The Combined Use of Cardiac Output and Intracranial Pressure Monitoring to Maintain Optimal Cerebral Perfusion Pressure and Minimize Complications for Severe Traumatic Brain Injury

소진섭,윤정호 대한신경손상학회 2017 Korean Journal of Neurotrauma Vol.14 No.2

Objective: To show the effect of dual monitoring including cardiac output (CO) and intracranial pressure (ICP) monitoring for severe traumatic brain injury (TBI) patiens. We hypothesized that meticulous treatment using dual monitoring iseffective to sustain maintain minimal intensive care unit (ICU) complications and maintain optimal ICP and cerebral perfusion pressure (CPP) for severe TBI patiens. Methods: We included severe TBI, below Glasgow Coma Scale (GCS) 8 and head abbreviation injury scale (AIS) > 4 andperformed decompressive craniectomy at trauma ICU of our hospital. We collected the demographic data, head AIS, injuryseverity score (ISS), initial GCS, ICU stay, sedation duration, fluid therapy related complications, Glasgow Outcome Scale(GOS) at 3 months and variable parameters of ICP and CO monitor. Results: Thirty patients with severe TBI were initially selected. Thirteen patients were excluded because 10 patients hadfxed pupillary reflexes and 3 patients had uncontrolled ICP due to severe brain edema. Overall 17 patients had head AIS 5except 2 patients and 10 patients (58.8%) had multiple traumas as mean ISS 29.1. Overall complication rate of the patientswas 64.7%. Among the parameters of CO monitoring, high stroke volume variation is associated with fluid therapy relatedcomplications (p=0.043) and low cardiac contractibility is associated with these complications (p=0.009) statistically. Conclusion: Combined use of CO and ICP monitors in severe TBI patients who could be necessary to decompressive craniectomy and postoperative sedation is good alternative methods to maintain an adequate ICP and CPP and reduce fluidtherapy related complications during postoperative ICU care.

Abusive Head Traumas in 4 Infants

이원재,임용철,윤수한 대한신경손상학회 2020 Korean Journal of Neurotrauma Vol.16 No.2

Pediatric abusive head trauma (AHT) is a serious, repeated child abuse that causes grave brain damage. In Korea, AHT cases have been reported rarely, especially infants. We present 4 cases of AHT in infants diagnosed in our institution during last 2 years. We collected the demographic data, ophthalmologic examination, imaging study, and outcomes. The mean age was 7.2 months, and 2 infants were girls and the others were boys. All four were admitted with no history of head trauma, and among them 2 patients presented with an episode of seizure and respiratory arrest with no history of head trauma. The initial mental status was semi-coma in 3 cases, and stupor in 1 case. There were multiple retinal hemorrhages in both eyes in 2 cases; one had multiple old fractures on the extremities and another child showed multiple skull fractures. All patients underwent emergent surgery for acute bilateral subdural hemorrhages; 3 had craniotomy and another had burr-hole drainage. Two children expired and the other 2 are in vegetative status. The AHT has recently become more frequent in Korea so that neurosurgeons must alert AHT even in infants with head trauma

Progression of Ossification of Posterior Longitudinal Ligament After Anterior Cervical Discectomy and Fusion in Military Patients Exposed to Minor Trauma

Jung Myung Koo,Sung Hwan Hwang,Sang Hoon Yoon,Hyung Jin Shin,Byung-Kyu Cho 대한신경손상학회 2022 Korean Journal of Neurotrauma Vol.18 No.2

Objective: Ossification of the posterior longitudinal ligament (OPLL) can progress even after cervical spine surgery and may cause neurological injury as a result of minor trauma. The purpose of this study was to investigate the preventive factors associated with OPLL progression after anterior cervical discectomy and fusion (ACDF), a procedure commonly performed in clinical practice. Methods: We retrospectively investigated 295 male soldiers who underwent ACDF surgery between 2012 and 2017. Patients who were followed up for >12 months using dynamic radiography and computed tomography (CT) were included in the study. Radiological parameters investigated included OPLL progression, C2-C7 angles on dynamic radiography, segmental angles, C2-C7 cervical sagittal vertical axis (C2-C7 SVA), and the T1 slope. These parameters were measured preoperatively and 1 year postoperatively. Results: A total of 49 patients were enrolled, and 10 patients were confirmed to have OPLL progression. Comparison between the OPLL progression and non-progression groups showed no statistically significant differences in pre- and postoperative cervical range of motion. However, statistically significant differences were observed in the postoperative neutral C2-C7 angle (progression −3.9°±6.4° vs. non-progression −13.4°±7.9°, p=0.001) and the SVA change (progression 5.8±7.9 mm vs. non-progression −3.7±6.3 mm, p=0.00). The cutoff values were −8.01° for the postoperative neutral C2-C7 angle and 1.4 mm for SVA changes. Conclusion: Increased SVA (>1.4 mm) and a small postoperative neutral C2-C7 angle (>−8.01°) 1 year after ACDF were associated with OPLL progression. It is important to be mindful of these factors during follow-up after ACDF, because additional surgical treatment may be necessary for OPLL progression due to neurological injury caused by minor trauma.

Predictable Values of Decompressive Craniectomy in Patients with Acute Subdural Hematoma: Comparison between Decompressive Craniectomy after Craniotomy Group and Craniotomy Only Group

Hyunjun Kim,Sang Jun Suh,Ho-Jun Kang,이민석,Yoon-Soo Lee,Jeong-Ho Lee,Dong-Gee Kang 대한신경손상학회 2018 Korean Journal of Neurotrauma Vol.15 No.1

Objective: Patients with traumatic acute subdural hematoma (ASDH) often require surgical treatment. Among patients who primarily underwent craniotomy for the removal of hematoma, some consequently developed aggressive intracranialhypertension and brain edema, and required secondary decompressive craniectomy (DC). To avoid reoperation, we investigated factors which predict the requirement of DC by comparing groups of ASDH patients who did and did not requireDC after craniotomy. Methods: The 129 patients with ASDH who underwent craniotomy from September 2007 to September 2017 were reviewed. Among these patients, 19 patients who needed additional DC (group A) and 105 patients who underwent primarycraniotomy only without reoperation (group B) were evaluated. A total of 17 preoperative and intraoperative factors wereanalyzed and compared statistically. Univariate and multivariate analyses were used to compare these factors. Results: Five factors showed signifcant differences between the two groups. They were the length of midline shifting tomaximal subdural hematoma thickness ratio (magnetization transfer [MT] ratio) greater than 1 (p<0.001), coexistence of intraventricular hemorrhage (IVH) (p<0.001), traumatic intracerebral hemorrhage (TICH) (p=0.001), intraoperative fndingsshowing intracranial hypertension combined with brain edema (p<0.001), and bleeding tendency (p=0.02). An average valueof 2.74±1.52 was obtained for these factors for group A, which was signifcantly different from that for group B (p<0.001). Conclusion: An MT ratio >1, IVH, and TICH on preoperative brain computed tomography images, intraoperative signsof intracranial hypertension, brain edema, and bleeding tendency were identifed as factors indicating that DC would berequired. The necessity for preemptive DC must be carefully considered in patients with such risk factors Objective: Patients with traumatic acute subdural hematoma (ASDH) often require surgical treatment. Among patientswho primarily underwent craniotomy for the removal of hematoma, some consequently developed aggressive intracranialhypertension and brain edema, and required secondary decompressive craniectomy (DC). To avoid reoperation, we investigated factors which predict the requirement of DC by comparing groups of ASDH patients who did and did not requireDC after craniotomy. Methods: The 129 patients with ASDH who underwent craniotomy from September 2007 to September 2017 were reviewed. Among these patients, 19 patients who needed additional DC (group A) and 105 patients who underwent primarycraniotomy only without reoperation (group B) were evaluated. A total of 17 preoperative and intraoperative factors wereanalyzed and compared statistically. Univariate and multivariate analyses were used to compare these factors. Results: Five factors showed signifcant differences between the two groups. They were the length of midline shifting tomaximal subdural hematoma thickness ratio (magnetization transfer [MT] ratio) greater than 1 (p<0.001), coexistence of intraventricular hemorrhage (IVH) (p<0.001), traumatic intracerebral hemorrhage (TICH) (p=0.001), intraoperative fndingsshowing intracranial hypertension combined with brain edema (p<0.001), and bleeding tendency (p=0.02). An average valueof 2.74±1.52 was obtained for these factors for group A, which was signifcantly different from that for group B (p<0.001). Conclusion: An MT ratio >1, IVH, and TICH on preoperative brain computed tomography images, intraoperative signsof intracranial hypertension, brain edema, and bleeding tendency were identifed as factors indicating that DC would berequired. The necessity for preemptive DC must be carefully considered in patients with such risk factors

Neurocritical Management of Traumatic Acute Subdural Hematomas

신동성,황선철 대한신경손상학회 2020 Korean Journal of Neurotrauma Vol.16 No.2

Acute subdural hematoma (ASDH) has been a major part of traumatic brain injury. Intracranial hypertension may be followed by ASDH and brain edema. Regardless of the complicated pathophysiology of ASDH, the extent of primary brain injury underlying the ASDH is the most important factor affecting outcome. Ongoing intracranial pressure (ICP) increasing lead to cerebral perfusion pressure (CPP) decrease and cerebral blood flow (CBF) decreasing occurred by CPP decrease. In additionally, disruption of cerebral autoregulation, vasospasm, decreasing of metabolic demand may lead to CBF decreasing. Various protocols for ICP lowering were introduced in neuro-trauma feld. Usage of anti-epileptic drugs (AEDs) for ASDH patients have controversy. AEDs may reduce the risk of early seizure (<7 days), but, does not for late-onset epilepsy. Usage of anticoagulants/antiplatelets is increasing due to life-long medical disease conditions in aging populations. It makes a difculty to decide the proper management. Tranexamic acid may use to reducing bleeding and reduce ASDH related death rate. Decompressive craniectomy for ASDH can reduce patient's death rate. However, it may be accompanied with surgical risks due to big operation and additional cranioplasty aferwards. If the craniotomy is a sufcient management for the ASDH, endoscopic surgery will be good alternative to a conventional larger craniotomy to evacuate the hematoma. The management plan for the ASDH should be individualized based on age, neurologic status, radiologic fndings, and the patient's conditions

Progression of Ossification of the Posterior Longitudinal Ligament after Cervical Total Disc Replacement

함정식,김장훈,윤준호,황성환,윤상훈 대한신경손상학회 2019 Korean Journal of Neurotrauma Vol.15 No.2

ObjectiveTotal disc replacement (TDR) is frequently performed anterior approaching method for the patients diagnosed with cervical disc herniation. This study aimed to assess the degree of ossification of the posterior longitudinal ligament (OPLL) progression after cervical TDR. MethodsTwenty-two male soldiers who underwent cervical TDR surgery from 2009 to 2016 and were followed-up for more than 12 months were enrolled. The enrolled patients were classified as; 1) patients with pre-existing OPLL and without; and 2) patient showing progression of OPLL or not. ResultsTwenty-two men were included in the analysis. The mean follow-up period from the surgery was 41.4 months (range, 12–114 months). The mean age of all patients was 40.7 years (range, 31–52 years). TDR-only was used in 7 cases, and the hybrid surgery (TDR+ACDF) was used in 15 cases. The incidence of progression or newly development of OPLL was significantly higher in pre-existing OPLL group (p=0.01). In 11 cases showing the progression of the OPLL, the mean size of OPLL progression was 4.16 mm (range, 0.34–18.87 mm) in the longitudinal height and 1.57 mm (range, 0.54–3.91 mm) in thickness. ConclusionThe progression of OPLL after cervical TDR was more frequent in patients with pre-existing OPLL than in patients without OPLL. Even though TDR is a major alternative to the treatment of cervical lesions to preserve vertebral segmental motion, careful attention should be paid to whether TDR should be used in patients with OPLL and this should be fully explained to the patient.

Traumatic Cervical Epidural Hematoma without Osseous Fracture Presenting as Hemiparesis

이학수,주창일,김석원 대한신경손상학회 2019 Korean Journal of Neurotrauma Vol.15 No.2

Traumatic cervical epidural hematoma (EDH) with no osseous fracture or underlying hematological abnormalities is a rare disorder that sometimes requires emergent surgical decompressive therapy. A 47-year-old woman was admitted to our emergency room due to severe neck pain and rapid onset hemiparesis after a car accident. Plain cervical radiographs and computed tomography scan did not reveal any abnormality. However, magnetic resonance imaging (MRI) revealed a large posterior EDH compressing the spinal cord extensively from C3 to C5. Emergent hematoma removal was performed following laminectomy, and subsequently the patient showed substantial clinical improvement. Complete removal of the hematoma was confirmed by MRI at 10 days after surgery. Here, the authors present a discussion of the etiology, pathogenesis, and prognosis of this rare pathologic entity.

Effectiveness of Osteoporosis Drug in Postmenopausal Women with Spinal Compression Fracture: Combined Consecutive Therapy of Teriparatide and Raloxifene versus Bisphosphonate Single

신창진,김시온,최천식,신현철,권영준 대한신경손상학회 2016 Korean Journal of Neurotrauma Vol.12 No.2

Objective: Bisphosphonate, a typical bone resorption inhibitor, is an important first-line drug for treating osteoporosis. Recent studies show a novel paradigm in stimulating bone formation. Teriparatide, which is composed of recombinant human parathyroid hormone, stimulates osteoblasts and induces bone regeneration. Bone mineral density (BMD) that was used before and after the treatment with anti-osteoporosis drug was compared for the effectiveness in therapy between a combination of teriparatide and selective estrogen receptor modulator (SERM), and bisphosphonate. Methods: We retrospectively reviewed the outcomes of 85 postmenopausal women who were concurrently diagnosed with osteoporosis and spinal compression fracture between November 2008 and January 2015. The targeted group were treated with teriparatide and SERM (TS group, n=26) and bisphosphonate (B group, n=59). Results: In both groups, BMD of femur neck was not improved after the medication. In the TS group, on the other hand the BMD and T-score of lumbar spine has significantly improved. BMD ratio of lumbar spine was prominently higher than those of TS group. Conclusion: The combination therapy of teriparatide and SERM was very effective in treating the lumbar spine, compared to that of bisphosphonate. Although the period of teriparatide treatment has been relatively short, the preventive effects of compression fracture were considerable. Thus, combination therapy of teriparatide and SERM is highly recommended for patients who are concerned with spinal compression fracture from osteoporosis.

Posterior Cord Syndrome After Spinal Cord Stimulation Electrode Lead Insertion: A Case Report

Young Min Kwon 대한신경손상학회 2022 Korean Journal of Neurotrauma Vol.18 No.2

Chronic neuropathic pain after spinal cord injury is often refractory to conventional treatments. Spinal cord stimulation (SCS) is used to manage intractable chronic neuropathic pain. A 42-year-old man presented with chronic neuropathic pain in his right lower extremity for 5 years. He had undergone posterior fusion from T11 to L3 for a burst fracture of L1 vertebra and conus medullaris syndrome. Conservative treatment with medications, pain blocks, and physical therapy did not relieve the neuropathic pain in the right lower limb. A paddle-type SCS electrode lead was inserted at the level of T9–11 vertebrae for test stimulation. Postoperatively, the patient immediately complained of decreased proprioception, while the motor and sensory neurologic states did not change. Since his neurological deficit did not recover spontaneously, we had to remove the epidural SCS electrode to resolve the neurological symptoms.

Exoskeleton-assisted Gait Training in Spinal Disease With Gait Disturbance

Tak Gun Jang,Su Hong Choi,Seung Han Yu,Dong Hwan Kim,In Ho Han,Kyoung Hyup Nam 대한신경손상학회 2022 Korean Journal of Neurotrauma Vol.18 No.2

Objective: Gait impairment reduces a patient’s quality of life. Exoskeletons and wearable robotics enable patients with gait disturbance to stand up and walk. An exoskeleton was developed for use in patients with stroke and spinal cord injuries. This study aimed to evaluate the effectiveness of overground exoskeleton-assisted gait training (OEGT) in spine diseases with gait disturbance. Methods: This was a single-group preliminary study. Five participants with gait disorders because of root dysfunction accompanying spinal stenosis were included in this study. All participants underwent surgical treatment and an exoskeleton training protocol scheduled for 2 or 3 days per week for 4 weeks. Each session was 60 minutes. Clinical tests were performed before (T1) and at the end of the training (T2). Results: One patient dropped out of the study because of medical issues that were not associated with the exoskeleton. Exoskeleton-assisted rehabilitation was feasible for all participants. All participants showed positive changes in gait performance, balance, proximal muscle strength, psychological state, and satisfaction with the rehabilitation. However, there was no significant improvement in neurological deficits. Conclusion: OEGT is a feasible rehabilitation method for patients with gait disorders caused by degenerative spinal disease.