Multimodal Analgesic Regimen for Spine Surgery: A Randomized Placebo-controlled Trial.

BACKGROUND: Various multimodal analgesic approaches have been proposed for spine surgery. The authors evaluated the effect of using a combination of four nonopioid analgesics versus placebo on Quality of Recovery, postoperative opioid consumption, and pain scores. METHODS: Adults having multilevel spine surgery who were at high risk for postoperative pain were double-blind randomized to placebos or the combination of single preoperative oral doses of acetaminophen 1,000 mg and gabapentin 600 mg, an infusion of ketamine 5 µg/kg/min throughout surgery, and an infusion of lidocaine 1.5 mg/kg/h intraoperatively and during the initial hour of recovery. Postoperative analgesia included acetaminophen, gabapentin, and opioids. The primary outcome was the Quality of Recovery 15-questionnaire (0 to 150 points, with 15% considered to be a clinically important difference) assessed on the third postoperative day. Secondary outcomes were opioid use in morphine equivalents (with 20% considered to be a clinically important change) and verbal-response pain scores (0 to 10, with a 1-point change considered important) over the initial postoperative 48 h. RESULTS: The trial was stopped early for futility per a priori guidelines. The average duration ± SD of surgery was 5.4 ± 2.1 h. The mean ± SD Quality of Recovery score was 109 ± 25 in the pathway patients (n = 150) versus 109 ± 23 in the placebo group (n = 149); estimated difference in means was 0 (95% CI, -6 to 6, P = 0.920). Pain management within the initial 48 postoperative hours was not superior in analgesic pathway group: 48-h opioid consumption median (Q1, Q3) was 72 (48, 113) mg in the analgesic pathway group and 75 (50, 152) mg in the placebo group, with the difference in medians being -9 (97.5% CI, -23 to 5, P = 0.175) mg. Mean 48-h pain scores were 4.8 ± 1.8 in the analgesic pathway group versus 5.2 ± 1.9 in the placebo group, with the difference in means being -0.4 (97.5% CI; -0.8, 0.1, P = 0.094). CONCLUSIONS: An analgesic pathway based on preoperative acetaminophen and gabapentin, combined with intraoperative infusions of lidocaine and ketamine, did not improve recovery in patients who had multilevel spine surgery.

Perioperative management of intracranial aneurysm and subarachnoid hemorrhage.

Stroke is the third leading cause of death and the leading cause of disability in contemporary society. Aneurysmal subarachnoid hemorrhage (aSAH) is a hemorrhagic stroke which accounts for 7% of all stroke cases and 22 to 25% of cerebrovascular deaths. Aneurysmal subarachnoid hemorrhage is a very complex disease and many controversies on its pathophysiology and management have not yet been settled. The aim of this review is to present the most recent evidence-based advances in the pathophysiology and perioperative management of aSAH.

Surgical briefings, checklists, and the creation of an environment of safety in the neurosurgical intraoperative magnetic resonance imaging suite.

Technological advances have made it possible to seamlessly integrate modern neuroimaging into the neurosurgical operative environment. This integration has introduced many new applications improving surgical treatments. One major addition to the neurosurgical armamentarium is intraoperative navigation and MRI, enabling real-time use during surgery. In the 1970s, the American College of Radiology issued safety guidelines for diagnostic MRI facilities. Until now, however, no such guidelines existed for the MRI-integrated operating room, which is a high-risk zone requiring standardized protocols to ensure the safety of both the patient and the operating room staff. The forces associated with the strong 1.5- and 3.0-T magnets used for MRI are potent and hazardous, creating distinct concerns regarding safety, infection control, and image interpretation. Authors of this paper provide an overview of the intraoperative MRI operating room, safety considerations, and a series of checklists and protocols for maintaining safety in this zero tolerance environment.

Neuronal and axonal loss are selectively linked to fibrillar amyloid-{beta} within plaques of the aged primate cerebral cortex.

The amyloid-beta peptide (Abeta) deposited in plaques in Alzheimer's disease has been shown to cause degeneration of neurons in experimental paradigms in vivo and in vitro. However, it has been difficult to convincingly demonstrate toxicity of native amyloid deposits in the aged and Alzheimer brains. Here we provide evidence that the fibrillar conformation of Abeta (fAbeta) deposited in compact plaques is associated with the pathologies observed in Alzheimer brains. fAbeta containing compact but not diffuse plaques in the aged rhesus cortex contained activated microglia and clusters of phosphorylated tau-positive swollen neurites. Scholl's quantitative analysis revealed that the area adjacent to fAbeta, containing compact but not diffuse plaques in aged rhesus, aged human, and Alzheimer's disease cortex, displays significant loss of neurons and small but statistically significant reduction in the density of cholinergic axons. These observations suggest that fAbeta toxicity may not be restricted to cultured cells and animal injection models. Rather, fAbeta deposited in native compact plaques in aged and AD brains may exert selective toxic effects on its surrounding neural environment.

Endoluminal stent-graft placement for repair of abdominal aortic aneurysms in the community setting.

PURPOSE: To demonstrate that results similar to high-volume academic centers can be achieved in the community setting when treating abdominal aortic aneurysm (AAA) using endovascular techniques, given appropriate volume and skill sets. METHODS: A retrospective review was conducted of 342 consecutive patients who underwent endovascular aneurysm repair (EVAR) by surgeons in a community hospital group from October 1999 through September 2005. In this population, 245 (71.6%) patients were treated with EVAR and 97 (28.4%) with open surgical repair. Of the 245 EVAR patients (203 men; mean age 73.4+/-9.2 years), 218 AneuRx, 19 Ancure, 6 Excluder, and 2 Zenith stent-grafts were implanted by 2 vascular surgeons to exclude AAAs with a mean diameter of 54+/-11 mm. Patients were followed postoperatively with office visits and computed tomography at 1, 6, and 12 months and annually thereafter. RESULTS: Technical success was achieved in 99.6% (244/245) with 1 intraoperative conversion. Mean operative time was 131+/-57 minutes, with a mean contrast load of 161.6+/-65.5 mL. Thirty-five (14.3%) patients required intraoperative blood transfusion. Length of stay was 2.3+/-4.5 days. Thirty-day mortality was 0.8% (2/245). Secondary procedures were required in 15 (6.1%) patients. Kaplan-Meier estimates of freedom from secondary interventions were 98%, 98%, 95%, and 90% at 12, 24, 36, and 48 months, respectively. At the same time points, freedom from surgical conversion was 99%, 99%, 97%, and 96%, and freedom from aneurysm-related death was 97%, 96%, 96%, and 96%. CONCLUSION: Endovascular AAA repair provides a less invasive method of managing aortic disease with resultant low perioperative mortality. Results in our community hospital demonstrate that this technology can be applied outside an academic environment in nearly three quarters of the population with excellent short and long-term results.

Acute encephalopathy with biphasic seizures and late restricted diffusion on MRI in a Japanese child living in the USA.

We report an 18-month-old Japanese female living in the USA whose clinical course and radiographic findings were consistent with acute encephalopathy with biphasic seizures and late reduced diffusion (AESD). She was initially diagnosed with complex febrile seizures. However, on day 3 of admission, she had a cluster of complex partial seizures and the onset of a global developmental regression. In contrast to the normal magnetic resonance image of the brain obtained on admission, subsequent imaging demonstrated transient subcortical diffusion-weighted abnormalities in the white matter of the bilateral posterosuperior frontal, parietal, temporal, and occipital regions, with sparing of the perirolandic area. One year later, her developmental delay, although improved, persisted and she continued to experience sporadic seizures while being treated with topiramate monotherapy. Repeat imaging showed diffuse, poorly defined, increased T2 signals in the white matter of the posterosuperior frontal, parietal, temporal and occipital regions and diffuse cerebral volume loss. Previous reports of AESD have been limited to children aged under 4 years living in Japan. With the identification of this case, it is important that all physicians, not only those in Japan, who care for children with febrile seizures be aware of AESD and its associated neurological morbidity.

Part I: spinal-cord neoplasms-intradural neoplasms.

Intradural spinal-cord tumours are an uncommon but important consideration in the differential diagnosis of patients with back pain, radicular pain, sensorimotor deficits, or sphincter dysfunction. Intradural spinal tumours can be divided into intramedullary and extramedullary spinal-cord tumours on the basis of their anatomical relation to the spinal parenchyma. The heterogeneous cell composition of the intradural compartment allows the formation of neoplasms, arising from glial cells, neurons, and cells of spinal vasculature. Additionally, developmental tumours, metastases, and intradural extension of extradural tumours are represented. In this Review, we discuss the published work on intradural spinal-cord tumours in terms of epidemiological, radiographic, and histological characteristics. Surgical and adjuvant treatment strategies are also reviewed.

Distribution, progression and chemical composition of cortical amyloid-beta deposits in aged rhesus monkeys: similarities to the human.

A comprehensive investigation of the incidence, distribution, progression and chemical composition of Abeta deposits in the brains of two young (5 years) and seven aged (25-30 years) rhesus monkeys was conducted to determine the similarity of this phenomenon to that in the human. The brains of the young rhesus were devoid of Abeta deposits. In contrast, Abeta deposits were observed within the cerebral cortex of all aged animals. In animals with mild Abeta burden, deposits were observed primarily in association cortical zones. In animals with moderate Abeta burden, many paralimbic cortical zones also contained Abeta deposits. Finally, in an animal with a heavy burden of Abeta, core limbic cortical zones were also involved. The primary sensory and motor cortices were relatively free of Abeta deposits. A higher proportion of plaques contained Abeta40 as compared with Abeta42. Abeta deposits contained a number of other constituents. Cholinesterases were present in nearly 50% of plaques and displayed the exact same biochemical characteristics as those in the human. Nearly 20% of Abeta deposits also contained apolipoprotein E and a smaller proportion contained heparin sulfate proteoglycans and alpha1-anti-chymotrypsin. The latter three chemicals were present in many compact plaques. These results indicate that the distribution, progression and chemical composition of plaques in the aged rhesus monkey display many similarities to those observed in the aged human and Alzheimer's disease. Therefore, despite some differences from the human, the aged rhesus may be a good model for studies of the pathological effects of Abeta in the primate brain.

Neonatal subependymal giant cell astrocytoma.

Subependymal giant cell astrocytoma (SEGCA) is a benign, slow-growing glial tumor that manifests with signs and symptoms of obstructive hydrocephalus most often in adolescent patients with tuberous sclerosis complex (TSC). Neonatal highly aggressive SEGCA is very rare. We report a 5-month-old child with TSC presenting with a cystic mass lesion in the left frontal lobe as well as multiple other periventricular masses. After initial conservative treatment, the child was readmitted with intractable seizures, a massive increase in the size of the left frontal lobe tumor and obstructive hydrocephalus. Despite surgical interventions, the child succumbed to the intracranial lesions. In this report, we discuss the challenges of managing SEGCA and the importance of further studies, including genetic studies, that may lead to a better understanding of its pathophysiology.