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Thomas J. Wilson, Grant M. Kleiber, Ryan M. Nunley, Susan E. Mackinnon and Robert J. Spinner

OBJECTIVE

The sciatic nerve, particularly its peroneal division, is at risk for injury during total hip arthroplasty (THA), especially when a posterior approach is used. The majority of the morbidity results from the loss of peroneal nerve–innervated muscle function. Approximately one-third of patients recover spontaneously. The objectives of this study were to report the outcomes of distal decompression of the peroneal nerve at the fibular tunnel following sciatic nerve injury secondary to THA and to attempt to identify predictors of a positive surgical outcome.

METHODS

A retrospective study of all patients who underwent peroneal decompression for the indication of sciatic nerve injury following THA at the Mayo Clinic or Washington University School of Medicine in St. Louis was performed. Patients with less than 6 months of postoperative follow-up were excluded. The primary outcome was dorsiflexion strength at latest follow-up. Univariate and multivariate logistic regression analyses were performed to assess the ability of the independent variables to predict a good surgical outcome.

RESULTS

The total included cohort consisted of 37 patients. The median preoperative dorsiflexion grade at the time of peroneal decompression was 0. Dorsiflexion at latest follow-up was Medical Research Council (MRC) ≥ 3 for 24 (65%) patients. Dorsiflexion recovered to MRC ≥ 4− for 15 (41%) patients. In multivariate logistic regression analysis, motor unit potentials in the tibialis anterior (OR 19.84, 95% CI 2.44–364.05; p = 0.004) and in the peroneus longus (OR 8.68, 95% CI 1.05–135.53; p = 0.04) on preoperative electromyography were significant predictors of a good surgical outcome.

CONCLUSIONS

After performing peroneal nerve decompression at the fibular tunnel, 65% of the patients in this study recovered dorsiflexion strength of MRC ≥ 3 at latest follow-up, potentially representing a significant improvement over the natural history.

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Stephen R. Parker, Peggy Harris, Thomas J. Cummings, Timothy George, Herbert Fuchs and Gerald Grant

Object

Posterior fossa decompression with duraplasty for Chiari malformation Type I (CM-I) is a common pediatric neurosurgery procedure. Published series report a complication rate ranging from 3% to 40% for this procedure. Historically, many dural substitutes have been used, including bovine grafts, human cadaveric pericardium, synthetic dura, and autologous pericranium. The authors hypothesized that a recently observed increase in complications was dependent on the graft used.

Methods

Between January 2004 and January 2008, 114 consecutive patients ≤ 18 years old underwent primary CM-I decompression using duraplasty. Records were retrospectively reviewed for short- and intermediate-term complications and operative technique, focusing on the choice of duraplasty graft with or without application of a tissue sealant.

Results

The average age of the patients was 8.6 years. The dural graft used was variable: 15 were treated with cadaveric pericardium, 12 with Durepair, and 87 with EnDura. Tisseel was used in 75 patients, DuraSeal in 12, and no tissue sealant was used in 27 patients. The overall complication rate was 21.1%. The most common complications included aseptic meningitis, symptomatic pseudomeningocele, or a CSF leak requiring reoperation. The overall complication rates were as follows: cadaveric pericardium 26.7%, Durepair 41.7%, and EnDura 17.2%; reoperation rates were 13%, 25%, and 8.1%, respectively. Prior to adopting a different graft product, the overall complication rate was 18.1%; following the change the rate increased to 35%. Complication rates for tissue sealants were 14.8% for no sealant, 18.7% for Tisseel, and 50% for DuraSeal. Nine patients were treated with the combination of Durepair and DuraSeal and this subgroup had a 56% complication rate.

Conclusions

Complication rates after CM-I decompression may be dependent on the dural graft with or without the addition of tissue sealant. The complication rate at the authors' institution approximately doubled following the adoption of a different graft product. Tissue sealants used in combination with a dural substitute to augment a duraplasty may increase the risk of aseptic meningitis and/or CSF leak. The mechanism of the apparent increased inflammation with this combination remains under investigation.

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Kathleen J. Helton, Michael Edwards, R. Grant Steen, Thomas E. Merchant, Mark V. Sapp, Frederick A. Boop and James Langston

Object. After the resection of brain tumors in pediatric patients, it can be difficult to differentiate recurrent tumor from treatment effects. Although late-delayed reactions are thought to be permanent, in this study the authors sought to characterize transient brain lesions (TBLs) in the late-delayed period that completely resolved without imaging or neurological sequelae.

Methods. In a retrospective review of an institutional neuroimaging brain tumor database, 11 patients were identified who met the imaging criteria (transient T2-weighted hyperintense enhancing lesions outside of the tumor bed, which occurred after radiation and/or chemotherapy) and had undergone three-dimensional dosimetry; their radiographic, clinical, and radiation-dosimetry results were analyzed. In the 11 patients who had been treated with multiple protocols 17 loci of abnormality, including 43 discrete, asymptomatic TBLs, were detected. The median TBL diameter was 1 cm or smaller, without mass effect or necrosis, and occurred 10 months after radiation therapy, 11 months after chemotherapy, resolved by 3 months, and occurred within the high-dose radiation treatment volume (median 55.8 Gy). The findings from extended follow up revealed the development of additional permanent complications of radiation therapy within the radiation port in five of the 11 patients.

Conclusions. A benign form of treatment-induced brain injury in children, TBLs should be treated using short-interval follow up. When these lesions are identified as a result of their characteristic imaging features, location, and temporal course, TBLs may be clearly distinguished from recurrent tumor or radiation necrosis and do not require biopsy. Further studies are needed to determine whether patients with TBLs are at an increased risk of developing more severe treatment-related brain injury.

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Kathleen J. Helton, Michael Edwards, R. Grant Steen, Thomas E. Merchant, Mark V. Sapp, Frederick A. Boop and James Langston

Object

After the resection of brain tumors in pediatric patients, it can be difficult to differentiate recurrent tumor from treatment effects. Although late-delayed reactions are thought to be permanent, in this study the authors sought to characterize transient brain lesions (TBLs) in the late-delayed period that completely resolved without imaging or neurological sequelae.

Methods

In a retrospective review of an institutional neuroimaging brain tumor database, 11 patients were identified who met the imaging criteria (transient T2-weighted hyperintense enhancing lesions outside of the tumor bed, which occurred after radiation and/or chemotherapy) and had undergone three-dimensional dosimetry; their radiographic, clinical, and radiation-dosimetry results were analyzed. In the 11 patients who had been treated with multiple protocols 17 loci of abnormality, including 43 discrete, asymptomatic TBLs, were detected. The median TBL diameter was 1 cm or smaller, without mass effect or necrosis, and occurred 10 months after radiation therapy, 11 months after chemotherapy, resolved by 3 months, and occurred within the high-dose radiation treatment volume (median 55.8 Gy). The findings from extended follow up revealed the development of additional permanent complications of radiation therapy within the radiation port in five of the 11 patients.

Conclusions

A benign form of treatment-induced brain injury in children, TBLs should be treated using short-interval follow up. When these lesions are identified as a result of their characteristic imaging features, location, and temporal course, TBLs may be clearly distinguished from recurrent tumor or radiation necrosis and do not require biopsy. Further studies are needed to determine whether patients with TBLs are at an increased risk of developing more severe treatment-related brain injury.

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Ken Y. Hsu, James F. Zucherman, Charles A. Hartjen, Thomas F. Mehalic, Dante A. Implicito, Michael J. Martin, Donald R. Johnson II, Grant A. Skidmore, Paul P. Vessa, James W. Dwyer, Joseph C. Cauthen and Richard M. Ozuna

Object

This study was conducted to compare the quality of life (QOL) in patients with neurogenic intermittent claudication (NIC) secondary to lumbar spinal stenosis (LSS). Using the 36-Item Short Form (SF-36) questionnaire, the authors compared the results obtained in patients treated with the X STOP Interspinous Process Decompression (IPD) System with those obtained in patients who underwent nonoperative therapies.

Methods

Patients with LSS were enrolled in a prospective 2-year multicenter study and randomized either to the X STOP or nonoperative group. The SF-36 survey was used to assess the QOL before treatment and at 6 weeks, 6 months, 1 year, and 2 years posttreatment. An analysis of variance was used to compare individual pre- and posttreatment mean SF-36 domain scores between the two groups and within each treatment group.

At all posttreatment time points, the authors observed the following: 1) mean domain scores in X STOP–treated patients were significantly greater than those in patients treated nonoperatively, with the exception of the mean General Health (GH), Role Emotional, and Mental Component Summary scores at 2 years; and 2) mean posttreatment domain scores documented in X STOP–treated patients were significantly greater than mean pretreatment scores, with the exception of mean GH scores at 6, 12, and 24 months.

Conclusions

The results of this study demonstrate that the X STOP device is significantly more effective than non-operative therapy in improving the QOL in patients with LSS. The results are comparable with those reported in other studies involving traditional decompressive techniques for LSS and suggest that the X STOP implant can provide an effective treatment compared with nonoperative and conventional surgical therapies.

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Edgar F. Fincher, Bronson S. Ray, Harold J. Stewart, Edgar F. Fincher, T. C. Erickson, L. W. Paul, Franc D. Ingraham, Orville T. Bailey, Frank E. Nulsen, James W. Watts, Walter Freeman, C. G. de Gutiérrez-Mahoney, Frank Turnbull, Carl F. List, William J. German, A. Earl Walker, J. Grafton Love, Francis C. Grant, I. M. Tarlov, Thomas I. Hoen and Rupert B. Raney