Prognostic Factors in Patients with Severe Head Injury

OBJECTIVE: To elucidate the problems that must be dealt with in the prognosis of patients with severe head injury and to find out the prognosis factors related to severe head injury. METHODS: A clinical analysis was carried out retrospectively with 292cases of severe head- injured patients (Glasgow coma scale score 3-8) admitted to the our department for 10 years from January 1987 to December 1996. RESULTS: Patients who were classified as having severe brain injury belonged to 13.1% of all craniocerebral trauma cases among which sixty-three cases had diffuse brain injury. The causes of head injuries were motor vehicle accident, falls from heights, bicycle and other causes in order of frequency. Pediatric patients showed better outcome(51.4%), compared with only 28.1% of all adult cases(p<0.0001). The patients with high initial GCS score(6-8, 47.9%) had significantly better outcome than the patients with low initial GCS socre(3-5, 16.9%) (p<0.0001). Fifty point three percents of patients with good motor response had good outcome, whereas only 15.8 percent in patients with poor motor response. The cases with diffuse head injury without basal cistern compression had significantly higher percentage of good outcome(74.0%) than those with basal cistern compression(16.9%, p<0.0001). The cases with normal pupillary reaction had significantly higher percentage of good outcome(50.3%) than those with bilateral oculomotor nerve palsy(18.4%, p<0.0001). The patients with skull fracture had good outcome(48.1%), compare to 20.3% of patients without skull fracture(p<0.0017). CONCLUSION: The good prognostic factors in this study were young age, initial high Glasgow coma scale, good motor response, diffuse brain injury type I, II, bilaterally intact light reflex, with skull fracture. Individual prognostic factor is significant to indicate the patient's outcome and may be utilized for assessing the relative efficacy of the alternative treatment and prognosis.

Clinical Evaluation of Anterolateral Surgical Decompression and Instrumentation in Thoracolumbar Bursting Fracture

The authors report clinical results of fifty-two traumatic thoracolumbar bburstfractures treated by internal fixation with Kaneda device after anterior decompression during recent six years. The burst fractures occurred most frequently at the age of twenties and thirties. The main causes of injury were vehicle accident and fall.In all cases, spinal decompression, internal instrumet fixation and bone fusion(rib, iliac bone) were performed. No patient showed neurological deterioration after surgery and almost all patients improved post operatively by on grade of Frankel's(classification). Thirty-three patients(85%) with Denis type I and II showed the correction of the fracture deformities with good bony fusion and 9 of 13 patients(70%) with Denis type IV showed bony fusion in serial follow-up. It if thus concluded that anterolateral internal fixation combined with bony fusion provide good mechanical stability and decompression of protruding ventral bone fragments above conus medullaris level.

Radioisotope Cisternographic Analysis of Post-operative Subdural Hygroma after Aneurysmal Surgery

Authors analyzed the post-operative subdural hygroma using radioisotope(RI) cisternography in 30 cases following aneurysmal surgery with pterional approach from October, 1995 to March, 1996. Age, CSF flow from basal cisterns, and etent of opening of Liliequist's membrane during operation were significantly related to the development of post-operative subdural hygroma. Computed tomography(CT) scan of brain and RI cisternography were performed in all patients at three weeks following operations. RI diffusion time from the interpeduncular cistern to the cerebral convexity of ipsilateral side with surgically opened Liliequist's membrane was compared with contralateral nonoperated normal side. Diffusion time of ipsilateral side(mean 5.2+/-8.4hr) was faster than that of contralateral one. Age, cerebrospinal fluid(CSF) from basal cistern, and extent of opening of Liliequist's membrane during operation were significantly related to development of post-operative subdural hygroma. Development of subdural hygroma after pterional approach for aneurysmal operations in our series is believed to be caused by stagnation of CSF in the convexity until its absorption into the arachnoid villi. Increased CSF flow from the infratentorial space to the supratentorial space through extensively opened Liliequist's membrane is considered to contribute development of its formation.

Comparative Analysis of Results by Operative Approaches for Thoracolumbar or Lumbar Fractures

A retrospective study of 100 cases with thoracolumbar fractures was performed to compare the results from different surgical approaches and to provide a guide line for surgical treatment. Fifty-three patients were operated through anterior approach and forty-two patients were through posterior approach. All patients were evaluated according to changes in the following parameters: kyphotic angles, compression heights, degrees of canal compromise, neurologic deficits, pain levels, delayed kyphosis and complications. There were no significant differences in kyphotic angles, compression heights, degrees of canal compromise, neurologic deficits, and pain levels between two approaches. Delayed kyphosis occurred in one(2.4%) of 42 cases treated by posterior approach and six(11.3%) of 53 cases treated by anterior approach. Dural lacerations were noted in fourteen(43.8%) of 32 cases associated with lamina fractures and were repaired in all of nine cases approached posteriorly but none of five cases approached anteriorly. In conclusion, posterior approach is simple, less extensive, is associated with lower incidence of delayed kyphosis and better dural repair than the anterior approach. Posterior approach could be, therefore, considered initially for those cases where surgery is indicated for thoracolumbar or lumbar fractures.