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Ketan Verma, Anne H. Freelin, Kelsey A. Atkinson, Robert S. Graham, and William C. Broaddus

OBJECTIVE

The aim of this study was to assess whether flat bed rest for > 24 hours after an incidental durotomy improves patient outcome or is a risk factor for medical and wound complications and longer hospital stay.

METHODS

Medical records of consecutive patients undergoing thoracic and lumbar decompression procedures from 2010 to 2020 were reviewed. Operative notes and progress notes were reviewed and searched to identify patients in whom incidental durotomies occurred. The need for revision surgery related to CSF leak or wound infection was recorded. The duration of bed rest, length of hospital stay, and complications (pulmonary, gastrointestinal, urinary, and wound) were recorded. The rates of complications were compared with regard to the duration of bed rest (≤ 24 hours vs > 24 hours).

RESULTS

A total of 420 incidental durotomies were identified, indicating a rate of 6.7% in the patient population. Of the 420 patients, 361 underwent primary repair of the dura; 254 patients were prescribed bed rest ≤ 24 hours, and 107 patients were prescribed bed rest > 24 hours. There was no statistically significant difference in the need for revision surgery (7.87% vs 8.41%, p = 0.86) between the two groups, but wound complications were increased in the prolonged bed rest group (8.66% vs 15.89%, p = 0.043). The average length of stay for patients with bed rest ≤ 24 hours was 4.47 ± 3.64 days versus 7.24 ± 4.23 days for patients with bed rest > 24 hours (p < 0.0001). There was a statistically significant increase in the frequency of ileus, urinary retention, urinary tract infections, pulmonary issues, and altered mental status in the group with prolonged bed rest after an incidental durotomy. The relative risk of complications in the group with bed rest ≤ 24 hours was 50% less than the group with > 24 hours of bed rest (RR 0.5, 95% CI 0.39–0.62; p < 0.0001).

CONCLUSIONS

In this retrospective study, the rate of revision surgery was not higher in patients with durotomy who underwent immediate mobilization, and medical complications were significantly decreased. Flat bed rest > 24 hours following incidental durotomy was associated with increased length of stay and increased rate of medical complications. After primary repair of an incidental durotomy, flat bed rest may not be necessary and appears to be associated with higher costs and complications.

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Hans J. Reulen, Robert Graham, Maria Spatz, and Igor Klatzo

✓ The authors present the results of an investigation of the vasogenic type of brain edema using cold injury in cats as a model. Their findings indicate that bulk flow and not diffusion should be considered the main mechanism for the spread of edema through the white matter. This conclusion is based on: 1) comparison of the distances actually traveled by various substances during edema spread with those calculated theoretically for migration of the substances by diffusion; 2) coincidence in the speed of movement by two substances (sucrose and albumin) with widely different diffusion coefficients; 3) measurement of interstitial fluid pressure (IFP) at various distances from the lesion showing the presence of increased IFP in the lesion area and decreasing pressures along the edema pathway toward the normal tissue; and 4) the fact that spreading of edema can be significantly impeded by inducing before the cold lesion an intracellular type of brain edema that reduces the size of the extracellular space (ECS) and increases the resistance to flow of edema fluid. The pressure-volume curve of the brain ECS, as derived from determinations of IFP and tissue water content, indicates that an initial steep slope in IFP probably represents the high resistance to fluid mobility through the small diameter extracellular channels and the counteracting resistance of the intermingled structures of brain parenchyma to be separated. Once the IFP exceeds these opposing forces, the ECS dilates, fluid mobility increases, and the edema front advances.

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Harvey S. Levin, Robert G. Grossman, James E. Rose, and Graham Teasdale

✓ Long-term recovery from severe closed head injury was investigated in predominantly young adults whose Glasgow Coma score was 8 or less at the time of admission. Of the 27 patients studied (median follow-up interval of 1 year), 10 attained a good recovery, 12 were moderately disabled, and five were severely disabled. In contrast to previous studies suggesting that intellectual ability after severe closed head injury eventually recovers to a normal level, our findings showed that residual intellectual level, memory storage and retrieval, linguistic deficit, and personal social adjustment corresponded to overall outcome. All severely disabled patients and several moderately disabled patients exhibited unequivocal cognitive and emotional sequelae after long follow-up intervals. Analysis of persistent neuropsychological deficit in relation to neurological indices of acute injury severity demonstrated the prognostic significance of oculovestibular deficit.

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Jamie Toms, Jason Harrison, Hope Richard, Adrienne Childers, Evan R. Reiter, and Robert S. Graham

Schwannomas are benign tumors that arise from Schwann cells in the peripheral nervous system. Patients with multiple schwannomas without signs and symptoms of neurofibromatosis Type 1 or 2 have the rare disease schwannomatosis. Tumors in these patients occur along peripheral nerves throughout the body. Mutations of the SMARCB1 gene have been described as one of the predisposing genetic factors in the development of this disease. This report describes a patient who was observed for 6 years after having undergone removal of 7 schwannomas, including bilateral maxillary sinus schwannomas, a tumor that has not been previously reported. Genetic analysis revealed a novel mutation of c.93G>A in exon 1 of the SMARCB1 gene.

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Peter Graham, Robert Howman-Giles, Ian Johnston, and Michael Besser

✓ Evaluation of 192 cerebrospinal fluid shunts was performed using 1 mCi of technetium-99m DTPA which was injected into the shunt tubing. This was found to be a safe, simple method of evaluating shunt patency. No complications were noted with this procedure, nor was there any documented case of infection related to the injection of the isotope. The sensitivity of the test for evaluation of patency was 97%, specificity 90%, and accuracy 93%. Various patterns of tracer clearance are noted and discussed. The role of this test as an aid in making management decisions is detailed.

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Experimental cerebral oligemia and ischemia produced by intracranial hypertension

Part 1: Pathophysiology, electroencephalography, cerebral blood flow, blood-brain barrier, and neurological function

Lawrence F. Marshall, Felix Durity, Robert Lounsbury, David I. Graham, Frank Welsh, and Thomas W. Langfitt

✓ Cerebral blood flow, electrical activity, and neurological function were studied in rabbits subjected to either 15 minutes of oligemia (20 torr cerebral perfusion pressure) or complete cerebral ischemia produced by cisterna magna infusion. During oligemia, flow was reduced from 68.4 ± 4.2 ml/100 gm/min to 26.3 ± 4.4 (p < .01), and during ischemia animals had no proven flow. By 5 minutes after oligemia or ischemia significant symmetrical hyperemia occurred and there was no evidence of the no-reflow phenomenon. The electroencephalogram became isoelectric significantly later and returned significantly sooner in oligemia than in ischemia. Oligemic animals had earlier and better return of neurological function than their ischemic counterparts, although postinsult hypocapnia improved functional recovery in both groups. These experiments do not support the concept that oligemia is a more severe insult than complete ischemia. In intracranial hypertension produced by this model, the no-reflow phenomenon does not occur.

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Lawrence F. Marshall, Frank Welsh, Felix Durity, Robert Lounsbury, David I. Graham, and Thomas W. Langfitt

✓ The authors studied the effect on cortical metabolites of intracranial hypertension produced by the infusion of mock cerebrospinal fluid into the cisterna magna in rabbits subjected to 15 minutes of cerebral oligemia (20 torr) or 15 minutes of complete ischemia. In both groups high-energy metabolites were exhausted within the first 5 minutes of the 15-minute insult. Significant recovery of the high-energy intermediates occurred within 15 minutes of reperfusion, well before return of electroencephalogram (EEG) activity. Continued reperfusion, during which electrical activity and function were returning, brought only moderate improvement in energy metabolites. In contrast, severe lactic acidosis persisted at least 15 minutes after insult, but was reduced by the time EEG activity returned. At no time were there striking differences in metabolites between the oligemic and ischemic groups. These results indicate that recovery in general, and the significantly earlier recovery of oligemic as compared to ischemic animals, cannot be explained on the basis of energy supply. Whether the persistence of lactic acidosis is an important factor limiting return of function requires further study.

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Lawrence F. Marshall, David I. Graham, Felix Durity, Robert Lounsbury, Frank Welsh, and Thomas W. Langfitt

✓ The authors studied the morphological sequelae of 15 minutes of cerebral oligemia (20 torr cerebral perfusion pressure) and complete cerebral ischemia produced by raised intracranial pressure in rabbits. Ischemic cell change was present in five of seven ischemic animals; it was most extensive in the striatum and hippocampus, with only a few ischemic nerve cells in the thalamus and neocortex. The brains of control and oligemic animals were normal. These results indicate the following: 1) ischemia is a more severe insult than oligemia; 2) compression ischemia results in a pattern of damage that differs from that produced by other types of ischemia; and 3) the method used to reduce cerebral perfusion pressure is an important factor in determining the pattern and extent of brain damage produced.

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Nelleke G. Langerak, Robert P. Lamberts, A. Graham Fieggen, Jonathan C. Peter, Lize van der Merwe, Warwick J. Peacock, and Christopher L. Vaughan

Object

Selective dorsal rhizotomy (SDR) has been widely performed for the reduction of spasticity in patients with cerebral palsy during the past 2 decades. The objective of this study was to determine whether the surgery has yielded long-term functional benefits for these patients.

Methods

The authors present results from a prospective 20-year follow-up study of locomotor function in 13 patients who underwent an SDR in 1985. For comparison, we also present gait data for 48 age-matched healthy controls (12 at each of 4 time points). Patients were studied preoperatively and then at 1, 3, 10, and 20 years after surgery. Study participants were recorded in the sagittal plane while walking using a digital video camera, and 6 standard gait parameters were measured.

Results

In this group of patients 20 years after surgery, knee range of motion (ROM) was on average 12° greater than preoperative values (p < 0.001). Hip ROM before surgery was no different from that in the healthy control group. This parameter increased markedly immediately after surgery (p < 0.001) but had returned to normal after 20 years. The knee and hip midrange values—a measure of the degree of “collapse” due to muscle weakness after surgery—had returned to preoperative levels after 20 years, although they were respectively 11 and 8° greater than those in healthy controls. Both temporal-distance parameters (dimensionless cadence and dimensionless step length) were significantly greater at 20 years than preoperative values (cadence, p = 0.003; step length, p = 0.02), leading to improved walking speed.

Conclusions

Twenty years after undergoing SDR, our patients showed improved locomotor function compared with their preoperative status.