Evolution of spinal cord injury treatment in military neurosurgery

During the mid-1900s, military medicine made historical advancements in the diagnosis, stabilization, and treatment of spinal cord injuries (SCIs). In particular, World War II was an inflection point for clinical practice related to SCIs because of the vast number of devastating injuries to soldiers seen during World War I (WWI). The unprecedented rate of SCI along with growth in the field served as a catalyst for surgical and interdisciplinary advancements through the increased exposure to this challenging pathology. Initially, a tragic fate was assumed for soldiers with SCIs in WWI resulting in a very conservative approach strategy given a multitude of factors. However, soldiers with similar injuries 20 years later saw improved outcomes with more aggressive management interventions by specialists in spine trauma, who applied measures such as spinal traction, arthrodesis, and internal fixation, and with the significant developments in the complex rehabilitation of these patients. This article describes the historical shift in the management of SCIs through the two world wars. These historical lessons of SCI and the fundamental advances in their neurosurgical intervention have molded not only military but also modern civilian treatment of SCI.

Diffusion Tensor Imaging Detects Acute and Subacute Changes in Corpus Callosum in Blast-Induced Traumatic Brain Injury

There is a critical need for understanding the progression of neuropathology in blast-induced traumatic brain injury using valid animal models to develop diagnostic approaches. In the present study, we used diffusion imaging and magnetic resonance (MR) morphometry to characterize axonal injury in white matter structures of the rat brain following a blast applied via blast tube to one side of the brain. Diffusion tensor imaging was performed on acute and subacute phases of pathology from which fractional anisotropy, mean diffusivity, axial diffusivity, and radial diffusivity were calculated for corpus callosum (CC), cingulum bundle, and fimbria. Ventricular volume and CC thickness were measured. Blast-injured rats showed temporally varying bilateral changes in diffusion metrics indicating persistent axonal pathology. Diffusion changes in the CC suggested vasogenic edema secondary to axonal injury in the acute phase. Axonal pathology persisted in the subacute phase marked by cytotoxic edema and demyelination which was confirmed by ultrastructural analysis. The evolution of pathology followed a different pattern in the cingulum bundle: axonal injury and demyelination in the acute phase followed by cytotoxic edema in the subacute phase. Spatially, structures close to midline were most affected. Changes in the genu were greater than in the body and splenium; the caudal cingulum bundle was more affected than the rostral cingulum. Thinning of CC and ventriculomegaly were greater only in the acute phase. Our results reveal the persistent nature of blast-induced axonal pathology and suggest that diffusion imaging may have potential for detecting the temporal evolution of blast injury.

Brainstem Monitoring in the Neurocritical Care Unit: A Rationale for Real-Time, Automated Neurophysiological Monitoring

Patients with severe traumatic brain injury or large intracranial space-occupying lesions (spontaneous cerebral hemorrhage, infarction, or tumor) commonly present to the neurocritical care unit with an altered mental status. Many experience progressive stupor and coma from mass effects and transtentorial brain herniation compromising the ascending arousal (reticular activating) system. Yet, little progress has been made in the practicality of bedside, noninvasive, real-time, automated, neurophysiological brainstem, or cerebral hemispheric monitoring. In this critical review, we discuss the ascending arousal system, brain herniation, and shortcomings of our current management including the neurological exam, intracranial pressure monitoring, and neuroimaging. We present a rationale for the development of nurse-friendly-continuous, automated, and alarmed-evoked potential monitoring, based upon the clinical and experimental literature, advances in the prognostication of cerebral anoxia, and intraoperative neurophysiological monitoring.

Effect of Internal Jugular Vein Compression on Intracranial Hemorrhage in a Porcine Controlled Cortical Impact Model

Internal jugular vein (IJV) compression has been shown to reduce axonal injury in pre-clinical traumatic brain injury (TBI) models and clinical concussion studies. However, this novel approach to prophylactically mitigating TBI through venous congestion raises concerns of increasing the propensity for hemorrhage and hemorrhagic propagation. This study aims to test the safety of IJV compression in a large animal controlled cortical impact (CCI) injury model and the resultant effects on hemorrhage. Twelve swine were randomized to placement of a bilateral IJV compression collar (CCI+collar) or control/no collar (CCI) prior to CCI injury. A histological grading of the extent of hemorrhage, both subarachnoid (SAH) and intraparenchymal (IPH), was conducted in a blinded manner by two neuropathologists. Other various measures of TBI histology were also analyzed including: β-amyloid precursor protein (β-APP) expression, presence of degenerating neurons, extent of cerebral edema, and inflammatory infiltrates. Euthanized 5 h after injury, the CCI+collar animals exhibited a significant reduction in total SAH (p = 0.024-0.026) and IPH scores (p = 0.03-0.05) compared with the CCI animals. There was no statistically significant difference in scoring for the other markers of TBI (β-APP, neuronal degeneration, cerebral edema, or inflammatory infiltration). In conclusion, IJV compression was shown to reduce hemorrhage (SAH and IPH) in the porcine CCI model when applied prior to injury. These results suggest the role of IJV compression for mitigation of not only axonal, but also hemorrhagic injury following TBI.

Assessment Center. A model for professional development and evaluation

The concern for ensuring the competence of physical therapists subsequent to their entry into the profession led the Missouri Physical Therapy Association to develop a mechanism that could be used both to assess competence and to foster professional growth. A self-assessment system using a multimethod testing scheme was designed and named The Assessment Center. Participation in The Assessment Center enables individuals to assess voluntarily their own practice competence and to use the results of this assessment to plan educational pursuits that may enhance professional growth. The purpose of this article is to describe the structure and operations of The Assessment Center. Proposals for further development of the testing scheme and diffusion of the project's concept are discussed.