Neurosurgery
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A three-view cervical spine series (anteroposterior, lateral, and odontoid views) is recommended for radiographic evaluation of the cervical spine in patients who are symptomatic after traumatic injury. This should be supplemented with computed tomography (CT) to further define areas that are suspicious or not well visualized on the plain cervical x-rays. ⋯ It is recommended that cervical spine immobilization in awake patients with neck pain or tenderness and normal cervical spine x-rays (including supplemental CT as necessary) be discontinued after either a) normal and adequate dynamic flexion/extension radiographs, or b) a normal magnetic resonance imaging study is obtained within 48 hours of injury. Cervical spine immobilization in obtunded patients with normal cervical spine x-rays (including supplemental CT as necessary) may be discontinued a) after dynamic flexion/extension studies performed under fluoroscopic guidance, or b) after a normal magnetic resonance imaging study is obtained within 48 hours of injury, or c) at the discretion of the treating physician.
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Review Comparative Study
Management of combination fractures of the atlas and axis in adults.
There is insufficient evidence to support treatment standards. ⋯ Treatment of atlas-axis combination fractures based primarily on the specific characteristics of the axis fracture is recommended. External immobilization of most C1--C2 combination fractures is recommended. C1--Type II odontoid combination fractures with an atlantodens interval of 5 mm or more and C1--hangman's combination fractures with C2--C3 angulation of 11 degrees or more should be considered for surgical stabilization and fusion. In some cases, the surgical technique must be modified as a result of loss of the integrity of the ring of the atlas.
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Clinical Trial
Early endovascular treatment of ruptured cerebral aneurysms in patients in very poor neurological condition.
In patients in very poor neurological condition (World Federation of Neurosurgical Societies Grade V) with aneurysmal subarachnoid hemorrhage, early surgery to prevent rebleeding and to allow appropriate treatment of complications is often difficult. The aim of the present study was to evaluate whether early endovascular treatment followed by aggressive proactive treatment of complications (prophylactic hypervolemic hemodilution, hypertensive treatment in the event of systemic hypotension, and appropriate treatment of intracranial hypertension) is an acceptable management strategy for these patients. ⋯ This study demonstrates that early endovascular treatment of acutely ruptured cerebral aneurysms in patients evaluated as World Federation of Neurosurgical Societies Grade V allows for aggressive treatment of intracranial hypertension and vasospasm. More than half of the patients had favorable outcomes. Therefore, early endovascular treatment seems to be a valuable alternative to early surgery in patients who present with a very poor clinical grade after subarachnoid hemorrhage. The results of this study are promising but must be interpreted with caution, because a small number of patients were studied.
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Comparative Study
Transportation of patients with acute traumatic cervical spine injuries.
There is insufficient evidence to support treatment standards. ⋯ Expeditious and careful transport of patients with acute cervical spine or spinal cord injuries is recommended, from the site of injury by the most appropriate mode of transportation available to the nearest capable definitive care medical facility.
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Nonvestibular schwannomas are uncommon tumors of the brain. Trigeminal nerve schwannomas are the most common of this group, followed by glossopharyngeal, vagal, facial, accessory, hypoglossal, oculomotor, trochlear, and abducens nerve schwannomas, in descending order of frequency. We present a series of nonvestibular schwannomas that were surgically treated during a 7-year period. ⋯ Nonvestibular schwannomas can be treated via microsurgical excision, with excellent functional results. Recurrence is rare after total tumor excision, although much longer follow-up monitoring is required.