

Research indicates that glial fibrillary acidic protein (GFAP), part of the astroglial skeleton, could be a marker of traumatic brain injury (TBI). S100B, an astroglial protein, is an acknowledged marker of TBI. Our goal was to analyze the relationship of GFAP/S100B to brain damage and outcome, and to compare the accuracy of GFAP/S100B for prediction of mortality after TBI. Our prospective study included 92 patients admitted <12 h after TBI (median injury severity score 25, median Glasgow Coma Scale 6). TBI was verfied by computerized tomography. GFAP/S100B were measured immunoluminometrically at admission and daily in the intensive care unit (average 10 days, range 1-21 days). We compared GFAP/S100B in non-survivors versus survivors, accuracy for mortality prediction according to receiver operated characteristic curve analysis, correlation between GFAP and S100B, relationship of GFAP/S100B to computerized tomography, cerebral perfusion pressure (CPP), mean arterial pressure (MAP) and 3-month Glasgow Outcome Score (GOS). GFAP (p < 0.005) and S100B (p < 0.0005) were higher in non-survivors than survivors. Both GFAP and S100B were accurate for mortality prediction (area under curve 0.84 versus 0.78 at <12 h after TBI). GFAP and S100B release correlated better later than 36 h after TBI (r = 0.75) than earlier (r = 0.58). GFAP was lower in focal lesions of <25 mL than in shifts of >0.5 cm (p < 0.0005) and non-evacuated mass lesions of >25 mL (p < 0.005). S100B was lower in focal lesions of <25 mL than in non-evacuated mass lesions (p < 0.0005) and lower in swelling than in shifts of >0.5 cm (p < 0.005). GFAP and S100B were lower in ICP < 25 than ICP > or = 25 (p < 0.0005), in CPP > or = 60 than CPP < 60 (p < 0.0005), in MAP > 70 than MAP < or = 70 mm Hg, and in GOS 4-5 than GOS 1 (p < 0.0005). Both measurement of GFAP and S100B is a useful non-invasive means of identifying brain damage with some differences based on the pattern of TBI and accompanying multiple trauma and/or shock.     

Ultrastructural findings in human spinal pia mater in relation to subarachnoid anesthesia

We examined ultrastructural details such as the cellular component and membrane thickness of human spinal pia mater with the aim of determining whether fenestrations are present. We hypothesized that pia mater is not a continuous membrane but, instead, that there are fenestrations across the pial cellular membrane. The lumbar dural sac from 7 fresh human cadavers was removed, and samples from lumbar spinal pia mater were studied by special staining techniques, immunohistochemistry, and transmission and scanning electron microscopy. A pial layer made by flat overlapping cells and subpial tissue was identified. We found fenestrations in samples from human spinal pia mater at the thoracic-lumbar junction, conus medullaris, and nerve root levels, but these fenestrations did not appear at the thoracic level. We speculate whether the presence of fenestrations in human spinal pia mater at the level of the lumbar spinal cord and at the nerve root levels has any influence on the transfer of local anesthetics across this membrane. IMPLICATIONS: The ultrastructural anatomy of the human pia mater, such as pial cells, membrane thickness, and subpial tissue at different levels of the thoracic and lumbar spinal cord and nerve roots, was studied by special staining techniques, immunohistochemistry, and transmission and scanning electron microscopy. Fenestrations were found in samples at the thoracic-lumbar junction, conus medullaris, and nerve root levels. No fenestrations were found in samples at the thoracic level. At present, we cannot determine the significance of these findings.     

Radiological abnormalities in children with asthma and their relation to the clinical findings and some respiratory function tests

Criteria are put forward for the recognition and assessment of radiographic abnormalities in childhood asthma. Using these criteria, radiographs of the chest in 218 children with asthma are compared with those of 162 normal children. In 73% of the asthmatic children the radiograph appeared to be normal, 15% presented a simple overinflation pattern with long narrow lungs and a narrow vertical heart (0-1 pattern), and 12% showed the same pattern together with enlargement of the hilar vessels relative to the lung vessels (0-2 pattern). Those children with the most marked radiographic abnormalities (0-2 pattern) were, without exception, suffering from severe or moderately severe constant asthma. Those with intermittent symptoms usually had radiographs which appeared to be normal even during their asthmatic episodes.     

Correlation between clinical, arthrographic and arthroscopic findings in meniscal lesions

There are many different references about the accuracy of physical examination and arthrographic exploration in diagnosing meniscal tears. Therefore we analysed retrospectively 334 arthroscopic examinations, which were done because of a suspected or a proven meniscal lesion. We found an accuracy of 84% true-positives and true-negatives with regard to the physical examination and an accuracy of only 71.2% with regard to the arthrographic investigation. Our results were converted into a formula (stated in [11]), declaring the predictive value of a result. These findings led us to a certain scheme in diagnosing meniscal or other knee pain, presented here.