Neurosurgical focus最新文献

Objective: Continued play following concussion can lead to worse outcomes and longer recoveries compared with athletes who immediately report. This has been well documented in youth athletes, while less attention has been paid to collegiate athletes despite differences in healthcare access, recovery trajectories, and additional pressures to play. Therefore, the purpose of this study was to determine if continuing to play immediately following a concussion influenced clinical outcomes and recovery time in collegiate athletes.

Methods: A prospective, repeated-measures design was used to compare clinical outcomes and recovery time between collegiate athletes who continued playing (n = 37) and those immediately removed (n = 56) after a concussion. Assessments were conducted within 5 days of the concussion and at full medical clearance (FMC; ± 3 days) using the Sport Concussion Assessment Tool-5th edition (SCAT5), Vestibular/Ocular Motor Screening assessment, and High-Level Mobility Assessment Tool. Mann-Whitney U-tests determined differences in clinical outcomes between groups. Cox proportional hazards regression models examined the relationship between factors associated with days to symptom resolution and days to FMC, and covariates were selected a priori based on previous literature. Hazard ratios with 95% CIs were reported for each predictor variable.

Results: Significant differences were found in SCAT5 concentration composite scores (p = 0.010) and SCAT5 delayed recall composite scores (p = 0.045) at the acute visit and near point of convergence average distance (cm; p = 0.005) at the FMC visit between the group who continued to play and those who were immediately removed. There were no differences between groups in days to symptom resolution (10 vs 7 days, p = 0.05) and days to clearance (13 vs 11.50 days, p = 0.13). The association between groups and days to symptom resolution (χ2[4] = 5.052, p = 0.282), and days to clearance (χ2[4] = 3.624, p = 0.459) were not significant when adjusting for covariates.

Conclusions: Collegiate athletes who continued to play following concussion did not exhibit worse clinical outcomes or recovery times compared with athletes who were immediately removed. While the lack of differences found in this study could be supported by prior literature, including improved education, awareness, reporting attitudes, and concussion management at the collegiate level in recent years, the authors believe discrepancies are more likely due to study-specific differences (e.g., sample size, care setting, and timing). Therefore, these findings should not diminish the dangers of continued play and the importance of timely removal after concussion.

Objective: In the United States, more than 1 million sport-related concussions afflict children annually, with many cases undetected or unreported. The Sport Concussion Assessment Tool (SCAT) is widely used to detect concussions in high school, collegiate, and professional sports. The objective of this study was to establish baseline values for the SCAT version 5 (SCAT5) in high school athletes.

Methods: Baseline SCAT5 evaluations were conducted in students (ages 14-19 years) from 19 high schools in central Illinois who were participating in various school-sponsored sports. The SCAT5 evaluations were retrospectively extracted from the electronic medical record system for analysis. Statistical analyses included the Wilcoxon rank-sum test for continuous variables and the chi-square test for categorical variables, considering significance at p < 0.05. Test-retest reliability at < 6 months, 10-14 months, and 16-20 months was computed using intraclass correlation and Spearman's rho (ρ). Reliable change indices are provided using the Iverson formula.

Results: A total of 2833 unique athletes were included, and the average age was 15.5 ± 1.14 (SD) years. There were 721 female (25.5%) and 2112 male (74.5%) athletes. Students ≥ 15 years old had more prior concussions (p < 0.001), and male athletes were more frequently hospitalized for head injury (p = 0.013). Female athletes exhibited a significantly higher prevalence of mood disorders (14.7% vs 4.6%, p < 0.001), whereas attention-deficit/hyperactivity disorder was more common in male athletes (5.2% vs 13.2%, p < 0.001). Symptom number and severity were significantly greater in female athletes (3.17 ± 4.39 vs 2.08 ± 3.49, p < 0.001; 5.47 ± 9.21 vs 3.52 ± 7.26, p < 0.001, respectively), with mood-related symptoms representing the largest differences. Female athletes and students ≥ 15 years old performed better on most cognitive assessments. Female athletes and students < 15 years old performed better on the modified Balance Error Scoring System (p < 0.001). Test-retest reliability was poor to moderate for most assessment components. Reliable change index cutoff values differed slightly by sex, with female athletes often having a greater cutoff value.

Conclusions: This study underscores the variability of SCAT5 baseline values influenced by age, sex, and medical history among adolescent athletes. It provides a robust dataset, delineating baseline values stratified by sex and age within this demographic. Additionally, the results provide enhanced guidance to clinicians for interpretation of change and reliability of baselines.

Objective: Concussions are self-limited forms of mild traumatic brain injury (TBI). Gradual return to play (RTP) is crucial to minimizing the risk of second impact syndrome. Online patient educational materials (OPEM) are often used to guide decision-making. Previous literature has reported that grade-level readability of OPEM is higher than recommended by the American Medical Association and the National Institutes of Health. The authors evaluated the readability of OPEM on concussion and RTP.

Methods: An online search engine was used to identify websites providing OPEM on concussion and RTP. Text specific to concussion and RTP was extracted from each website and readability was assessed using the following six standardized indices: Flesch Reading Ease (FRE), Flesch-Kincaid Grade Level, Gunning Fog Index, Coleman-Liau Index, Simple Measure of Gobbledygook Index, and Automated Readability Index. One-way ANOVA and Tukey's post hoc test were used to compare readability across sources of information.

Results: There were 59 concussion and RTP articles, and readability levels exceeded the recommended 6th grade level, irrespective of the source of information. Academic institutions published OPEM at simpler readability levels (higher FRE scores). Private organizations published OPEM at more complex (higher) grade-level readability levels in comparison with academic and nonprofit institutions (p < 0.05).

Conclusions: The readability of OPEM on RTP after concussions exceeds the literacy of the average American. There is a critical need to modify the concussion and RTP OPEM to improve comprehension by a broad audience.

Objective: Concussions can occur at any level of ice hockey. Incidence estimates of concussions in ice hockey vary, and optimal prevention strategies and return-to-play (RTP) considerations have remained in evolution. The authors performed a mixed-methods study with the aim of elucidating the landscape of concussion in ice hockey and catalyzing initiatives to standardize preventative mechanisms and RTP considerations.

Methods: The authors performed a five-part mixed-methods study that includes: 1) an analysis of the impact of concussions on games missed and income for National Hockey League (NHL) players using a publicly available database, 2) a systematic review of the incidence of concussion in ice hockey, 3) a systematic review of preventative strategies, 4) a systematic review of RTP, and 5) a policy review of documents from major governing bodies related to concussions in sports with a focus on ice hockey. The PubMed, Embase, and Scopus databases were used for the systematic reviews and focused on any level of hockey.

Results: In the NHL, 689 players had 1054 concussions from the 2000-2001 to 2022-2023 seasons. A concussion led to a mean of 13.77 ± 19.23 (range 1-82) games missed during the same season. After cap hit per game data became available in 2008-2009, players missed 10,024 games due to 668 concussions (mean 15.13 ± 3.81 per concussion, range 8.81-22.60 per concussion), with a cap hit per game missed of $35,880.85 ± $25,010.48 (range $5792.68-$134,146.30). The total cap hit of all missed games was $385,960,790.00, equating to $577,635.91 per concussion and $25,724,052.70 per NHL season. On systematic review, the incidence of concussions was 0.54-1.18 per 1000 athlete-exposures. Prevention mechanisms involved education, behavioral and cognitive interventions, protective equipment, biomechanical studies, and policy/rule changes. Rules prohibiting body checking in youth players were most effective. Determination of RTP was variable. Concussion protocols from both North American governing bodies and two leagues mandated that a player suspected of having a concussion be removed from play and undergo a six-step RTP strategy. The 6th International Conference on Concussion in Sport recommended the use of mouthguards for children and adolescents and disallowing body checking for all children and most levels of adolescents.

Conclusions: Concussions in ice hockey lead to substantial missed time from play. The authors strongly encourage all hockey leagues to adopt and adhere to age-appropriate rules to limit hits to the head, increase compliance in wearing protective equipment, and utilize high-quality concussion protocols.

The evolution of neurosurgical approaches to spasticity spans centuries, marked by key milestones and innovative practitioners. Probable ancient descriptions of spasmodic conditions were first classified as spasticity in the 19th century through the interventions of Dr. William John Little on patients with cerebral palsy. The late 19th century witnessed pioneering efforts by surgeons such as Dr. Charles Loomis Dana, who explored neurotomies, and Dr. Charles Sherrington, who proposed dorsal rhizotomy to address spasticity. Dorsal rhizotomy rose to prominence under the expertise of Dr. Otfrid Foerster but saw a decline in the 1920s due to emerging alternative procedures and associated complications. The mid-20th century saw a shift toward myelotomy but the revival of dorsal rhizotomy under Dr. Claude Gros' selective approach and Dr. Marc Sindou's dorsal root entry zone (DREZ) lesioning. In the late 1970s, Dr. Victor Fasano introduced functional dorsal rhizotomy, incorporating electrophysiological evaluations. Dr. Warwick Peacock and Dr. Leila Arens further modified selective dorsal rhizotomy, focusing on approaches at the cauda equina level. Later, baclofen delivered intrathecally via an implanted programmable pump emerged as a promising alternative around the late 1980s, pioneered by Richard Penn and Jeffrey Kroin and then led by A. Leland Albright. Moreover, intraventricular baclofen has also been tried in this matter. The evolution of these neurosurgical interventions highlights the dynamic nature of medical progress, with each era building upon and refining the work of significant individuals, ultimately contributing to successful outcomes in the management of spasticity.

Objective: Intrathecal baclofen (ITB) is an effective treatment for hypertonia in children involving the implantation of a pump and catheter system. The highest concentration of ITB is at the catheter tip. The catheter tip location is most commonly within the lumbar or thoracic spine. The cervical tip location has traditionally been avoided because of concerns of hypoventilation and pneumonia; however, these complications in cervical compared with thoracic or lumbar placement have not been reliably proven. Some studies have suggested that cervical ITB location better treats upper-extremity hypertonia. There are limited data describing the safety and efficacy of cervical ITB on hypertonia. The authors present a single-institution retrospective case series highlighting the safety and efficacy of using cervical ITB location for the treatment of hypertonia.

Methods: Retrospective data analysis was performed for children who underwent continuous dosing cervical ITB between April 2022 and October 2023. Nonmodifiable risk factors, clinical variables, operative characteristics, and adverse outcomes were collected.

Results: This study included 25 patients (8 female). The mean age at implantation was 12.4 years, and the mean operative duration was 90 minutes. The mean Barry-Albright Dystonia Scale score decreased by 9.5 points (p = 0.01). The mean aggregated modified Ashworth scale score in the upper extremities decreased by 2.14 points (p = 0.04), and that in the lower extremities decreased by 4.98 points (p < 0.01). One patient each (4%) had infection and baclofen toxicity. Two patients (8%) had respiratory depression requiring continuous positive airway pressure. There was no incidence of pneumonia or wound dehiscence.

Conclusions: The cervical catheter tip location for ITB is safe, is effective to control tone, and should be considered for the treatment of hypertonia. Larger studies with longer follow-up are necessary to further determine upper-limit dosing safety along with long-term functional benefits in these patients.

Objective: Spasticity is a challenging feature of cerebral palsy (CP) that may be managed with selective dorsal rhizotomy (SDR). Although standard work tools (SWTs) have recently been utilized to inform a standard of care for neurosurgical procedures, no SWTs for SDR have been previously described. The authors present the multidisciplinary approach SWTs for SDR used at their institutions to promote consistency in the field and minimize complication rates.

Methods: A multidisciplinary approach was used to define all steps in the SDR pathway. Preoperative, intraoperative, and postoperative workflows were synthesized, with specific efforts to improve mobility through inpatient rehabilitation and minimize infection.

Results: The SWTs have been implemented at two institutions for 7 years. An illustrative case of a patient aged 3 years 10 months with a history of premature birth at 29 weeks, spastic-diplegic CP, right-sided periventricular leukomalacia, and developmental delay who underwent L2-S1 SDR is presented.

Conclusions: The authors detail SWTs for SDR developed by a multidisciplinary team with specific steps at all points in the patient pathway. The illustrative case emphasizes that SWTs may help ensure the safety of SDR while maximizing its long-term efficacy for individuals with CP.

Objective: Essential tremor (ET) is the most common movement disorder. Deep brain stimulation (DBS) targeting the ventral intermediate nucleus (VIM) is known to improve symptoms in patients with medication-resistant ET. However, the clinical effectiveness of VIM-DBS may vary, and other targets have been proposed. The authors aimed to investigate whether the same anatomical structure is responsible for tremor control both immediately after VIM-DBS and at later follow-up evaluations.

Methods: Of 68 electrodes from 41 patients with ET, the authors mapped the distances of the active contact from the VIM, the dentatorubrothalamic tract (DRTT), and the caudal zona incerta (cZI) and compared them using Friedman's ANOVA and the Wilcoxon signed-rank follow-up test. The same distances were also compared between the initially planned target and the final implantation site after intraoperative macrostimulation. Finally, the comparison among the three structures was repeated for 16 electrodes whose active contact was changed after a mean 37.5 months follow-up to improve tremor control.

Results: After lead implantation, the VIM was statistically significantly closer to the active contact than both the DRTT (p = 0.008) and cZI (p < 0.001). This result did not change if the target was moved based on intraoperative macrostimulation. At the last follow-up, the active contact distance from the VIM was always significantly less than that of the cZI (p < 0.001), but the distance from the DRTT was reduced and even less than the distance from the VIM.

Conclusions: In patients receiving VIM-DBS, the VIM itself is the structure driving the anti-tremor effect and remains more effective than the cZI, even years after implantation. Nevertheless, the role of the DRTT may become more important over time and may help sustain the clinical efficacy when the habituation from the VIM stimulation ensues.