Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia
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Meta Analysis
Dexmedetomidine as an anesthetic adjuvant for intracranial procedures: meta-analysis of randomized controlled trials.
This meta-analysis aimed to systematically collect the current evidence regarding the efficacy and safety of dexmedetomidine (DEX) as an anesthetic adjuvant for patients undergoing intracranial surgery. A systematic literature search of randomized controlled trials (RCT) was conducted to compare DEX with placebo or opioids in patients undergoing intracranial procedures. Hemodynamic data, opioid consumption, and recovery parameters were pooled. ⋯ Patients also had lower mean arterial pressure and heart rate when extubated (mean difference [MD]=-9.74 mm Hg, 95% CI -12.35 to -7.12, p<0.00001; and MD=-16.35 beats/minute, 95% CI -20.00 to -12.70, p<0.00001, respectively), a lower intraoperative additional fentanyl consumption (MD=-0.78 μg/kg, 95% CI -1.51 to -0.05, p=0.04), and lower postoperative antiemetic requests (RR=0.51, 95% CI 0.33-0.80, p=0.003). DEX may not increase extubation time, postoperative PaCO2, or the risk of perioperative bradycardia. Only a small number of RCT are available, but meta-analysis shows evidence that DEX as an anesthetic adjuvant during intracranial procedures leads to better perioperative hemodynamic control, less intraoperative opioid consumption, and fewer postoperative antiemetic requests.
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Cervical disc arthroplasty has emerged as a viable technique for the treatment of cervical radiculopathy and myelopathy, with the proposed benefit of maintenance of segmental range of motion. There are relatively few, non-industry sponsored studies examining the outcomes and complications of cervical disc arthroplasty. Therefore, we set out to perform a single center evaluation of the outcomes and complications of cervical disc arthroplasty. ⋯ Symptomatic cervical radiculopathy is a common problem in both the civilian and active duty military populations and can cause significant disability leading to loss of work and decreased operational readiness. There exist several surgical treatment options for appropriately indicated patients. Based on our findings, cervical disc arthroplasty is a safe and effective treatment for symptomatic cervical radiculopathy and myelopathy, with a low incidence of complications and high rate of symptom relief.
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With continuous refinement of neurosurgical techniques and higher resolution in neuroimaging, the management of pontine lesions is constantly improving. Among pontine structures with vital functions that are at risk of being damaged by surgical manipulation, cranial nerves (CN) and cranial nerve nuclei (CNN) such as CN V, VI, and VII are critical. Pre-operative localization of the intrapontine course of CN and CNN should be beneficial for surgical outcomes. ⋯ Clinical associations between post-operative improvements and the corresponding CN area of the pons were demonstrated. Our results suggest that pre- and post-operative DTI allows identification of key anatomical structures in the pons and enables estimation of their involvement by pathology. It may predict clinical outcome and help us to better understand the involvement of the intrinsic anatomy by pathological processes.
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Clinical Trial
Microdiscectomy with and without insertion of interspinous device for herniated disc at the L5-S1 level.
The role of interspinous devices (ISD) after lumbar herniated disc surgery for the prevention of postoperative back pain is controversial. The aim of this comparative prospective study was to determine outcomes in a selective cohort with L5-S1 disc herniation and degenerative disc changes after microdiscectomy with or without insertion of an ISD. One hundred and two consecutive patients underwent an L5-S1 microdiscectomy with or without implantation of an ISD. ⋯ Forty four percent of Group 1 patients and 80% of Group 2 patients showed improvement using the modified MacNab criteria. Patients in both groups reported significant improvement in sciatic pain and disability after microdiscectomy with or without an ISD implant. Patients with mild degenerative disc changes were more likely to achieve improvement of their low-back pain when treated with both microdiscectomy and ISD insertion.
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Observational Study
Reversal of warfarin associated coagulopathy with 4-factor prothrombin complex concentrate in traumatic brain injury and intracranial hemorrhage.
Warfarin-associated intracranial hemorrhage is associated with a high mortality rate. Ongoing coagulopathy increases the likelihood of hematoma expansion and can result in catastrophic hemorrhage if surgery is performed without reversal. The current standard of care for emergency reversal of warfarin is with fresh frozen plasma (FFP). ⋯ When operations were performed, the time delay to perform operations was also significantly shorter in the PCC group (FFP 307 minutes, PCC 159 minutes, p<0.05). In this preliminary experience, PCC appears to provide a rapid reversal of coagulopathy. Normalization of coagulation parameters may prevent further intracranial hematoma expansion and facilitate rapid surgical evacuation, thereby improving neurological outcomes.