Multicenter and prospective trial of anti-epileptics for early seizure prevention in mild traumatic brain injury with a positive computed tomography scan.

Background: Posttraumatic seizures (PTSs) are a major source of disability after traumatic brain injury (TBI). The Brain Trauma Foundation Guidelines recommend prophylactic anti-epileptics (AEDs) for early PTS in severe TBI, but high-quality evidence is lacking in mild TBI. Methods: To determine the benefit of administering prophylactic AEDs, we performed a prospective and multicenter study evaluating consecutive patients who presented to a Level 1 trauma center from January 2017 to December 2020. We included all patients with mild TBI defined as Glasgow Coma Scale (GCS) 13-15 and a positive head computed tomography (CT). Patients were excluded for previous seizure history, current AED use, or a neurosurgical procedure. Patients were given a prophylactic 7-day course of AEDs on a week-on versus week-off basis and followed with in-person clinic visits, in-hospital evaluation, or a validated phone questionnaire. Results: Four hundred and ninety patients were enrolled, 349 (71.2%) had follow-up, and 139 (39.8%) were given prophylactic AEDs. There was no difference between seizure rates for the prophylactic AED group (0.7%) and those without (2.9%; P = 0.25). Patients who had a PTS were on average older (81.4 years) than patients without a seizure (64.8 years; P = 0.02). Seizure rate increased linearly by age groups: <60 years old (0%); 60-70 years old (1.7%); 70-80 years old (2.3%); and >80 years old (4.6%). Conclusion: Prophylactic AEDs did not provide a benefit for PTS reduction in mild TBI patients with a positive CT head scan.

Hemispherotomy for pediatric epilepsy: a systematic review and critical analysis.

PURPOSE: Several variations of functional disconnection surgery have been described for the treatment of lateralized, hemispheric, drug-resistant epilepsy in children. The purpose of this study is to investigate the existing literature regarding patient selection, approach, and outcomes after hemispherotomy. METHODS: A systematic review of the English literature through February 2019 was performed in accordance with the PRISMA statement. The articles were classified by level of evidence and summarized in an evidentiary table. Seizure outcomes, functional outcomes, surgical techniques, complications, and patient selection were critically analyzed. RESULTS: A total of 173 papers were reviewed, of which 37 met criteria of inclusion and exclusion. Thirteen studies were classified as level III evidence, the remaining reached level IV. Vertical and lateral hemispherotomy achieve similar rates of seizure freedom and functional outcomes, though parasagittal and interhemispheric approaches may have shorter operative times and less blood loss. Etiology, bilateral MRI abnormalities, and nonlateralizing EEG did not predict worse seizure or functional outcomes. CONCLUSIONS: Both vertical and lateral hemispherotomy approaches result in durable, reproducible benefits to epilepsy severity and functional status in appropriately selected pediatric patients.

Temporal Profile of Descending Cortical Modulation of Spinal Excitability: Group and Individual-Specific Effects.

Sensorimotor control is modulated through complex interactions between descending corticomotor pathways and ascending sensory inputs. Pairing sub-threshold transcranial magnetic stimulation (TMS) with peripheral nerve stimulation (PNS) modulates the Hoffmann's reflex (H-reflex), providing a neurophysiologic probe into the influence of descending cortical drive on spinal segmental circuits. However, individual variability in the timing and magnitude of H-reflex modulation is poorly understood. Here, we varied the inter-stimulus interval (ISI) between TMS and PNS to systematically manipulate the relative timing of convergence of descending TMS-induced volleys with respect to ascending PNS-induced afferent volleys in the spinal cord to: (1) characterize effective connectivity between the primary motor cortex (M1) and spinal circuits, mediated by both direct, fastest-conducting, and indirect, slower-conducting descending pathways; and (2) compare the effect of individual-specific vs. standard ISIs. Unconditioned and TMS-conditioned H-reflexes (24 different ISIs ranging from -6 to 12 ms) were recorded from the soleus muscle in 10 able-bodied individuals. The magnitude of H-reflex modulation at individualized ISIs (earliest facilitation delay or EFD and individual-specific peak facilitation) was compared with standard ISIs. Our results revealed a significant effect of ISI on H-reflex modulation. ISIs eliciting earliest-onset facilitation (EFD 0 ms) ranged from -3 to -5 ms across individuals. No difference in the magnitude of facilitation was observed at EFD 0 ms vs. a standardized short-interval ISI of -1.5 ms. Peak facilitation occurred at longer ISIs, ranging from +3 to +11 ms. The magnitude of H-reflex facilitation derived using an individual-specific peak facilitation was significantly larger than facilitation observed at a standardized longer-interval ISI of +10 ms. Our results suggest that unique insights can be provided with individual-specific measures of top-down effective connectivity mediated by direct and/or fastest-conducting pathways (indicated by the magnitude of facilitation observed at EFD 0 ms) and other descending pathways that encompass relatively slower and/or indirect connections from M1 to spinal circuits (indicated by peak facilitation and facilitation at longer ISIs). By comprehensively characterizing the temporal profile and inter-individual variability of descending modulation of spinal reflexes, our findings provide methodological guidelines and normative reference values to inform future studies on neurophysiological correlates of the complex array of descending neural connections between M1 and spinal circuits.

Integration of Convergent Sensorimotor Inputs Within Spinal Reflex Circuits in Healthy Adults.

The output from motor neuron pools is influenced by the integration of synaptic inputs originating from descending corticomotor and spinal reflex pathways. In this study, using paired non-invasive brain and peripheral nerve stimulation, we investigated how descending corticomotor pathways influence the physiologic recruitment order of the soleus Hoffmann (H-) reflex. Eleven neurologically unimpaired adults (9 females; mean age 25 ± 3 years) completed an assessment of transcranial magnetic stimulation (TMS)-conditioning of the soleus H-reflex over a range of peripheral nerve stimulation (PNS) intensities. Unconditioned H-reflex recruitment curves were obtained by delivering PNS pulses to the posterior tibial nerve. Subsequently, TMS-conditioned H-reflex recruitment curves were obtained by pairing PNS with subthreshold TMS at short (-1.5 ms) and long (+10 ms) intervals. We evaluated unconditioned and TMS-conditioned H-reflex amplitudes along the ascending limb, peak, and descending limb of the H-reflex recruitment curve. Our results revealed that, for long-interval facilitation, TMS-conditioned H-reflex amplitudes were significantly larger than unconditioned H-reflex amplitudes along the ascending limb and peak of the H-reflex recruitment curve. Additionally, significantly lower PNS intensities were needed to elicit peak H-reflex amplitude (Hmax) for long-interval facilitation compared to unconditioned. These findings suggest that the influence of descending corticomotor pathways, particularly those mediating long-interval facilitation, contribute to changing the recruitment gain of the motor neuron pool, and can inform future methodological protocols for TMS-conditioning of H-reflexes. By characterizing and inducing short-term plasticity in circuitry mediating short- and long-interval TMS-conditioning of H-reflex amplitudes, future studies can investigate supraspinal and spinal circuit contributions to abnormal motor control, as well as develop novel therapeutic targets for neuromodulation.

Systematic review of corpus callosotomy utilizing MRI guided laser interstitial thermal therapy.

Corpus callosotomy is a palliative surgical option for patients with refractory epilepsy and frequent drop attacks, decreasing seizure frequency and severity by disconnecting the cerebral hemispheres. Though often successful, open surgery is not without risk. Corpus callosotomy by MRI-guided laser interstitial thermal therapy (MRgLITT) is a minimally invasive alternative to the standard open procedure. This report aims to present an illustrative case and systematically review the current literature on the surgical technique. A systematic review of the English literature through January 2019 was performed. Articles were searched by title utilizing the following key word combinations: "laser" and "callosotomy", "callosotomy" and "ablation", "laser" and "corpus", "callosotomy" and "thermal", and "stereotactic" and callosotomy". The articles recovered were then classified by level of evidence and summarized. Fifteen papers were reviewed, of which 6 met inclusion and exclusion criteria. All included studies were classified as level IV evidence. There was a total of 13 patients ranging from 13 months to 44 years old (mean 23.5 years old). The number of laser fibers utilized ranged from 1 to 3. Engel class I was achieved in 5 patients, II in 4, III in 2, IV in 1. Reported patient follow up was 4-39.7 months (mean 15.43). Corpus callosotomy utilizing MRI-guided laser interstitial thermal therapy results in improvement in seizure frequency and severity with minimal complications. Prospective trials are needed to compare its seizure control and long-term outcomes to that of standard open callosotomy.

Understanding the electrochemistry of armchair graphene nanoribbons containing nitrogen and oxygen functional groups: DFT calculations.

The surface and edge chemistry are vital points to assess a specific application of graphene and other carbon nanomaterials. Based on first-principles density functional theory, we investigate twenty-four chemical functional groups containing oxygen and nitrogen atoms anchored to the edges of armchair graphene nanoribbons (AGNRs). Results for the band structures, formation energy, band gaps, electronic charge deficit, oxidation energy, reduction energy, and global hydrophilicity index are analyzed. Among the oxygen functional groups, carbonyl, anhydride, quinone, lactone, phenol, ethyl-ester, carboxyl, α-ester-methyl, and methoxy act as electron-withdrawing groups and, conversely, pyrane, pyrone, and ethoxy act as electron-donating groups. In the case of nitrogen-functional groups, amine, N-p-toluidine, ethylamine, pyridine-N-oxide, pyridone, lactam, and pyridinium transfer electrons to the AGNRs. Nitro, amide, and N-ethylamine act as electron-withdrawing groups. The carbonyl and pyridinium group-AGNRs show metallic behavior. The formation energy calculations revealed that AGNRs with pyridinium, amine, pyrane, carbonyl, and phenol are the most stable structures. In terms of the global hydrophilicity index, the quinone and N-ethylamine groups showed the most significant values, suggesting that they are highly efficient in accepting electrons from other chemical species. The oxidation and reduction energies as a function of the ribbon's width are discussed for AGNRs with quinone, hydroquinone, nitro, and nitro + 2H. Besides, we discuss the effect of nitrogen-doping in AGNRs on the oxidation and reduction energies for the quinone and hydroquinone functional groups.

Oxygenated Surface of Carbon Nanotube Sponges: Electroactivity and Magnetic Studies.

We report the synthesis of nitrogen-doped carbon nanotube sponges (N-CNSs) by pyrolysis of solutions of benzylamine, ferrocene, thiophene, and isopropanol-based mixture at 1020 °C for 4 h using an aerosol-assisted chemical vapor deposition system. The precursors were transported through a quartz tube using a dynamic flow of H2/Ar. We characterized the N-CNSs by scanning electron microscopy, transmission electron microscopy, X-ray diffraction, X-ray photoelectron spectroscopy, Fourier transform infrared spectroscopy, Raman spectroscopy, and thermogravimetric analysis. We found that isopropanol, isopropanol-ethanol, and isopropanol-acetone as precursors promote the formation of complex-entangled carbon fibers making knots and junctions. The N-CNSs displayed an outstanding oxygen concentration reaching a value of 9.2% for those synthesized with only isopropanol. We identified oxygen and nitrogen functional groups; in particular, the carbon fibers produced using only isopropanol exhibited a high concentration of ether groups (C-O bonds). This fact suggests the presence of phenols, carboxyl, methoxy, ethoxy, epoxy, and more complex functional groups. Usually, the functionalization of graphitic materials is carried out through aggressive acid treatments; here, we offer an alternative route to produce a superoxygenated surface. The understanding of the chemical surface of these novel materials represents a huge challenge and offers an opportunity to study complex oxygen functional groups different from the conventional quinone, carboxyl, phenols, carbonyl, methoxy, ethoxy, among others. The cyclic voltammetry measurements confirmed the importance of oxygen in N-CNSs, showing that with high oxygen concentration, the highest anodic and cathodic currents are displayed. N-CNSs displayed ferromagnetic behavior with an outstanding saturation magnetization. We envisage that our sponges are promising for anodes in lithium-ion batteries and magnetic sensor devices.

Two Sprayer CVD Synthesis of Nitrogen-doped Carbon Sponge-type Nanomaterials.

Nitrogen-doped carbon sponge-type nanostructures (N-CSTNs) containing coaxial multiwalled carbon nanotubes are synthesized at 1020 °C by using a modified chemical vapor deposition (CVD) arrangement. Here, the CVD reactor is supplied by two flows coming from two independent sprayers (called sprayer A and sprayer B). The nebulized material in each sprayer is transported by two different gases with different flow velocities. The synthesis of carbon N-CSTNs is performed using different precursors: sprayer A contains a solution composed of ethanol, thiophene and ferrocene, whereas sprayer B contains a solution of benzylamine, thiophene and ferrocene. Samples are classified according to the position inside the reactor and characterized by scanning electron microscopy (SEM), transmission electron microscopy (TEM), X-ray diffraction (XRD), X-ray photoelectron spectroscopy (XPS), Raman spectroscopy and thermogravimetric analysis (TGA). Samples collected at the beginning of the reactor contain curly structures with diameters of 10-100 nm. At the end of the reactor, the sample is mainly formed by one type of structure. A spongy-type material is mainly formed in the hottest zone of the tubular furnace. The N-CSTNs are highly hydrophobic with oil sorption properties, which could be used for adsorption of oil spills.

Lumbar Spinous Process Fixation and Fusion: A Systematic Review and Critical Analysis of an Emerging Spinal Technology.

STUDY DESIGN: A systematic review. OBJECTIVE: The available literature on interspinous rigid fixation/fusion devices (IFD) was systematically reviewed to explore the devices' efficacy and complication profile. SUMMARY OF BACKGROUND DATA: The clinical application of new spinal technologies may proceed without well-established evidence, as is the case with IFDs. IFDs are plate-like devices that are attached to the lateral aspects of 2 adjacent spinous processes to promote rigidity at that segment. Despite almost a decade since the devices' introduction, the literature regarding efficacy and safety is sparse. Complications have been reported but no definitive study is known to the authors. METHODS: A systematic review of the past 10 years of English literature was conducted according to PRISMA guidelines. The timeframe was chosen based on publication of the first study containing a modern IFD, the SPIRE, in 2006. All PubMed publications containing MeSH headings or with title or abstract containing any combination of the words "interspinous," "spinous process," "fusion," "fixation," "plate," or "plating" were included. Exclusion criteria consisted of dynamic stabilization devices (X-Stop, DIAM, etc.), cervical spine, pediatrics, and animal models. The articles were blinded to author and journal, assigned a level of evidence by Oxford Centre of Evidence-Based Medicine (OCEBM) criteria, and summarized in an evidentiary table. RESULTS: A total of 293 articles were found in the initial search, of which 15 remained after examination for exclusion criteria. No class I or class II evidence regarding IFDs was found. IFDs have been shown by methodologically flawed and highly biased class III evidence to reduce instability at 1 year, without statistical comparison of complication rates against other treatment modalities. CONCLUSIONS: Although IFDs are heavily marketed and commonly applied in modern practice, data on safety and efficacy are inadequate. The paucity of evidence warrants reexamination of these devices' value and indications by the spine surgery community.

Comparison of hinged and contoured rods for occipitocervical arthrodesis in adults: A clinical study.

INTRODUCTION: A rigid construct that employs an occipital plate and upper cervical screws and rods is the current standard treatment for craniovertebral junction (CVJ) instability. A rod is contoured to accommodate the occipitocervical angle. Fatigue failure has been associated these acute bends. Hinged rod systems have been developed to obviate intraoperative rod contouring. OBJECT: The aim of this study is to determine the safety and efficacy of the hinged rod system in occipitocervical fusion. MATERIALS AND METHODS: This study retrospectively evaluated 39 patients who underwent occipitocervical arthrodesis. Twenty patients were treated with hinged rods versus 19 with contoured rods. Clinical and radiographic data were compared and analyzed. RESULTS: Preoperative and postoperative Nurick and Frankel scores were similar between both groups. The use of allograft, autograft or bone morphogenetic protein was similar in both groups. The average number of levels fused was 4.1 (±2.4) and 3.4 (±2) for hinged and contoured rods, respectively. The operative time, estimated blood loss, and length of stay were similar between both groups. The occiput to C2 angle was similarly maintained in both groups and all patients demonstrated no movement across the CVJ on flexion-extension X-rays during their last follow-up. The average follow-up for the hinged and contoured rod groups was 12.2 months and 15.9 months, respectively. CONCLUSION: Hinged rods provide a safe and effective alternative to contoured rods during occipitocervical arthrodesis.

Spontaneous cerebrospinal fluid leak from an anomalous thoracic nerve root: case report.

The authors report the case of a 28-year-old woman with a spontaneous cerebrospinal fluid leak from the sleeve of a redundant thoracic nerve root. She presented with postural headaches and orthostatic symptoms indicative of intracranial hypotension. CT myelography revealed that the lesion was located at the T-11 nerve root. After failure of conservative management, including blood patches and thrombin glue injections, the patient was successfully treated with surgical decompression and ligation of the duplicate nerve, resulting in full resolution of her orthostatic symptoms.

Management of delayed posttraumatic cervical kyphosis.

We describe three patients with misdiagnosed unstable fractures of the cervical spine, who were treated conservatively and developed kyphotic deformity, myelopathy, and radiculopathy. All three patients were then managed with closed reductions by crown halo traction, followed by instrumented fusions. Their neurologic function was regained without permanent disability in any patient. Unstable fractures of the cervical spine will progress to catastrophic neurologic injuries without surgical fixation. Posttraumatic kyphosis and the delayed reduction of partially healed fracture dislocations by preoperative traction are not well characterized in the subaxial cervical spine. The complete evaluation of any subaxial cervical spine fracture requires CT scanning to assess for bony fractures, and MRI to assess for ligamentous injury. This allows for assessment of the degree of instability and appropriate management. In patients with delayed posttraumatic cervical kyphosis, preoperative closed reduction provided adequate realignment, facilitating subsequent operative stabilization.

The concave versus convex approach for minimally invasive lateral lumbar interbody fusion for thoracolumbar degenerative scoliosis.

We retrospectively reviewed patient charts to compare the approach-related (convex versus concave) neurological complications and magnitude of correction in patients undergoing lateral lumbar interbody fusion (LLIF). It is yet to be quantitatively determined if correction of adult degenerative scoliosis from either side of the curve apex using a LLIF results in a reduction in complications and/or improved corrective ability. The inclusion criteria for this study were patients who underwent a LLIF for adult degenerative thoracolumbar scoliosis and had the LLIF prior to any other supplemental procedures. Patients were grouped based on the approach toward the curve apex concavity (CAVE) or the convexity (VEX). Standard coronal and sagittal radiographic measurements were made. Neurological complications and reoperation indications were also recorded. We included 32 patients for review (CAVE: 17; VEX: 15) with a mean age of 65.5 years±a standard deviation of 10.2, and mean follow-up of 17.0 months±15.7. There were eight postoperative neurological complications in eight patients (25.0%), and seven reoperations for six patients (18.8%; CAVE: 4/17 [23.5%]; VEX: 2/15 [13.3%]). The CAVE group had 6/17 neurological complications (35.3%; four ipsilateral and two contralateral to approach side) and VEX had 2/15 (13.3%; one ipsilateral and one bilateral to approach side; p>0.05). All patients significantly improved in the mean regional and segmental Cobb angles (p<0.05), except for T11-T12 (p>0.05). There were no significant differences between the groups for any of the radiographic parameters measured (p>0.05). Approaching the curve apex from either the concave or convex side resulted in significant improvements. The concave approach was associated with more postoperative neurological complications.

Management of flexion distraction injuries to the thoracolumbar spine.

We present an updated overview of the literature regarding the management of flexion distraction injuries (FDI). FDI are unstable fractures of the thoracolumbar spine, which require surgical management by long segment open fusion or minimally invasive posterior fixation with pedicle screws. While associated with concomitant intra-abdominal injuries that may delay operative stabilization, FDI frequently involve reversible spinal cord injuries and rapid correction is indicated. Modern biomechanical studies have identified valuable prognostic indicators that may be elucidated from determining the mechanism of injury, including the degree of flexion and presence of compression at the time of injury. An improved understanding of FDI will contribute to more appropriate diagnoses and treatment of these fractures.

Anatomy and biomechanics of the craniovertebral junction.

The craniovertebral junction (CVJ) has unique anatomical structures that separate it from the subaxial cervical spine. In addition to housing vital neural and vascular structures, the majority of cranial flexion, extension, and axial rotation is accomplished at the CVJ. A complex combination of osseous and ligamentous supports allow for stability despite a large degree of motion. An understanding of anatomy and biomechanics is essential to effectively evaluate and address the various pathological processes that may affect this region. Therefore, the authors present an up-to-date narrative review of CVJ anatomy, normal and pathological biomechanics, and fixation techniques.

Phylogenetic, expression, and functional analyses of anoctamin homologs in Caenorhabditis elegans.

Ca(2+)-activated Cl(-) channels (CaCCs) are critical to processes such as epithelial transport, membrane excitability, and signal transduction. Anoctamin, or TMEM16, is a family of 10 mammalian transmembrane proteins, 2 of which were recently shown to function as CaCCs. The functions of other family members have not been firmly established, and almost nothing is known about anoctamins in invertebrates. Therefore, we performed a phylogenetic analysis of anoctamins across the animal kingdom and examined the expression and function of anoctamins in the genetically tractable nematode Caenorhabditis elegans. Phylogenetic analyses support five anoctamin clades that are at least as old as the deuterostome/protosome ancestor. This includes a branch containing two Drosophila paralogs that group with mammalian ANO1 and ANO2, the two best characterized CaCCs. We identify two anoctamins in C. elegans (ANOH-1 and ANOH-2) that are also present in basal metazoans. The anoh-1 promoter is active in amphid sensory neurons that detect external chemical and nociceptive cues. Within amphid neurons, ANOH-1::GFP fusion protein is enriched within sensory cilia. RNA interference silencing of anoh-1 reduced avoidance of steep osmotic gradients without disrupting amphid cilia development, chemotaxis, or withdrawal from noxious stimuli, suggesting that ANOH-1 functions in a sensory mode-specific manner. The anoh-2 promoter is active in mechanoreceptive neurons and the spermatheca, but loss of anoh-2 had no effect on motility or brood size. Our study indicates that at least five anoctamin duplicates are evolutionarily ancient and suggests that sensory signaling may be a basal function of the anoctamin protein family.