Surgical neurology international
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Coccidioidomycosis is a fungal infection that is endemic to parts of the Southwestern United States. When infection involves the spine, the treatment strategies can be challenging. We have devised a management protocol for spinal coccidioidomycosis based on a review of the literature and our experience. ⋯ This work provides a working protocol involving assessment and reassessment for the management of spinal coccidioidomycosis. Medical management with antifungal agents in some cases can provide satisfactory disease control. However, in patients with mechanical instability, neurologic deficit, medically intractable pain or disease progression disease control may only be achieved with surgical debridement and stabilization.
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Review
Mannitol or hypertonic saline in the setting of traumatic brain injury: What have we learned?
Intracranial hypertension, defined as an intracranial pressure (ICP) >20 mmHg for a period of more than 5 min, worsens neurologic outcome in traumatic brain injury (TBI). While several mechanisms contribute to poor outcome, impaired cerebral perfusion appears to be a highly significant common denominator. Management guidelines from the Brain Trauma Foundation recommend measuring ICP to guide therapy. In particular, hyperosmolar therapy, which includes mannitol or hypertonic saline (HTS), is frequently administered to reduce ICP. Currently, mannitol (20%) is considered the gold standard hyperosmolar agent. However, HTS is increasingly used in this setting. This review sought to compare the efficacy of mannitol to HTS in severe TBI. ⋯ While all seven studies found that both mannitol and HTS were effective in reducing ICP, there was heterogeneity with regard to which agent was most efficacious.
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The authors sought to demonstrate the safety and effectiveness of the multilevel stabilization screw (MLSS) technique in decreasing the incidence of proximal junctional failure in long segmental instrumented fusions for adult degenerative scoliosis. ⋯ PJK and failure are well-recognized suboptimal outcomes of long-segmental fusions of the thoracolumbar spine that can lead to significant neurological morbidity and costly revision surgeries. With no known proximal junction failures to date, the MLSS technique has shown promising results in preventing adverse proximal junctional conditions and can be safely performed under fluoroscopy guidance. Future direction includes a comparative study establishing the relative risk of developing PJK with this novel technique versus a traditional long-segmental thoracolumbar fusion.
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Seizures account for significant morbidity and mortality early in the course of traumatic brain injury (TBI). Although there is sufficient literature suggesting short-term benefits of antiepileptic drugs (AEDs) in post-TBI patients, there has been no study to suggest a time frame for continuing AEDs in patients who have undergone a decompressive craniectomy for more severe TBI. We examined trends in a level-II trauma center in southern California that may provide guidelines for AED treatment in craniectomy patients. ⋯ Our study shows a trend toward increased seizure incidence in craniectomy group, which does not reach significance, but suggests they are at higher risk. Whether this higher risk translates into a benefit on being on AEDs for a longer duration than the current standard of 7 days cannot be concluded as there is no significant difference or trend on the onset date for seizures in either group. Moreover, a prospective study will be necessary to more profoundly evaluate the duration of AED prophylaxis for each one of the stated groups.
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Acute bilateral extradural hematoma is a rare presentation of head trauma injury. In sporadic cases, they represent 0.5-10% of all extradural hematomas. However, higher mortality rates have been reported in previous series. ⋯ The correct approach on bilateral epidural hematomas depends on the volume, moment of diagnosis, and neurological deficit level. Simultaneous drainage of bilateral hematomas has been demonstrated to be an effective technique for it, which soon decreases the intracranial pressure and promotes an efficient resolution to the neurological damage.