Detection of alphaII-spectrin and breakdown products in humans after severe traumatic brain injury.

AIM: alphaII-Spectrin is the major structural component of the cortical membrane cytoskeleton. It is a major substrate for the calpain and caspase-3 cysteine proteases there are considerable evidence that alfaII-spectrin is processed by the calpains and caspase-3 to signature cleavage products in vivo after experimental traumatic brain injury (TBI). We sought to determine whether aII-spectrin proteolysis is a potentially reliable biomarker for TBI in humans measuring the levels of spectrin and spectrin breakdown products (SBDPs) in cerebrospinal fluid (CSF) from adults with severe TBI, and studying the relationship between these levels and clinical outcome. METHODS: This prospective case control study enrolled 8 patients with severe TBI, defined by a Glasgow Coma Score (GCS) of <8, and requiring intraventricular pressure monitoring. Patients without TBI requiring CSF drainage served as controls. Ventricular CSF was drained from each patient at 6, 12, 24, 48, 72, and 96 h following TBI and measured for spectrin and SBDPs. Outcome was assessed using the Glasgow Outcome Score (GOS) 6 months after injury. RESULTS: CSF alphaII-spectrin and calpain and caspase-3 mediated SBDP levels were significantly increased compared to control patients at all time points examined (P<0.001). In patients with a better outcome, CSF spectrin and SBDPs significantly decreased from 6 to 96 h. Patients whose spectrin and SBDP levels remained elevated or failed to decline had a worse outcome (P<0.019). CONCLUSIONS: The present work provides the first evidence that protein degradation of alphaII-spectrin is a reliable marker of severe TBI in humans and that both necrotic and apoptotic cell death mechanisms are activated in humans following a severe TBI. Moreover, the temporal profile of degradation may be an important indicator of clinical outcome.

Does early decompression improve neurological outcome of spinal cord injured patients? Appraisal of the literature using a meta-analytical approach.

STUDY DESIGN: Definitive and unequivocal evidence to support the practice of early or late surgery is still lacking in clinical studies. Accordingly, meta-analysis is one of the few methods that offer a rational, statistical approach to management decision. A review of the clinical literature on spinal cord injury with emphasis on the role of early surgical decompression and a meta-analysis of results was performed. OBJECTIVES: To determine whether neurological outcome is improved in traumatic spinal cord-injured patients who had surgery within 24 h as compared with those who had late surgery or conservative treatment. METHODS: A Medline search covering the period 1966-2000, supplemented with manual search, was used to locate studies containing information on indication, rationale and timing of surgical decompression after spinal cord injuries. The analysis included a total of 1687 eligible patients. RESULTS: Statistically, early decompression resulted in better outcome compared with both conservative (P<0.001) and late management (P<0.001). Nevertheless, analysis of homogeneity showed that only data regarding patients with incomplete neurological deficits who had early surgery were reliable. CONCLUSIONS: Although statistically the percentage of patients with incomplete neurological deficits improving after early decompression appear 89.7% (95% confidence interval: 83.9, 95.5%), to be better than with the other modes of treatment when taking into consideration the material available for analysis and the various other factors including clinical limitations; early surgical decompression can only be considered as practice option for all groups of patients.

Traumatic acute subdural haematomas of the posterior fossa: clinicoradiological analysis of 24 patients.

BACKGROUND: We report 24 patients with a traumatic acute subdural haematoma of the posterior fossa managed between 1997 and 1999 at 8 Italian neurosurgical centres. METHOD: Each centre provided data about patients' clinico-radiological findings, management, and outcomes, which were retrospectively reviewed. FINDINGS: A poor result occurred in 14 patients (58.3%). Ten patients (41.7%) had favourable results. Patients were divided into two groups according to their admission Glasgow Coma Scale (GCS) scores. In Group 1 (12/24 cases; GCS score, > or =8), the outcome was favourable in 75% of cases. In Group 2 (12/12 cases; GCS score, <8), the outcome was poor in 91.6% of cases. Nineteen patients underwent posterior fossa surgery. Factors correlating to outcome were GCS score, status of the basal cisterns and the fourth ventricle, and the presence of supratentorial hydrocephalus. Multivariate analysis showed significant independent prognostic effect only for GCS score (P<0.05). INTERPRETATION: acute posterior fossa subdural haematomas can be divided into two distinct groups: those patients admitted in a comatose state and those with a moderate/mild head injury on admission. Comatose patients present usually with signs of posterior fossa mass effect and have a high percentage of bad outcomes. On the contrary, patients admitted with a GCS of 8 or higher are expected to recover. In these patients the thickness of the haematoma (<1 cm) seems to be a guide to indicate surgical evacuation of the haematoma.

Role of inflammation in the secondary injury following experimental spinal cord trauma.

AIM: The primary traumatic mechanical injury to the spinal cord causes the death of a number of neurons that cannot be recovered, neither regenerated. However, neurons continue to die for hours after spinal cord injury (SCI), and this represents a potentially avoidable event. One of mechanisms that have been touted to contribute importantly to the evolution of such secondary cell death is the local inflammatory response in the injured spinal cord. In this report we have used an in vivo model to induce acute SCI and reproduce the acute pathological events associated with inflammation after traumatic SCI in rats. METHODS: Twenty-two adult male Sprague-Dawley rats were used in the study. SCI was produced by extradural clip compression at T5-T9 level. The rats spinal cord was analysed at 1 hour to measure the malonildialdehyde (MDA) levels considered an index of lipid peroxidation. At 4 hours were measured the levels of myeloperoxidase (MPO) activity considered as the index of leukocytes activity. Finally the spinal cord was extracted 12 hours after the trauma to measure the cytoplasmatic levels of IkB-a considered as the index of activity of the transcriptional factor nuclear factor-kB (NF-kB). RESULTS: After the SCI, both the levels of MDA and MPO were significantly higher compared with naive and sham-operated rats (p=0.01). Western blotting analysis demonstrated the disappearance of IkB-alpha in the cytoplasm indicating nuclear translocation of the NF-kB. CONCLUSION: The study confirms the role of inflammation in contributing to the secondary injury after experimental SCI in the rat.

Assistance of intraoperative microvascular Doppler in the surgical obliteration of spinal dural arteriovenous fistula: cases description and technical considerations.

BACKGROUND: Intraoperative microvascular Doppler may be valuable in assisting in the surgical obliteration of dural arteriovenous fistula of the spinal cord. It enables identification, through flow spectrum analysis, of the anatomic components and haemodynamic features of this type of vascular malformation. METHODS: In two cases, intraoperative microvascular Doppler was used to assist in the surgical obliteration of dural arteriovenous fistula of the spinal cord. The fistulas were identified prior to the dura opening, and for this only minimally invasive surgery was required. Direct recordings of the arterialised draining vein and the nidus of the fistula demonstrated a pathological spectrum caused by the arterial supply and the disturbed venous outflow in which a high-resistance flow pattern and low diastolic flow resembling an arterial-like flow velocity were observed. FINDINGS: The fistulas were obliterated by interruption of the draining vein, and Doppler measurements provided information on flow velocity changes in the medullary veins from an arterial to a venous pattern. The absence of any residual flow in the draining vein confirmed successful haemodynamic treatment. INTERPRETATION: Intraoperative microvascular Doppler recording is valuable assistance in surgical closure of spinal arteriovenous fistula.

Traumatic intracerebellar hemorrhagic contusions and hematomas.

BACKGROUND: Traumatic intracerebellar hemorrhagic contusions and hematomas (TIHC) are unusual lesions and their surgical management remains controversial. METHODS: From January 1990 to July, 1998, 3290 patients underwent computed tomography for acute head trauma at our Institution. Eighteen patients (0.54%) were retrospectively identified as harboring TIHC. Patients were divided into two groups. In Group I (n=78) GCS at admission was > or = 9. Seven patients presented with isolated TIHC and one with an associated supratentorial lesion. Three patients exhibited an evolving clinico-radiological course. In Group II patients (n=10) GCS at admission was < or = 7. All but one presented with severe supratentorial lesions and associated brainstem signs. RESULTS: In group I six patients had their TIHC managed conservatively, and two were operated on, and all recovered completely. In group II, two patients were operated on. The outcome was poor in 90% of cases. CONCLUSIONS: TIHC constitute a protean clinico-pathological entity. Non-comatose patients with intracerebellar clots less than 3 cm in diameter should be treated conservatively and expected to make a good recovery. Surgery is indicated for larger hematomas causing cisternal and IV ventricle compression ab initio or as a result of their secondary evolution. In severely ill patients admitted comatose, it is generally the primary brain stem damage and the concomitant severe supratentorial lesions to dictate the prognosis. In these cases obliteration of the posterior fossa cisterns is the most reliable indicator of poor outcome.

Posterior fusion compared with posterior interbody fusion in segmental spinal fixation for adult spondylolisthesis.

OBJECT: Clinical and radiographic results in 30 consecutive patients who underwent posterior lumbar fixation and posterior facet joint or posterior interbody fusion for Meyerding Grade II/III spondylolisthesis were assessed: 1) to address the suitability of a dynamic stabilization; and 2) to investigate whether there are differences in terms of clinical and functional results and biomechanical properties between these two types of arthrodesis. METHODS: Between June 1998 and April 2000, 16 patients underwent posterior interfacet fusion and implantation of the SOCON-SRI system. In 14 patients posterior lumbar interbody fusion (PLIF) and placement of the same system were performed. Clinical, economic, functional, and radiographic data were recorded pre- and postoperatively. The average changes in the Prolo Scale economic and functional scores were 1.25 and 1.62, respectively, in patients who underwent posterior fusion; the average measured preoperative vertebral slippage was 47.8% (range 30-65%), and postoperatively it was 18.5% (range 15-25%). In patients in whom PLIF was performed, the average changes in economic and functional score were 1.21 and 1.36, respectively, and the average preoperative vertebral slippage was 43.5% (range 30-55%) compared with 20% (range 15-25%) postoperatively. CONCLUSIONS: The use of a segmental pedicle screw fixation with the SOCON-SRI system successfully combines the goal of solid fusion with the requirements of nerve root decompression. When the two fusion techniques were compared, an overall superior reliability and resistance of the systems was associated with the PLIF procedure (p = 0.04) but clinical outcomes did not differ greatly (p < 0.05).

Intraoperative microvascular Doppler monitoring of blood flow within a spinal dural arteriovenous fistula: a precious surgical tool. Case report.

The authors describe a case of spinal arteriovenous fistula (AVF) treated by a microvascular Doppler-assisted surgical interruption of the arterialized vein. Microvascular Doppler monitoring represents a valid, widely available, noninvasive tool that enables identification, through flow spectrum analysis, of components of this type of vascular malformation. In this case because the location of the fistula was identified prior to opening the dura only minimally invasive surgery was required. Direct recordings of the arterialized draining vein and the nidus of the fistula demonstrated a pathological spectrum caused by the arterial supply and the disturbed venous outflow in which a high-resistance flow pattern and low diastolic flow resembling an arterial-like flow velocity were observed. The fistula was obliterated by interruption of the draining vein, and Doppler measurements provided information on flow velocity changes in the medullary veins from an arterial to a venous pattern. The absence of any residual flow in the AVF confirmed successful hemodynamic treatment. Intraoperative microvascular Doppler recording during surgical closure of spinal AVF is a widely available and reliable monitoring modality that helps to produce excellent clinical results.

Magnetic resonance imaging-monitored conservative management of traumatic spinal epidural hematomas. Report of four cases.

Spinal epidural hematomas (SEHs) are uncommon complications of traumatic injury to the spine. Emergency surgical evacuation is the standard treatment. Although it is recognized in the literature, the possibility of nonsurgical treatment of traumatic SEH is far from being codified. The authors report excellent outcomes in four conservatively managed patients who had sustained a severe spine injury with fracture of the lumbar vertebral body and in whom traumatic SEHs were diagnosed by magnetic resonance imaging. Although in the authors' experience a good spontaneous outcome in this subgroup of minimally symptomatic patients harboring moderate-sized SEHs has been achieved, further studies are necessary to understand the real spectrum of nonsurgical treatment of such lesions.