Clinical Practice Guideline: The Treatment of Peripheral Nerve Injuries.

BACKGROUND: Nerve lesions often heal incompletely, leading to lifelong functional impairment and high costs for the health care system. The updated German clinical practice guideline is intended to promote the early recognition of nerve lesions and the timely initiation of proper treatment for optimal restoration of function. METHODS: The recommendations are based on an assessment of all the evidence revealed by a systematic search of the literature, as well as on the expertise of the multiprofessional guideline group. RESULTS: Only a few publications contain high-quality evidence. This version of the guideline contains a more detailed discussion of war injuries, iatrogenic injuries, MR neurography, and specific treatments than the previous version. As for the different methods of nerve replacement, a comparison of autologous transplantation versus the use of conduits and tubes revealed no significant difference between these two methods on the mBMRC scale, and minimal superiority of autologous transplantation with respect to two-point discrimination. As for the use of nerve transfers when nerve reconstruction is not feasible or unlikely to succeed, nerve transfer yielded slightly better results than proximal reconstruction for elbow flexion, but the difference did not reach statistical significance (mBMRC ≥ 3: RR 1.16, 95% confidence interval [1.02; 1.32]). The treatment of neuromas with targeted muscle reinnervation was superior to the classic approach in decreasing both stump pain (MD 2.0 +/- 2.8) and phantom limb pain (MD 3.4 +/- 4.03). CONCLUSION: The delayed or improper treatment of peripheral nerve lesions can lead to severe impairment. Timely diagnosis, the use of appropriate treatments in conformity with the guidelines, and interdisciplinary collaboration among specialists are all essential for optimizing the outcome.

Prolonged course of brain edema and neurological recovery in a translational model of decompressive craniectomy after closed head injury in mice.

Background: The use of decompressive craniectomy in traumatic brain injury (TBI) remains a matter of debate. According to the DECRA trial, craniectomy may have a negative impact on functional outcome, while the RescueICP trial revealed a positive effect of surgical decompression, which is evolving over time. This ambivalence of craniectomy has not been studied extensively in controlled laboratory experiments. Objective: The goal of the current study was to investigate the prolonged effects of decompressive craniectomy (both positive and negative) in an animal model. Methods: Male mice were assigned to the following groups: sham, decompressive craniectomy, TBI and TBI followed by craniectomy. The analysis of functional outcome was performed at time points 3d, 7d, 14d and 28d post trauma according to the Neurological Severity Score and Beam Balance Score. At the same time points, magnetic resonance imaging was performed, and brain edema was analyzed. Results: Animals subjected to both trauma and craniectomy presented the exacerbation of the neurological impairment that was apparent mostly in the early course (up to 7d) after injury. Decompressive craniectomy also caused a significant increase in brain edema volume (initially cytotoxic with a secondary shift to vasogenic edema and gliosis). Notably, delayed edema plus gliosis appeared also after decompression even without preceding trauma. Conclusion: In prolonged outcomes, craniectomy applied after closed head injury in mice aggravates posttraumatic brain edema, leading to additional functional impairment. This effect is, however, transient. Treatment options that reduce brain swelling after decompression may accelerate neurological recovery and should be explored in future experiments.

Prevention of thromboembolism in spinal cord injury -S1 guideline.

INTRODUCTION: Traumatic and non-traumatic spinal cord injury bears a high risk for thromboembolism in the first few months after injury. So far, there is no consented guideline regarding diagnostic and prophylactic measures to prevent thromboembolic events in spinal cord injury. Based on a Pubmed research of related original papers and review articles, international guidelines and a survey conducted in German-speaking spinal cord injury centers about best practice prophylactic procedures at each site, a consensus process was initiated, which included spinal cord medicine experts and representatives from medical societies involved in the comprehensive care of spinal cord injury patients. The recommendations comply with the German S3 practice guidelines on prevention of venous thromboembolism. RECOMMENDATIONS: Specific clinical or instrument-based screening methods are not recommended in asymptomatic SCI patients. Based on the severity of neurological dysfunction (motor completeness, ambulatory function) low dose low molecular weight heparins are recommended to be administered up to 24 weeks after injury. Besides, mechanical methods (compression stockings, intermittent pneumatic compression) can be applied. In chronic SCI patients admitted to the hospital, thromboembolism prophylactic measures need to be based on the reason for admission and the necessity for immobilization. CONCLUSIONS: Recommendations for thromboembolism diagnostic and prophylactic measures follow best practice in most spinal cord injury centers. More research evidence needs to be generated to administer more individually tailored risk-adapted prophylactic strategies in the future, which may help to further prevent thromboembolic events without causing major side effects. The present article is a translation of the guideline recently published online (https://www.awmf.org/uploads/tx_szleitlinien/179-015l_S1_Thromboembolieprophylaxe-bei-Querschnittlaehmung_2020-09.pdf).

Time-Multiplexed Illumination for simultaneous Structural and Functional Voltage Sensitive Dye Recordings with a single Photo Sensor.

The in-vivo optical imaging of the cortical surface provides the ability to record different types of biophysiological signals, e.g., structural information, intrinsic signals, like blood oxygenation coupled reflection changes as well as extrinsic properties of voltage sensitive probes, like fluorescent voltage-sensitive dyes. The recorded data sets have very high temporal and spatial resolutions on a meso- to macroscopic scale, which surpass conventional multi-electrode recordings. Both, intrinsic and functional data sets, each provide unique information about temporal and spatial dynamics of cortical functioning, yet have individual drawbacks. To optimize the informational value it would thus be opportune to combine different types of optical imaging in a near simultaneous recording.Due to the low signal-to-noise ratio of voltage-sensitive dyes it is necessary to reduce stray light pollution below the level of the camera's dark noise. It is thus impossible to record full-spectrum optical data sets. We address this problem by a time-multiplexed illumination, bespoke to the utilized voltage sensitive dye, to record an alternating series of intrinsic and extrinsic frames by a high-frequency CMOS sensor. These near simultaneous data series can be used to compare the mutual influence of intrinsic and extrinsic dynamics (with regards to extracorporeal functional imaging) as well as for motion compensation and thus for minimizing frame averaging, which in turn results in increased spatial precision of functional data and in a reduction of necessary experimental data sets (3R principle).

The Microsurgical Treatment of Lumbar Disc Herniation: A Report of 158 Patients With a Mean Follow-up of More Than 32 Years.

STUDY DESIGN: Level 3, cohort study. OBJECTIVE: The aim of this study was to assess long-term clinical outcome, and rate of reoperation following microsurgical subtotal discectomy (MSD). SUMMARY OF BACKGROUND DATA: Lumbar disc herniation (LDH) is a common cause of discomfort. Studies with >25 years of follow-up are rare and the reported rate of clinical success and reoperation are not well understood. METHODS: Retrospectively, files with complete documentation of preoperative and postoperative neurological status, process during hospitalization, detailed report of MSD, outpatient visit notes, and full contact information of patients who underwent MSD for the treatment of LDH with a minimum follow-up of 25 years were reviewed. Patients were contacted for personal follow-up assessment which included Oswestry Disability Index (ODI), EQ-5D, and MacNab criteria, usage of pain medication for leg and back pain, limitations in daily life, and repeated procedures at the lumbar spine. RESULTS: A total of 355 patients were randomly selected and contacted for final follow-up and 158 patients with a mean follow-up 32 years participated in the study. Clinical success rate was 86.0%, mean ODI was 9% (0-58%), 69.6% of the patients were pain free, 13.9% of patients reported the daily intake of pain medication for back and leg pain. Reoperations were performed in 47 of the patients (29.7%), whereas the rate for recurrent disc herniation at the same level was 8.2%. Reoperation within the first 2 years after initial MSD had negative influence on clinical success. The preoperative physical working status and sex and working status had no influence on the clinical success. CONCLUSION: The MSD is an effective technique to achieve a high rate of patient satisfaction, and high rate of functional recovery. The overall reoperation rate is 30% within 30 years but only 8.2% of the patients underwent reoperation because of recurrent disc herniation at the same level. LEVEL OF EVIDENCE: 3.

Brain Edema Formation and Functional Outcome After Surgical Decompression in Murine Closed Head Injury Are Modulated by Acetazolamide Administration.

Acetazolamide (ACZ), carbonic anhydrase inhibitor, has been successfully applied in several neurosurgical conditions for diagnostic or therapeutic purposes. Furthermore, neuroprotective and anti-edematous properties of ACZ have been postulated. However, its use in traumatic brain injury (TBI) is limited, since ACZ-caused vasodilatation according to the Monro-Kellie doctrine may lead to increased intracranial blood volume / raise of intracranial pressure. We hypothesized that these negative effects of ACZ will be reduced or prevented, if the drug is administered after already performed decompression. To test this hypothesis, we used a mouse model of closed head injury (CHI) and decompressive craniectomy (DC). Mice were assigned into following experimental groups: sham, DC, CHI, CHI+ACZ, CHI+DC, and CHI+DC+ACZ (n = 8 each group). 1d and 3d post injury, the neurological function was assessed according to Neurological Severity Score (NSS) and Beam Balance Score (BBS). At the same time points, brain edema was quantified by MRI investigations. Functional impairment and edema volume were compared between groups and over time. Among the animals without skull decompression, the group additionally treated with acetazolamide demonstrated the most severe functional impairment. This pattern was reversed among the mice with decompressive craniectomy: CHI+DC treated but not CHI+DC+ACZ treated animals showed a significant neurological deficit. Accordingly, radiological assessment revealed most severe edema formation in the CHI+DC group while in CHI+DC+ACZ animals, volume of brain edema did not differ from DC-only animals. In our CHI model, the response to acetazolamide treatment varies between animals with decompressive craniectomy and those without surgical treatment. Opening the cranial vault potentially creates an opportunity for acetazolamide to exert its beneficial effects while vasodilatation-related risks are attenuated. Therefore, we recommend further exploration of this potentially beneficial drug in translational research projects.

Imaging of Microhemodynamics in Peripheral Nerves by Contact Endoscope.

BACKGROUND: Entrapment neuropathies include a wide field of locations. In most cases, the microsurgical decompression is still the therapy of choice. However, the role of venous stasis and ischemia is still discussed controversially. Here the authors evaluated the visualization of microvessels and the microperfusion at peripheral nerves with a contact endoscope during the surgical decompression for the first time. METHODS: Eight patients were subjected to endoscopic or endoscopically assisted peripheral nerve decompression. In 3 patients with nerve tumors, the tumor carrying nerve was inspected endoscopically proximal and distal to the tumor site before and after resection. Microcirculation was assessed by a contact endoscope, allowing a 150-fold magnification, at superficial areas proximal and distal to the compression site. The electronically stored records were analyzed retrospectively using image processing software. Vessel diameter, red blood cell velocity, and blood flow, before and after decompression, were extracted. RESULTS: The contact endoscope was easy to handle intraoperatively without problems. All minimally invasive procedures were performed without complications. In the offline computer-assisted analysis, single arterioles and veins were visualized showing decreased red blood cell velocity prior to decompression. After surgical treatment, a statistically significant increase of blood flow was observed. CONCLUSIONS: Basically, the application of a contact endoscope for visualization of peripheral nerves' microcirculation is feasible. The observed effect of increased blood flow after decompression should be compared with the clinical outcome in a further prospective randomized study.

Changes in Posttraumatic Brain Edema in Craniectomy-Selective Brain Hypothermia Model Are Associated With Modulation of Aquaporin-4 Level.

Both hypothermia and decompressive craniectomy have been considered as a treatment for traumatic brain injury. In previous experiments we established a murine model of decompressive craniectomy and we presented attenuated edema formation due to focal brain cooling. Since edema development is regulated via function of water channel proteins, our hypothesis was that the effects of decompressive craniectomy and of hypothermia are associated with a change in aquaporin-4 (AQP4) concentration. Male CD-1 mice were assigned into following groups (n = 5): sham, decompressive craniectomy, trauma, trauma followed by decompressive craniectomy and trauma + decompressive craniectomy followed by focal hypothermia. After 24 h, magnetic resonance imaging with volumetric evaluation of edema and contusion were performed, followed by ELISA analysis of AQP4 concentration in brain homogenates. Additional histopathological analysis of AQP4 immunoreactivity has been performed at more remote time point of 28d. Correlation analysis revealed a relationship between AQP4 level and both volume of edema (r 2 = 0.45, p < 0.01, **) and contusion (r 2 = 0.41, p < 0.01, **) 24 h after injury. Aggregated analysis of AQP4 level (mean ± SEM) presented increased AQP4 concentration in animals subjected to trauma and decompressive craniectomy (52.1 ± 5.2 pg/mL, p = 0.01; *), but not to trauma, decompressive craniectomy and hypothermia (45.3 ± 3.6 pg/mL, p > 0.05; ns) as compared with animals subjected to decompressive craniectomy only (32.8 ± 2.4 pg/mL). However, semiquantitative histopathological analysis at remote time point revealed no significant difference in AQP4 immunoreactivity across the experimental groups. This suggests that AQP4 is involved in early stages of brain edema formation after surgical decompression. The protective effect of selective brain cooling may be related to change in AQP4 response after decompressive craniectomy. The therapeutic potential of this interaction should be further explored.

Clinical outcome following anterior cervical discectomy and fusion with and without anterior cervical plating for the treatment of cervical disc herniation-a 25-year follow-up study.

Extreme long-term clinical outcome studies following anterior cervical discectomy and fusion (ACDF) with an autologous iliac crest with and without Caspar plating (ACDF + CP) for the treatment of radiculopathy caused by cervical disc herniation (CDH) are extremely rare. Hospital records of patients who underwent ACDF or ACDF + CP for the treatment of CDH at least 17 years ago were reviewed. Information about diagnosis, surgery, pre- and postoperative clinical process, and repeated procedure was analyzed. At final follow-up, patients were reviewed with a standardized questionnaire including the current neurological status, Neck Disability Index (NDI), Odom's criteria, a modified EQ-5D, and limitations in quality of life. One hundred twenty-two patients with a mean follow-up of 25 years were evaluated. ACDF was performed in 80 and ACDF + CP in 42 patients, respectively. At final follow-up, 81.1% of patients were free of radicular pain and had no repeated procedure. According to Odom's criteria, 86.1% of good to excellent functional recovery was noted. The mean NDI and EQ-5D was 14% and 5 points, respectively. There was no significant difference in the assessed clinical outcome parameters between patients treated with ACDF and ACDF + CP. The rate for repeated procedure due to degenerative cervical disorders was 10.7 and 7.4% due to symptomatic adjacent segment disease with 25 years. ACDF and ACDF + CP achieved a high rate radicular pain relief (89.3%) and clinical success (86.1%) for the treatment of CDH within a 25 years follow-up. No statistical difference concerning clinical outcome and rate of repeated procedure was detected.

Pyramid approach for the reduction of parallax-related artefacts in optical recordings of moving translucent volumes.

Functional optical imaging (OI) of intrinsic signals (like blood oxygenation coupled reflection changes) and of extrinsic properties of voltage sensitive probes (like voltage-sensitive dyes (VSD)) forms a group of invasive neuroimaging techniques, that possess up to date the highest temporal and spatial resolution on a meso- to macroscopic scale. There are different sources that contribute to the OI signal of which many are noise. In our previous works, we have used dense optical flow for the reduction of movement artefacts. The translucent surface of the cortex allows contributions from multiple depths. Due to the depth offield (DOF) effect, we get an implicit relation of depth and 2D frequency components. In this work, we introduce registration on the levels of a Laplacian pyramid to remove movement artefacts which have different motion components in different spatial frequency bands. This aims to resolve artefacts that remain after normal registration and are caused e.g. by parallax motion, dead pixels or dust on the sensor and other high frequent, moving particles on the cortex surface without the compromise of using high smoothness weights.

Prognosis of pituitary adenomas in the early 1970s and today-Is there a benefit of modern surgical techniques and treatment modalities?

OBJECTIVE: Neurosurgical techniques for the treatment of sellar pathologies have been evolving continuously over the last decades. Additionally to the innovation of approaches and surgical techniques, this progress yielded to the application of modern intraoperative surgical tools as well as peri- and intraoperative imaging. Until now, no long-term analysis of the impact of new therapy concepts on the patient's outcome exists. Aim of this study was to analyse the impact of new operative approaches on perioperative mortality and morbidity as well as the long-term outcome after pituitary surgery. PATIENTS AND METHODS: Three groups of patients were compared in this retrospective analysis of surgically treated pituitary adenomas between the years of 1963 and 2014. Group A contains 93 patients, treated between 1963-1980 with a mean follow-up of 12.1 years (±14.3years), group B comprises 89 patients treated between 1990 and 2000 with a mean follow-up of 10.1 years (±8.1years) and group C consists of 95 patients treated between 2011-2014 with a mean follow-up of 3.4 years (±1.9years). RESULTS: The surgical treatment was performed significantly earlier today on smaller tumors with less preoperative complaints (p<0.01). Panhypopituitarism was detected only in 9.5% of the cases in group C compared to 50.8% in group A (p<0.01). Also, the incidence of revision surgery (5.6 vs. 2% vs 0%), postoperative hemorrhage (10.8% vs. 3.4% vs. 1%) and diabetes insipidus (34.4% vs. 11.2% vs. 5.2%) was decreased (p<0.01). Moreover, a significant postoperative improvement of ophthalmological complaints was detected (p<0.001). The long-term follow-up showed 40% of the entire recurrence rate occurring after the ninth postoperative year. The progression-free survival time increased significantly from group A to group B (p<0.05). CONCLUSIONS: The results demonstrate a benefit of the recent developments of pituitary surgery in the short-term results as well as in the long-term outcome. The prognosis of pituitary adenoma patients could be improved by the introduction of new surgical approaches and techniques in the last decades. Also the perioperative morbidity and mortality rate has been reduced clearly since the 1970s. Furthermore our results emphasise the necessity of lifelong follow-up of all patients with successfully treated pituitary adenomas.

Smith-Robinson procedure with and without Caspar plating as a treatment for cervical spondylotic myelopathy: A 26-year follow-up of 23 patients.

PURPOSE: The purpose of this study was to assess long-term follow-up data after anterior cervical decompression and fusion (ACDF) with and without Caspar plating (ACDF + PS) for the treatment of cervical spondylotic myelopathy (CSM) with special focus on functional outcome, pain, and repeat surgery for adjacent segment disease (ASD). METHOD: Hospital records of 45 patients who were affected by CSM and underwent ACDF or ACDF + PS at least 17 years ago were reviewed. Information about diagnosis, surgical report, pre- and postoperative clinical process, and complications was analyzed. Clinical outcome was assessed using a standardized questionnaire including the Neck Disability Index (NDI), modified JOA-score, Odom's criteria, limitations in quality of life, and questions about the current neurological status and pain. RESULTS: Twenty-three patients with a mean follow-up of 26 years were evaluated. ACDF was performed in nine and ACDF + PS in 14 patients, respectively. At follow-up 78.3% of patients were free of pain, 91.3% had no motor deficit, 73.9% had no sensory deficit, and 60.7% had no gait disturbance. The current mean NDI is 14% (range 2-44%), the mean modified JOA-score was 17.2 (range 15-18). According to Odom's criteria 78.3% of patients had clinical success. In four patients repeat surgery was indicated due to pseudarthrosis or symptomatic ASD (17.4%). CONCLUSIONS: ACDF and ACDF + PS yield significant decrease in neck pain, a significant increase in sensorimotor function and a high rate of clinical success. Patients with preoperative gait disturbance completely recovered in about 60% of cases. Overall prevalence for ASD was 17.4% after 25 years.

Selective Brain Hypothermia Mitigates Brain Damage and Improves Neurological Outcome after Post-Traumatic Decompressive Craniectomy in Mice.

Hypothermia and decompressive craniectomy (DC) have been considered as treatment for traumatic brain injury. The present study investigates whether selective brain hypothermia added to craniectomy could improve neurological outcome after brain trauma. Male CD-1 mice were assigned into the following groups: sham; DC; closed head injury (CHI); CHI followed by craniectomy (CHI+DC); and CHI+DC followed by focal hypothermia (CHI+DC+H). At 24 h post-trauma, animals were subjected to Neurological Severity Score (NSS) test and Beam Balance Score test. At the same time point, magnetic resonance imaging using a 9.4 Tesla scanner and subsequent volumetric evaluation of edema and contusion were performed. Thereafter, the animals were sacrificed and subjected to histopathological analysis. According to NSS, there was a significant impairment among all the groups subjected to trauma. Animals with both trauma and craniectomy performed significantly worse than animals with craniectomy alone. This deleterious effect disappeared when additional hypothermia was applied. BBS was significantly worse in the CHI and CHI+DC groups, but not in the CHI+DC+H group, compared to the sham animals. Edema and contusion volumes were significantly increased in CHI+DC animals, but not in the CHI+DC+H group, compared to the DC group. Histopathological analysis showed that neuronal loss and contusional blossoming could be attenuated by application of selective brain hypothermia. Selective brain cooling applied post-trauma and craniectomy improved neurological function and reduced structural damage and may be therefore an alternative to complication-burdened systemic hypothermia. Clinical studies are recommended in order to explore the potential of this treatment.

Preoperative navigated transcranial magnetic stimulation in patients with motor eloquent lesions with emphasis on metastasis.

Navigated transcranial magnetic stimulation (nTMS) is a frequently used, non-invasive method to map the motor cortex. It is of great value in the preoperative workup of patients that suffer from motor eloquent brain lesions. Here, we present a single-center experience using preoperative nTMS in cortical motor eloquent lesions with emphasis on metastasis. All patients that underwent preoperative nTMS between June 2013 and January 2016 were evaluated. A total of 61 patients underwent nTMS before undergoing surgery for a motor eloquent brain lesion. Patients suffered from cerebral metastasis (23), glioblastoma (16), high grade glioma WHO III (4), low grade glioma WHO II (4), lymphoma (2), meningioma (8), cavernous hemangioma (3), or arteriovenous malformation (1). Thirty patients (49.2%) presented with a preoperative motor deficit. One week after surgery, paresis had resolved or improved in 56.7% of the patients. Out of the patients with postoperative paresis, 89.5% experienced an improvement of motor status at follow-up. All metastatic lesions were completely resected compared to 78.9% of non-metastatic lesions (P = 0.02). Only 4.3% of patients with a metastatic lesion, but 26.3% of patients with a non-metastatic lesion experienced deterioration of motor function after surgery (P = 0.04). Preoperative nTMS is suitable for mapping of a variety of motor eloquent brain lesions resulting in favorable neurological outcome. Particularly in metastatic motor eloquent lesion, motor function appears to be preserved after surgery. Clin. Anat. 29:925-931, 2016. © 2016 Wiley Periodicals, Inc.

Factors Affecting Outcome in Treatment of Chronic Subdural Hematoma in ICU Patients: Impact of Anticoagulation.

BACKGROUND: The use of anticoagulants and older age are the main risk factors for chronic subdural hematoma (CSDH). Because the age of the population and use of anticoagulants are increasing, a growing number of CSDH cases is expected. To address this issue, we analyzed the impact of anticoagulants on postsurgical outcome in patients in the intensive care unit (ICU). METHODS: Demographic data, coagulation parameters, surgical details, radiologic appearance of hematoma, Glasgow Coma Scale (GCS) score on admission, and Glasgow Outcome Scale (GOS) score on discharge were retrieved and retrospectively analyzed in 98 patients with CSDH treated in the neurosurgical ICU using correlation coefficient tests and multivariate analysis test. RESULTS: Overall outcome was good (GOS score 4 and 5) in 55.1% of patients. Overall mortality was 9.1%. There was a correlation between GCS score on admission and GOS score. There was no correlation between hematoma thickness/radiologic appearance and impaired coagulation. Disturbance in thrombocyte function (usually resulting from aspirin intake) correlated with improved outcome, whereas warfarin-related coagulopathy correlated with poor recovery. Nevertheless, patients with thrombocytopathy presented with better initial GCS scores. Neither hematoma size nor recurrence rate affected the outcome. CONCLUSIONS: The size of CSDH was not associated with poor outcome and is not necessarily determined by the use of anticoagulants. Coagulopathy does not rule out a good outcome, but the impact of anticoagulation on treatment results in CSDH varies between the main groups of drugs (warfarin vs. antiplatelet drugs). Patients in good neurologic condition on ICU admission have better chances of recovery.

Smith-Robinson Procedure with an Autologous Iliac Crest for Degenerative Cervical Disc Disease: A 28-Year Follow-Up of 95 Patients.

BACKGROUND: Long-term clinical results after anterior cervical discectomy and fusion (ACDF) with an autologous iliac crest are rare. The purpose of this study was to assess this, with special focus on pain, functional outcome, and repeat surgery for adjacent segment disease (ASD). METHODS: Hospital records of 212 patients who were affected by degenerative cervical disc disease and treated by the Smith-Robinson technique were reviewed. Information about diagnosis, surgery, pre- and postoperative clinical process, and complications was analyzed. Patients were reviewed with a standardized questionnaire including the current neurologic status, Neck Disability Index, EQ-5D, Patient Satisfaction Index, Odom criteria, and limitations in quality of life. RESULTS: Ninety-five patients with a mean follow-up of 28 years were evaluated. ACDF was performed at 1 level in 67 and 2 levels in 28 patients. Ninety-two patients reported pain before surgery and 68 patients remained pain free and did not require second surgery. At follow-up, the mean Neck Disability Index was 14%, and mean EQ-5D score was 5. Postoperatively, 96.8% of patients were satisfied and 84.2% of patients reported good to excellent functional recovery. One patient had a hairline fracture at the iliac crest donor site. Fourteen patients underwent second surgery because of degenerative changes, including 11 at the symptomatic ASD. CONCLUSIONS: ACDF yields significant decrease in pain, a significant increase in function, and a high degree of patient satisfaction. Overall prevalence for ASD was 12.0% after 25 years. Patients with reoperation had similar clinical outcome regarding pain, compared with patients without reoperation.

Smith-Robinson Procedure with an Autologous Iliac Crest Graft and Caspar Plating: Report of 65 Patients with an Average Follow-up of 22 Years.

BACKGROUND: Anterior cervical discectomy and fusion with plate stabilization (ACDF+PS) is an accepted surgical procedure. We sought to evaluate the long-term clinical results of ACDF+PS with a special focus on pain, functional outcome, and adjacent segment disease. METHODS: Retrospectively, 139 patients who underwent ACDF+PS were reviewed with a standardized questionnaire including the current neurologic status, Neck Disability Index, EuroQuol-5 Dimension, Patient Satisfaction Index, Hospital Anxiety and Depression Scale, the Odom criteria, complications at the iliac crest donor side, and limitations in quality of life. RESULTS: Mean follow-up time was 22 years (range: 17-34 years). Sixty five (46.8%) patients were evaluated by completed questionnaires, and 74 (53.2%) did not participate. Forty-six patients attended a physical examination. ACDF+PS were performed at 1 level in 28 patients, at 2 levels in 29 patients, and at 3 levels in 8 patients. Fifty (83.3%) of the patients with preoperative pain remained free of pain and did not require another procedure as the result of degenerative cervical disease. The mean NDI was 14%; according to the Odom criteria 86.2% of patients reported good-to-excellent functional recovery. A total of 100% of patients were satisfied or very satisfied with their outcome and would decide to undergo ACDF+PS again. Two developed adjacent segment disease and needed a second procedure. CONCLUSIONS: ACDF+PS resulted in a significant increase in function, pain relief, and to a high degree of patient satisfaction. The rate for symptomatic adjacent segment disease was 4.5% after 20 years' follow-up.

Decompressive Craniectomy Increases Brain Lesion Volume and Exacerbates Functional Impairment in Closed Head Injury in Mice.

Decompressive craniectomy has been widely used in patients with head trauma. The randomized clinical trial on an early decompression (DECRA) demonstrated that craniectomy did not improve the neurological outcome, in contrast to previous animal experiments. The goal of our study was to analyze the effect of decompressive craniectomy in a murine model of head injury. Male mice were assigned into the following groups: sham, decompressive craniectomy, closed head injury (CHI), and CHI followed by craniectomy. At 24 h post-trauma, animals underwent the Neurological Severity Score test (NSS) and Beam Balance Score test (BBS). At the same time point, magnetic resonance imaging was performed, and volume of edema and contusion was assessed, followed by histopathological analysis. According to NSS, animals undergoing both trauma and craniectomy presented the most severe neurological impairment. Also, balancing time was reduced in this group compared with sham animals. Both edema and contusion volume were increased in the trauma and craniectomy group compared with sham animals. Histopathological analysis showed that all animals that underwent trauma presented substantial neuronal loss. In animals treated with craniectomy after trauma, a massive increase of edema with hemorrhagic transformation of contusion was documented. Decompressive craniectomy applied after closed head injury in mice leads to additional structural and functional impairment. The surgical decompression via craniectomy promotes brain edema formation and contusional blossoming in our model. This additive effect of combined mechanical and surgical trauma may explain the results of the DECRA trial and should be explored further in experiments.

Motion invariant contrast enhancement of optical imaging data in the gradient domain.

Functional optical imaging (OI) of intrinsic signals (like blood oxygenation coupled reflection changes) and of extrinsic properties of voltage sensitive probes (like voltage-sensitive dyes (VSD)) forms a group of neuroimaging techniques that possess up to date highest temporal and spatial resolution on a meso-to macroscopic scale. An inherent problem of OI is a very low signal to noise ratio (SNR), which restricts the recordings to be completely motionless and requires detailed knowledge of the properties of the different noise sources. In our experiments we performed a durectomy and did not use an imaging chamber to allow us future joint electroencephalography-optical imaging (EEG-OI) measures, which resulted in movement artifacts. With the goal of motion compensation in OI recordings and magnification of signal changes, we present a novel processing pipeline, which is based on optic flow guided denoising and gradient domain tone mapping for spatiotemporal contrast enhancement.