Cara L. Sedney

Omega-3 fatty acid supplementation and reduction of traumatic axonal injury in a rodent head injury model

OBJECT Traumatic brain injury remains the most common cause of death in persons under 45 years of age in the Western world. Recent evidence from animal studies suggests that supplementation with omega-3 fatty acid (O3FA) (particularly eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA]) improves functional outcomes following focal neural injury. The purpose of this study is to determine the benefits of O3FA supplementation following diffuse axonal injury in rats. METHODS Forty adult male Sprague-Dawley rats were used. Three groups of 10 rats were subjected to an impact acceleration injury and the remaining group underwent a sham-injury procedure (surgery, but no impact injury). Two of the groups subjected to the injury were supplemented with 10 or 40 mg/kg/day of O3FA; the third injured group served as an unsupplemented control group. The sham-injured rats likewise received no O3FA supplementation. Serum fatty acid levels were determined from the isolated plasma phospholipids prior to the injury and at the end of the 30 days of supplementation. After the animals had been killed, immunohistochemical analysis of brainstem white matter tracts was performed to assess the presence of β-amyloid precursor protein (APP), a marker of axonal injury. Immunohistochemical analyses of axonal injury mechanisms-including analysis for caspase-3, a marker of apoptosis; RMO-14, a marker of neurofilament compaction; and cytochrome c, a marker of mitochondrial injury-were performed. RESULTS Dietary supplementation with a fish oil concentrate rich in EPA and DHA for 30 days resulted in significant increases in O3FA serum levels: 11.6% ± 4.9% over initial levels in the 10 mg/kg/day group and 30.7% ± 3.6% in the 40 mg/kg/day group. Immunohistochemical analysis revealed significantly (p < 0.05) decreased numbers of APP-positive axons in animals receiving O3FA supplementation: 7.7 ± 14.4 axons per mm(2) in the 10 mg/kg/day group and 6.2 ± 11.4 axons per mm(2) in the 40 mg/kg/day group, versus 182.2 ± 44.6 axons per mm(2) in unsupplemented animals. Sham-injured animals had 4.1 ± 1.3 APP-positive axons per mm(2). Similarly, immunohistochemical analysis of caspase-3 expression demonstrated significant (p < 0.05) reduction in animals receiving O3FA supplementation, 18.5 ± 28.3 axons per mm(2) in the 10 mg/kg/day group and 13.8 ± 18.9 axons per mm(2) in the 40 mg/kg/day group, versus 129.3 ± 49.1 axons per mm(2) in unsupplemented animals. CONCLUSIONS Dietary supplementation with a fish oil concentrate rich in the O3FAs EPA and DHA increases serum levels of these same fatty acids in a dose-response effect. Omega-3 fatty acid supplementation significantly reduces the number of APP-positive axons at 30 days postinjury to levels similar to those in uninjured animals. Omega-3 fatty acids are safe, affordable, and readily available worldwide to potentially reduce the burden of traumatic brain injury.

When to consider retiring an athlete after sports-related concussion

The pathophysiology of concussion may lead to a variety of both short- and long-term effects, which may lead to a decision to retire from contact sports. These effects follow a recognizable progression and may cause an athlete to opt out of play at any point along this progression. To elucidate the effect of concussion or mild traumatic brain injury and weigh in on a decision to retire, the treating physician needs to take into account the history, neurologic examination, brain imaging, and neuropsychological testing. In addition, myriad social factors surrounding play must be taken into consideration.

Microsurgical Management of Jugular Foramen Schwannomas

BACKGROUND Jugular foramen schwannomas are uncommon and surgically challenging lesions. OBJECTIVE To determine the importance of surgical technique on morbidity and recurrence of jugular foramen schwannomas. METHODS A retrospective review and case-control analysis of a single-senior-surgeon series of 81 patients with surgically treated jugular foramen schwannomas was performed, focusing on operative technique. Patients undergoing an aggressive, total tumor resection (series 1) were compared with those undergoing more conservative resection focusing on preserving the pars nervosa (series 2). RESULTS There was a statistically significant (P = .04) decrease in permanent deficits of the cranial nerve 9/10 complex with a conservative technique. Recurrence was seen in 3 patients (5.7%) in series 1 and in 3 patients (10.7%) in series 2 (P = .36). Recurrence was treated with reoperation in 1 patient, radiation in 1 patient, and observation in the others. CONCLUSION Although radical gross total resection is desirable, it is not optimal for cranial nerve preservation in patients with jugular foramen schwannomas. A more conservative approach resulted in a statistically significant decrease in lower cranial nerve deficits. There was a nonstatistically significant trend toward increasing recurrence, which may be treated with multiple modality therapy in the modern era.

Clinical spectrum and radiographic features of the syndrome of the trephined

Object: Craniectomy is a common neurosurgical procedure. Syndrome of the trephined (ST) occurring after craniectomy results in neurologic symptoms that are reversible with cranioplasty. While well-documented, previous literature consisted of case reports, symptom spectrum and risk factors have not been well characterized. Materials and Methods: A retrospective review of 29 consecutive cases who underwent decompressive craniectomy within a 30-month period was performed. Patients were considered affected by ST if a previously stable neurological deficit improved within 3 weeks after cranioplasty. Prevalence of ST was measured and association with demographic information, clinical symptoms patterns, indication for and size of craniectomy, as well as radiological signs were tested. Results: Seven patients (24%) developed ST. Chronic rehabilitation arrest was more common than acute neurologic decline. Factors such as craniectomy size and patient age did not reach statistical significance in development of ST. Radiographic factors were predictive, with a sunken skin flap contour being most sensitive, while ventricular effacement was most specific. Conclusion: ST may have a higher incidence than previously thought, with a chronic rehabilitation arrest being a more common presentation than an acute decline. Medical providers involved in the post surgical care and rehabilitation of these patients should maintain a high index of suspicion for ST.

A qualitative assessment of the benefits and challenges of international neurosurgical teaching collaboration in Ethiopia.

OBJECTIVE To explore the perspectives of Ethiopian and international neurosurgeons on the development of a sustainable academic neurosurgery teaching unit in Addis Ababa, Ethiopia. METHODS A qualitative case study methodology was employed. RESULTS Ethiopian and international surgeons describe a rewarding cross-cultural experience. Areas in need of improvement include communication, educational infrastructure, and structured morbidity and mortality discussions. Data collection that aims to understand better the burden of neurosurgical disease in Ethiopia along with rapidly expanding Ethiopian government initiatives to improve the health care system will lead to improved patient care. CONCLUSIONS Genuine partnerships between surgeons who have trained and worked in well-developed neurosurgical centers and those that are working within the confines of limited resources have the mutual desire to improve neurosurgical care. Understanding each others perspective is an important aspect of program development.

The effect of craniectomy size on mortality, outcome, and complications after decompressive craniectomy at a rural trauma center.

Introduction: Decompressive craniectomy (DC) has increasing support with current studies suggesting an improvement in both survival rates and outcomes with this intervention. However, questions surround this procedure; specifically, no evidence has indicated the optimal craniectomy size. Larger craniectomy is thought to better decrease intracranial pressure, but with a possible increase in complication rates. Our hypothesis is that a larger craniectomy may improve mortality and outcome, but may increase complication rates. Materials and Methods: A retrospective observational therapeutic study was undertaken to determine if craniectomy size is related to complication rates, mortality, or outcome. Our institutions Trauma Registry was searched for patients undergoing DC. Craniectomy size was measured by antero-posterior (AP) diameter. Mortality, outcome (through admission and discharge Glasgow Coma Score and Glasgow Outcome Scale), and complications (such as re-bleeding, re-operation, hygroma, hydrocephalus, infection, and syndrome of the trephined) were noted. Complications, mortality, and outcome were then compared to craniectomy size, to determine if any relation existed to support our hypothesis. Results: 20 patients met criteria for inclusion in this study. Craniectomy size as measured by AP diameter was correlated with a statistically significant improvement in mortality within the group. All patients with a craniectomy size less than 10 cm died. However, outcome was not significantly related to craniectomy size in the group. Similarly, complication rates did not differ significantly compared to craniectomy size. Discussion: This study provides Level 3 evidence that craniectomy size may be significantly related to improved mortality within our group, supporting our initial hypothesis; however, no significant improvement in outcome was seen. Similarly, in contrast to our hypothesis, complication rates did not significantly correlate with craniectomy size.

International Neurosurgical Volunteerism: A Temporal, Geographic, and Thematic Analysis of Foundation for International Education in Neurological Surgery Volunteer Reports

OBJECTIVE To examine the experiences of volunteers of the Foundation for International Education in Neurological Surgery. METHODS A qualitative analysis of >150 volunteer reports from 2004-2013 was performed using grounded theory. Various themes were explored based on their occurrence in the reports. RESULTS Volunteer reports of extended trips appeared to peak in 2009, with a heavy emphasis on activity in Africa. Prominent themes in the reports included volunteer contributions, successful strategies, challenges, and future directions. CONCLUSIONS Volunteers demonstrated wide-ranging contributions. Successful strategies included continuity and collaboration with other organizations. Challenges were overwhelmingly related to equipment or infrastructure. Common suggestions for future directions included institutional collaboration and subspecialty development.

Cervical abnormalities causing vertebral artery dissection in children.

Vertebral artery dissection (VAD) is rare in children but is increasingly recognized as a cause of stroke in the pediatric population. Traditionally, VAD was thought to be attributable to either trauma or spontaneous dissections. Recently, several underlying causes, such as bony cervical abnormalities, connective tissue diseases, and infection, have been determined to account for spontaneous VAD or those cases associated with only minor trauma. Two pediatric cases of VAD are presented, both caused by bony cervical abnormalities and each treated with different surgical procedures for symptom resolution. The first case required suboccipital decompression and endovascular sacrifice of the vertebral artery. The second case was treated with surgical decompression of the foramen transversarium at C-1 and C-2. The treatment of both of these patients required accurate diagnosis via cervical spine CT to define the bone anatomy and delineate a cause for what was originally theorized to be spontaneous VAD.

A Comparison of Open and Percutaneous Techniques in the Operative Fixation of Spinal Fractures Associated with Ankylosing Spinal Disorders

Background The operative care of patients with ankylosing spinal conditions such as ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) after a spine fracture is not well represented in the literature. This work seeks to determine the effect of minimally invasive techniques on patients with spinal fractures and ankylosing spinal conditions through a retrospective case-control analysis. Methods The operative logs from 1996-2013 of seven fellowship-trained spine surgeons from two academic, Level I trauma centers were reviewed for cases of operatively treated thoracic and lumbar spinal fractures in patients with ankylosing spinal disorders. Results A total of 38 patients with an ankylosing spinal condition and a spinal fracture were identified. The minimally invasive group demonstrated a statistically significant decrease in estimated blood loss, operative time, and need for transfusion when compared to either the hybrid or open group. There was no difference between the three subgroups in overall hospital stay or mortality. Conclusions Patients with ankylosing spinal conditions present unique challenges for operative fixation of spinal fractures. Minimally invasive techniques for internal fixation offer less blood loss, operative time, and need for transfusion compared to traditional techniques; however, no difference in hospital stay or mortality was reflected in this series of patients. Level of Evidence: 4. Clinical Relevance Ankylosing spinal disorders are increasingly common in an aging population.

Fracture of fusion mass after hardware removal in patients with high sagittal imbalance

OBJECT As spinal fusions become more common and more complex, so do the sequelae of these procedures, some of which remain poorly understood. The authors report on a series of patients who underwent removal of hardware after CT-proven solid fusion, confirmed by intraoperative findings. These patients later developed a spontaneous fracture of the fusion mass that was not associated with trauma. A series of such patients has not previously been described in the literature. METHODS An unfunded, retrospective review of the surgical logs of 3 fellowship-trained spine surgeons yielded 7 patients who suffered a fracture of a fusion mass after hardware removal. Adult patients from the West Virginia University Department of Orthopaedics who underwent hardware removal in the setting of adjacent-segment disease (ASD), and subsequently experienced fracture of the fusion mass through the uninstrumented segment, were studied. The medical records and radiological studies of these patients were examined for patient demographics and comorbidities, initial indication for surgery, total number of surgeries, timeline of fracture occurrence, risk factors for fracture, as well as sagittal imbalance. RESULTS All 7 patients underwent hardware removal in conjunction with an extension of fusion for ASD. All had CT-proven solid fusion of their previously fused segments, which was confirmed intraoperatively. All patients had previously undergone multiple operations for a variety of indications, 4 patients were smokers, and 3 patients had osteoporosis. Spontaneous fracture of the fusion mass occurred in all patients and was not due to trauma. These fractures occurred 4 months to 4 years after hardware removal. All patients had significant sagittal imbalance of 13-15 cm. The fracture level was L-5 in 6 of the 7 patients, which was the first uninstrumented level caudal to the newly placed hardware in all 6 of these patients. Six patients underwent surgery due to this fracture. CONCLUSIONS The authors present a case series of 7 patients who underwent surgery for ASD after a remote fusion. These patients later developed a fracture of the fusion mass after hardware removal from their previously successfully fused segment. All patients had a high sagittal imbalance and had previously undergone multiple spinal operations. The development of a spontaneous fracture of the fusion mass may be related to sagittal imbalance. Consideration should be given to reimplanting hardware for these patients, even across good fusions, to prevent spontaneous fracture of these areas if the sagittal imbalance is not corrected.