Posterior implant removal in patients with thoracolumbar spine fractures: long-term results.

PURPOSE: Debate remains whether posterior implants after thoracolumbar spine fracture stabilization should be removed routinely or only in symptomatic cases. Implant related problems might be resolved or even prevented but removal includes secondary risks. The aim of this study was to evaluate safety, patient satisfaction and quality of life after implant removal. METHODS: A retrospective cohort study was performed concerning 102 patients that underwent posterior implant removal after stabilization of a traumatic thoracolumbar fracture between 2003 and 2015. Patients were invited to fill in SF-36, EQ-5D and RMDQ questionnaires after implant removal. Additionally, questions concerning satisfaction were presented. Cobb angles before and after removal were measured and in- or decrease of symptoms was gathered from hospital charts. RESULTS: Mean age at removal was 38 years and time from implant removal to questionnaire was approximately 7 years, 62 patients filled in the questionnaires. Complications were present in 8% and quality of life was reported as fairly good. Patients had less back pain related disability compared to chronic low back pain patients. After removal there was a kyphosis increase which did not correspond with worsened clinical outcome. Removal decreased most symptoms and even asymptomatic patients reported benefit in most cases. An increase of symptoms after removal was reported in 11% of patients. CONCLUSION: Implant removal is generally safe and provides high patient satisfaction. Overall, patients have a fairly good quality of life. Most symptomatic and asymptomatic patients report benefit from removal. However, low risks of complications and increase of symptoms have to be weighted for individual patients.

Comparison of management strategies for extreme prematurity in New Jersey and the Netherlands: outcomes and resource expenditure.

OBJECTIVE: To quantify differences in resource expenditure in the perinatal period and long-term outcome of extremely premature infants who received systematically different approaches to neonatal intensive care. METHODS: Perinatal management, mortality, prevalence of disabling cerebral palsy (DCP), and resource expenditure of 2 population-based inception cohorts of extremely premature infants born in the mid-1980s were compared. Electronic fetal monitoring, tocolysis, cesarean section delivery, and assisted ventilation were used to characterize management approaches. Participants included all live births at 23 to 26 weeks' gestation in a 3-county area of central New Jersey (NJ) from 1984 to 1987 (N = 146) and throughout the Netherlands (NETH) in 1983 (N = 142). Mortality and the prevalence of DCP were the primary outcomes. Numbers of hospital days with and without assisted ventilation were the measures of resource expenditure. RESULTS: Electronic fetal monitoring (100% vs 38%), cesarean section (28% vs 6%), and assisted ventilation (95% vs 64%) were all more commonly used in NJ than in NETH. Ten percent of NJ deaths occurred without assisted ventilation, compared with 45% of Dutch deaths. A total of 1820 ventilator days were expended per 100 live births in NJ, compared with 448 in NETH. The increase in the number of nonventilator days (3174 vs 2265 days per 100 live births) did not reach statistical significance. Survival to age 2 (46 vs 22%) and the prevalence of DCP among survivors (17.2 vs 3.4%) were significantly greater in NJ at age 2 than in NETH at age 5. CONCLUSIONS: Near universal initiation of intensive care in NJ, compared with selective initiation of intensive care in NETH, was associated with 24.1 additional survivors per 100 live births, 7.2 additional cases of DCP per 100 live births, and a cost of 1372 additional ventilator days per 100 live births.

Which Is Better: Simultaneous or Sequential Choice?

The term "diversification bias" refers to the tendency for people to take more variety when choosing several items simultaneously than when choosing them sequentially. In this article, we investigate whether this really is a bias by measuring evaluations of sets chosen simultaneously or sequentially. In Experiment 1 participants made two choices between audio tracks for consecutive consumption. Participants liked low-variety sets most and were more likely to choose high-variety sets in simultaneous choice. In Experiment 2 participants chose between three gambles which varied in the probability of winning and their expected value. Again, simultaneous choices seemed worse than sequential ones: The simultaneous-choice groups took far more low expected value gambles than did sequential-choice subjects and rated their enjoyment as lower. We conclude that simultaneous choice often leads to outcomes that are worse than sequential choice and discuss the circumstances when this is likely to be true.

Value of cranial ultrasound and magnetic resonance imaging in predicting neurodevelopmental outcome in preterm infants.

In this prospective study, cranial ultrasound was performed to detect periventricular-intraventricular hemorrhage and periventricular leukomalacia in 33 preterm infants of less than 32 weeks' gestation. At 44 weeks postmenstrual age magnetic resonance imaging was performed to detect the stage of myelination. Neurodevelopmental outcome was assessed at 3 years of age in 31 children (2 children died in the first year of life). Significant correlations were found between neurodevelopmental outcome and ultrasound findings (chi 2 = 32.8; P less than .0001) and stage of myelination (chi 2 = 20.5; P less than .0005). To establish the criterion with the best predictive factor, multiple regression analysis was performed with outcome as dependent variable and periventricular-intraventricular hemorrhage, periventricular leukomalacia, and stage of myelination as independent variables. It appeared that the detection of periventricular leukomalacia with ultrasound showed the best predictive factor for neurodevelopmental outcome. Routine magnetic resonance imaging at 44 weeks postmenstrual age should not be performed just for the purpose of predicting neurodevelopmental outcome more reliably.

Is it correct to correct? Developmental milestones in 555 "normal" preterm infants compared with term infants.

To determine whether correction for preterm birth should be applied during developmental assessment, we conducted a prospective national survey of very premature infants (born at less than 32 weeks of gestation); neurodevelopment in the first 2 years was studied with the Dutch child health care developmental assessment. In 555 preterm children who had no evidence of handicap at 2 years of age, the age at which developmental milestones were reached was established. The results were compared with the results of the same assessment in Dutch children born at term. During the first year, the development of the very premature children equaled the development of normal children when full correction was applied. At 2 years of age, development was equal to or better than normal children's development without correction. We conclude that full correction for prematurity should be applied in the first year to avoid overreferral for developmental stimulation, whereas at 2 years of age correction is not necessary.

Fetal and neonatal cerebral blood velocity in the normal fetus and neonate: a longitudinal Doppler ultrasound study.

In a longitudinal Doppler ultrasound study fetal and early neonatal cerebral blood flow velocities were assessed in the middle cerebral artery in 40 uncomplicated pregnancies during the third trimester of pregnancy and in 22 neonates born from these pregnancies. Peak systolic (PSFV), temporal mean (TMFV), and end diastolic flow velocities (EDFV) were determined and pulsatility index (PI = (PSFV - EDFV)/TMFV) and Pourcelot's resistance index (RI = (PSFV - EDFV)/PSFV) calculated. PSFV, TMFV and EDFV increased during the third trimester of pregnancy and were significantly higher from 36 weeks of gestation onward as compared to values obtained at 28 weeks of gestation, suggesting an increase in actual cerebral blood flow. PI and RI of the MCA did not differ significantly during this period. Immediately after birth PSFV, TMFV and EDFV decreased significantly and remained lower during the first 5 postnatal days compared to fetal values. PI and RI of the MCA tended to decrease during the first postnatal day, but stabilized afterwards.

Serum CK-BB activity in the preterm infant and outcome at two and four years of age.

The relationship between serum creatine kinase brain-specific isoenzyme (CK-BB) activity immediately after birth and neurodevelopmental outcome at two and four years corrected age was studied prospectively in 45 preterm infants (less than 34 weeks gestation). Nine infants died during the neonatal period and one was lost to follow-up. Of the 35 children available for follow-up, seven had motor disabilities: four severe diplegia, two mild to moderate diplegia and one hemiplegia. No relationship existed between these motor disabilities and serum CK-BB activity after birth. There seemed to be a relationship between increased serum CK-BB after birth and low scores on the Bayley Scales of Mental Development, but this did not reach statistical significance. At the age of four years, four of the five survivors with high serum CK-BB activity after birth (greater than 25U/L) needed special schooling because of mental retardation. Increased serum CK-BB activity after birth may be associated with delayed mental development, but further study is needed, especially of asphyxiated infants.

Neonatal seizures in very preterm and very low birthweight infants: mortality and handicaps at two years of age in a nationwide cohort.

In a nationwide, prospective survey on very preterm and/or very low birthweight infants (less than 32 weeks of gestational age and/or less than 1500 g birthweight) we studied the outcome at the corrected age of two years of children with neonatal seizures. Of the 1338 infants, originally enrolled in the study, 72 had neonatal seizures; of these 44 died and 11 developed a major handicap. Using a multivariate statistical method, a significantly increased risk of death as well as handicap was found in infants with seizures compared to infants without seizures. Nevertheless, 16 of the 28 survivors with neonatal seizures were considered normal at the corrected age of two years.

Neonatal neurological dysfunction in a cohort of very preterm and/or very low birthweight infants--relation to other perinatal factors and outcome at 2 years.

Neonatal neurological dysfunction was found in only a small part of 1192 infants enrolled in an epidemiologic survey on very preterm (less than 32 weeks) and very low birthweight (less than 1500 gram) infants. A routine neurological examination was performed in the neonatal period by the attending paediatrician throughout all levels of care. The incidence of obvious neurological dysfunction was 8.1% and incidence of suspect neurological dysfunction was 6.1%. Multivariate analysis showed that gestational age, birthweight, low Apgar score, IRDS and, most of all, ICH were significantly associated with neonatal neurological dysfunction (N.D.). The mortality rate was very high in obvious and suspect ND infants (81.1% and 35.6% respectively) compared to neurologically normal infants (17.8%). This phenomenon was also found regarding the handicap rate at two years of age. Only 6% (n = 6) of the 96 infants with obvious ND survived without handicap. Using routine physical examination, a quarter of the very preterm or VLBW infants with later neurological disturbances were identified. A more standardized neurological examination, incorporated in the routine examination of newborns in all levels of care, might improve early identification of infants at risk for handicaps.

Prediction of neurodevelopmental outcome in the preterm infant: MR-staged myelination compared with cranial US.

In this prospective study, 26 very preterm infants underwent magnetic resonance (MR) imaging of the brain at 44 weeks postmenstrual age (PMA) for staging of myelination. Neurodevelopmental outcome was assessed at 1 year of age. A significant correlation was demonstrated between delayed myelination and neurodevelopmental outcome (Chi 2 = 16.6, P = .01). A significant correlation was also found between ultrasound (US) findings in the neonatal period and outcome at 1 year (Chi 2 = 22.9, P = .03). To establish the criterion with the best predictive value, a multiple regression analysis was performed with periventricular-intraventricular hemorrhage, periventricular leukomalacia (PVL), and the stage of myelination at 44 weeks PMA as independent variables and neurodevelopmental outcome at 1 year of age as a dependent variable. Staging of myelination with MR imaging in the early postnatal period of very preterm infants had predictive value with regard to neurodevelopmental outcome. Detection of PVL with US, however, showed a better correlation with outcome, a result that seems to limit the potential role of MR imaging in this population for this purpose only.

Does very preterm birth impair myelination of the central nervous system?

Myelination of the central nervous system (CNS) can be demonstrated with magnetic resonance (MR) imaging. Myelin formation may be reduced in conditions of neonatal "undernutrition". Very preterm infants have a reduced postnatal growth rate when compared with intrauterine fetuses of the same gestational age. Using MR imaging, we studied qualitative myelination patterns in healthy preterm infants of less than 30 weeks gestation with an optimal nutritional intake and in term infants at 44 weeks postmenstrual age (PMA). At that age, preterm infants had a significantly lower mean body weight than term infants, but mean head circumference did not differ significantly. All preterm and term infants had reached myelination stage M3 (myelin in brainstem, internal capsule, and corona radiata) and M4 (myelin in brainstem, internal capsule, corona radiata, and centrum semiovale). There was no significant difference in myelination stage between the preterm and term infants. We conclude that adequate nutrition in the neonatal period leads to qualitatively adequate myelination of the CNS in very preterm infants.

Cerebral blood-flow velocity during the first week of life of preterm infants and neurodevelopment at two years.

Disturbances in perinatal cerebral perfusion appear to be associated with unfavourable neurodevelopmental outcome. Using transcutaneous Doppler technique, the authors investigated cerebral blood-flow velocity patterns in the anterior cerebral artery (ACA) of an intensive care-unit population of preterm infants during the first week of life. The results were correlated with neurodevelopmental outcome at two years of age. Children with major disability at two years of age had significantly higher pulsatility index (PI) values, mainly increased peak systolic flow velocity (PSFV), compared with children with normal or more favourable outcome. End diastolic flow velocity and area under the velocity curve values of the ACA did not differ between the groups, indicating that cerebrovascular resistance and cerebral blood-flow were not different. It is thought that the higher PI and PSFV values were caused by increased compliance of the vascular bed supplied by the ACA, possibly induced by congestion and oedema of the periventricular white-matter due to ischaemic lesions, which also cause periventricular leukomalacia.