bluuebunny/crossref_metadata_2025 huggingface dataset:
Cardiovascular Hemodynamic Changes After Antenatal Corticosteroids in Growth Restricted and Appropriate for Gestational Age Fetuses
Authors: Marchi Laura , Pasquini Lucia , Elvan-Taspinar Ayten , Bilardo Caterina Maddalena
Published: October 2018

Purpose To investigate hemodynamic effects after antenatal corticosteroids (ACS) administration in appropriate for gestational age (AGA) and early growth restricted (GR) fetuses by measurement of Doppler cardiovascular function parameters.

Materials and Methods Prospective cohort study. AGA and GR singleton pregnancies receiving ACS for fetal lung maturation between 24 + 0–33 + 6 weeks were enrolled. Feto-placental vascular hemodynamics were studied by: umbilical artery (UA) pulsatility index (PI), middle cerebral artery (MCA) PI, renal artery (RenA) PI. Cardiac function was evaluated by ductus venosus (DV) PI and by echocardiographic parameters: E to A wave ratios (E/A) and mitral and tricuspid annular plane systolic excursion (MAPSE and TAPSE) for diastolic function, left and right myocardial performance index (MPI) for overall (diastolic and systolic) function. A single operator performed all the measurements at 3 different time points (E): E0 before or within 4 hours of ACS administration (baseline examination), E1 24–48 hours after the first dose and E2 7 days after the second dose of ACS. The values were expressed as z-scores. Pairwise comparisons with paired t-test were performed to compare measurements before and after exposure to ACS.

Results 25 AGA and 20 GR fetuses (mean gestational age: 31 + 1 and 30 + 6, respectively) were included in the analysis. In the AGA group ACS administration was associated with a significant reduction in UA PI. In the GR fetuses ACS temporarily (E0-E1) restored UA-end diastolic flow (EDF) in 6 of 9 fetuses with A/R-EDF (“Return of EDF phenomenon”) and produced a significant increase (worsening) in right MPI (both in E1-E2 and in E0-E2).

Conclusion ACS administration is associated with UA vasodilation in both AGA and GR fetuses and with an increase in right MPI in the latter group. This suggests a worsening in cardiac function in GR fetuses.
Sonographic Bedside Quantification of Pleural Effusion Compared to Computed Tomography Volumetry in ICU Patients
Authors: Teichgräber Ulf , Hackbarth Judith
Published: October 2018

To date, the reliability of ultrasound for the quantitative assessment of pleural effusion has been limited. In the following study, an easy and cost-effective bedside ultrasound method was developed and investigated for specific use in the intensive care unit (ICU).

22 patients (median age: 58.5 years, range: 37–88 years, 14 men and 8 women) with a total of 31 pleural effusions were examined in the ICU. The inclusion criterion was complete visualization of the effusion on chest computed tomography (CT). The ultrasound (US) examination was performed less than 6 h after the diagnostic CT scan. The pleural effusion volume was calculated volumetrically from the CT scan data. Within 4.58 +/- 2.87 h after the CT scan, all patients were re-examined with US in the ICU. The fluid crescent's thickness was measured between each intercostal space (ICS) with the patient in a supine position and a 30° inclination of the torso. The US measurements were compared to the calculated CT volumes using regression analysis, resulting in the following formula: V=13.330 x ICS6 (V=volume of the effusion [ml]; ICS6=sonographic measurement of the thickness of the liquid crescent [mm] in the sixth ICS).

A significant correlation between the sonographically measured and the CT-calculated volumes was best observed for the sixth ICS (R2=0.589; ICC=0.7469 with p<0.0001 and a 95% CI of 0.5364–0.8705).

The sonographic assessment of pleural effusions in a supine position and a 30° inclination of the torso is feasible for the volumetric estimation of pleural effusion. This is especially true for ICU patients with severe primary diseases and orthopnea who are unable to sit upright or lie flat.
Identification of Factors Related to Cases of Benign Paroxysmal Positional Vertigo Refractory to Canalicular Repositioning Maneuvers and Evaluation of the Need for Magnetic Resonance Imaging in their Management: Retrospective Analysis of a Series of 176 Cases
Authors: Carnevale Claudio , Til Pérez Guillermo , Arancibia Tagle Diego , Tomás Barberán Manuel , Sarría Echegaray Pedro
Published: October 2018

Introduction Benign paroxysmal positional vertigo (BPPV) is the most common form of peripheral vertigo, and, in most cases, it presents a favorable prognosis. The treatment is based on a series of specific canalicular repositioning maneuvers that offer an efficacy close to 100%. Despite this, there are cases that are refractory to treatment, with the persistence of the vertigo symptoms.

Objectives The objective of the present paper is to analyze the factors associated with an increased risk of refractory BPPV and the importance of nuclear magnetic resonance in the study of these patients.

Methods We retrospectively reviewed the cases of 176 patients diagnosed with BPPV in our center. We divided them into two groups: responders and non-responders to the treatment, and analyzed the possible risk factors associated with a higher risk of refractory vertigo. Fischer exact test was used.

Results We found 11 cases refractory to treatment; all of them underwent magnetic resonance imaging (MRI) with gadolinium according to our protocol. Of these, four had an otoneurologic background or pathology, and two other patients presented a multicanal involvement. The difference between the two groups was statistically significant (p < 0.05).

Conclusion Otoneurologic background and multicanal involvement were associated with a higher risk of refractory BPPV. When dealing with a BPPV with persistent symptomatology/nystagmus or with early relapse after an initial improvement, other entities that enter into the differential diagnosis must always be considered. We consider it essential to perform an MRI with gadolinium to rule out cases of BPPV that have a central cause.
The Physiologic and Psychophysical Consequences of Severe-to-Profound Hearing Loss
Authors: Hoover Eric , Souza Pamela
Published: October 2018

Substantial loss of cochlear function is required to elevate pure-tone thresholds to the severe hearing loss range; yet, individuals with severe or profound hearing loss continue to rely on hearing for communication. Despite the impairment, sufficient information is encoded at the periphery to make acoustic hearing a viable option. However, the probability of significant cochlear and/or neural damage associated with the loss has consequences for sound perception and speech recognition. These consequences include degraded frequency selectivity, which can be assessed with tests including psychoacoustic tuning curves and broadband rippled stimuli. Because speech recognition depends on the ability to resolve frequency detail, a listener with severe hearing loss is likely to have impaired communication in both quiet and noisy environments. However, the extent of the impairment varies widely among individuals. A better understanding of the fundamental abilities of listeners with severe and profound hearing loss and the consequences of those abilities for communication can support directed treatment options in this population.
Religions, poverty reduction and global development institutions
Authors: Tomalin Emma
Published: October 2018

Religious traditions have always played a central role in supporting those experiencing poverty, through service delivery as well as the provision of spiritual resources that provide mechanisms for resilience at both the individual and community level. However, the fact that religions can be seen to support social structures and practices that contribute towards inequality and conflict, also underscores a role for religious traditions in creating conditions of poverty. While the Western-led modern global development institutions that have emerged since the Second World War have tended to be secular in nature, over the past decade or so there has been an apparent ‘turn to religion’ by these global development institutions, as well as in academic development studies. This reflects the realization that modernization and secularization do not necessarily go together, and that religious values and faith actors are important determinants in the drive to reduce poverty, as well as in structures and practices that underpin it. This paper traces three phases of engagement between religions and global development institutions. In phase one, the ‘pre-secular’ or the ‘integrated phase’ seen during the colonial era, religion and poverty reduction were intimately entwined, with the contemporary global development project being a legacy of this. The second phase is the ‘secular’ or the ‘fragmented’ phase, and relates to the era of the global development industry, which is founded on the normative secularist position that modernization will and indeed should lead to secularization. The third phase is characterized by the ‘turn to religion’ from the early 2000s. Drawing the three phases together and reflecting on the nature of the dynamics within the third phase, the ‘turn to religion’, this paper is underpinned by two main questions. First, what does this mean for the apparent processes of secularization? Is this evidence that they are being reversed and that we are witnessing the emergence of the ‘desecularization of development’ or of a ‘post-secular development praxis’? Second, to what extent are FBOs working in development to be defined as neo-liberalism’s ‘little platoons’—shaped by and instrumentalized to the service of secular neo-liberal social, political and economic systems, or do we need to develop a more sophisticated account that can contribute towards better policy and practice around poverty reduction?
Correction: A bibliometric analysis of the interdisciplinary field of cultural evolution
Authors: Youngblood Mason , Lahti David
Published: October 2018

In the original version of the manuscript the legend of Figure 2 was ambiguous as to how individuals were excluded from the network to maximize legibility, potentially leading to the perception that it may have been a subjective decision on the authors’ part. As such, a higher resolution image has been included in Figure 2, and additional detail in the legend. These changes do not reflect a change in the study’s underlying data or results.
Recent advances in Wigner function approaches
Authors: Weinbub J. , Ferry D. K.
Published: October 2018

The Wigner function was formulated in 1932 by Eugene Paul Wigner, at a time when quantum mechanics was in its infancy. In doing so, he brought phase space representations into quantum mechanics. However, its unique nature also made it very interesting for classical approaches and for identifying the deviations from classical behavior and the entanglement that can occur in quantum systems. What stands out, though, is the feature to experimentally reconstruct the Wigner function, which provides far more information on the system than can be obtained by any other quantum approach. This feature is particularly important for the field of quantum information processing and quantum physics. However, the Wigner function finds wide-ranging use cases in other dominant and highly active fields as well, such as in quantum electronics—to model the electron transport, in quantum chemistry—to calculate the static and dynamical properties of many-body quantum systems, and in signal processing—to investigate waves passing through certain media. What is peculiar in recent years is a strong increase in applying it: Although originally formulated 86 years ago, only today the full potential of the Wigner function—both in ability and diversity—begins to surface. This review, as well as a growing, dedicated Wigner community, is a testament to this development and gives a broad and concise overview of recent advancements in different fields.
Electronic structure and magnetism of SrTi1-xMnxO3 ceramics
Authors: Dang N. T. , Long Phan The , Kozlenko D. P. , Petrov Dimitar N. , Ho T. A. , Tran N. , Yang D. S.
Published: October 2018

Having reviewed the previous studies on Mn-doped SrTiO3 materials, we found that Mn2+ and/or Mn4+ ions are usually present in the SrTiO3 host lattice and lead to paramagnetic, spin-glass, or ferromagnetic (FM) behavior. Mn2+ can occupy at both octahedral (Ti) and dodecahedral (Sr) sites, while Mn4+ only occupies the Ti site. To get more insight into this material system, we have prepared polycrystalline SrTi1-xMnxO3 (x = 0–0.10) samples by solid-state reactions. The results obtained from analyzing the powder X-ray diffraction patterns, and Raman scattering, X-ray absorption, and electron-spin-resonance spectra indicate an incorporation of Mn2+ and Mn3+ ions into the SrTiO3 host lattice. Isolated Mn2+ ions are dominant in the samples with x ≤ 0.02 and can occupy both Ti and Sr sites, leading to two sets of the hyperfine sextet lines. An increase in the Mn content with x > 0.02 enhances the Mn3+ concentration and stimulates the formation of a minor tetragonal phase besides the main cubic phase of SrTiO3. This enhances the Lorentzian-shaped broad background line of dipolar and magnetic interactions between Mn ions. Besides the resonant signals of isolated Mn2+ ions and dipolar/magnetic interactions between Mn ions, there is also the resonant signal associated with intrinsic defects. We believe that intrinsic defects together with the Mn doping at suitable concentrations (x > 0.02) are an important pivot for tailoring room-temperature FM order in SrTi1-xMnxO3 ceramics.
Ultrafast pulse characterization method is updated and optimized for picosecond applications
Authors: Majors J. H.
Published: October 2018

Frequency-resolved optical gating, a pulse characterization typically available only to femtosecond systems, is adapted for single-shot characterization of high-intensity picosecond lasers.
How can we restore the generality of the General Theory?
Authors: Togati Teodoro Dario
Published: October 2018

In this paper, I tackle the key issue raised by Pasinetti, namely why Keynes failed to accomplish his revolution and build a unifying ‘monetary theory of production’ framework. I argue that this occurred because, following his Marshallian background, he adopted an oversimplified view of the structure of theories, a problem which, following Leontief, might be labelled as ‘implicit theorising’ (IT). By making a comparison between the General Theory and standard macroeconomics based on Lakatos’s ‘research programme’ notion, this paper explores IT in a systematic fashion and stresses two key points. First, Keynes did not attack the ‘true’ orthodox postulates but only the conclusions deriving from them. Secondly, he failed to articulate his own research programme effectively. Based on these points, the paper concludes that filling such gaps in Keynes’s theory is the precondition for restoring his generality claim.
Widows, Native Law and the Long Shadow of England in Thirteenth-Century Wales
Authors: Cavell Emma
Published: October 2018

This article examines complex core–periphery relationships in the medieval British Isles and, for the first time, explores the role of elite women in facilitating and shaping those relationships. It takes the advent of English-style dower in native Wales before Wales’s conquest by Edward I of England (1282) as a case-study, and explores the interrelationship between ‘law’ and ‘custom’ in the native legal culture, in order to shed new light on Wales’s relationship with England in the final eighty or so years of Welsh independence. It contends not only that Wales, like other ‘peripheral’ regions of the British Isles, was complicit (however unwittingly) in its own subjection to the English ‘core’, but also that the elite women for whom the dower provisions were made were integral to the very processes of cultural exchange that led to the development of ‘Welsh dower’. While modelled on English common law provisions, Welsh dower—a hybrid phenomenon—was also consistent with Welsh legal norms. By variously turning to the law courts, and employing extra-curial and extra-legal methods of negotiation and redress, the women helped to shape and promote these changes, and to embed them in native Welsh before its final conquest by England. It also makes clear not only that the experiences of Wales in these matters differed from those of other of England’s insular neighbours, such as Ireland, but also that the right of these women to suitable provision was always upheld, no matter how mixed or contested the legal environment.
Johnson, ‘Misargyrus’, and Richard Bathurst
Authors: Dixon Peter , Mannion David , Burgess W G
Published: October 2018

Four letters in the Adventurer are currently attributed to Johnson, who allegedly disguised his style so that they could be plausibly ascribed to his friend Richard Bathurst. A stylometric analysis, supported by internal evidence, finds the case for disguise implausible, and suggests that the letters are a collaboration between Johnson and Bathurst.
Use of Thrombolytics
Authors: Scappaticci Albert. A. , Patel Ronak , Ahn Sun Ho
Published: October 2018

This chapter recounts the history of thrombolytic agents, those agents currently available, and indications for use. Clinical agents have expanded over the 80 years since they were discovered, primarily in the pleural space. Thrombolytic agents can be administered systemically (i.e., intravenously) to treat ischemic stroke, massive pulmonary embolism (PE), and acute myocardial infarction. They also can be delivered directly to the site of a thrombus via catheter, also known as catheter-directed therapy (CDT). To perform CDT safely and effectively, an understanding of the pharmacology and technical aspects of delivering agents is critical. This chapter will review in detail the indications for use, contraindications to CDT, technical aspects, and specific recommendations for monitoring during use.
Superficial Venous Disease
Authors: Winokur Ronald S. , Abbey-Mensah Geraldine , Khilnani Neil M.
Published: October 2018

Superficial venous insufficiency (SVI) is an extremely common condition affecting up to 39% of Americans, which results in significant patient morbidity and high healthcare costs (up to $3 billion per year for treatment). In addition to patients with asymptomatic spider veins and painful varicose veins, over 2 million adults have advanced chronic venous disease (CVD), and at least 20,000 individuals develop new venous ulcers each year. Patients suffering from venous insufficiency can benefit greatly from office-based, minimally invasive treatments. Successful treatment depends on understanding of superficial venous anatomy and pathophysiology, how to conduct a targeted history and physical exam, and performance and interpretation of Duplex ultrasound (DUS), as well as knowledge and application of the available treatment options.
Peripheral Nerve Neurosurgery
Authors: Yang Lynda J-S
Published: October 2018

This book presents cases in peripheral nerve surgery divided into four distinct areas of pathology: entrapment and inflammatory neuropathies, peripheral nerve pain syndromes, peripheral nerve tumors, and peripheral nerve trauma. Each chapter also presents pearls for the accurate diagnosis of, successful treatment of, and effective complication management for each clinical entity. The latter three focus areas will be especially helpful to neurosurgeons preparing to sit for the American Board of Neurological Surgery oral examination, which bases scoring on the three areas. Finally, each chapter contains a review of the medical evidence and expected outcomes, which is helpful for counseling patients and setting accurate expectations. Rather than exhaustive reference lists, the authors provide selected references recommended to deepen understanding.
Failed Carpal Tunnel Release—Recurrent Carpal Tunnel Syndrome
Authors: Winfree Christopher J.
Published: October 2018

Peripheral nerve decompression is the typical definitive treatment for peripheral nerve entrapment. Unfortunately, some patients continue to have pain after surgical decompression. A careful history, physical examination, electrodiagnostic studies, laboratory studies, and imaging can help determine why this occurs and whether further surgery is warranted, as it may not be necessary in all cases.
Ulnar Neuropathy—Cubital Tunnel Syndrome
Authors: Cheng Ron Ron , Varma Abhay K.
Published: October 2018

The chapter presents the typical scenario of ulnar nerve entrapment at the elbow. The clinical picture can mimic pathology of nerve roots, of the brachial plexus, or of the ulnar nerve at different sites. Electrodiagnostic study helps to differentiate ulnar nerve entrapment from radiculopathy and to localize the site of compression, while imaging (ultrasound and MR imaging) are useful adjuncts to clinical examination. Conservative management is recommended for intermittent symptoms and absence of motor involvement. Surgical procedures include in situ, open, or endoscopic decompression and nerve transposition. Subluxation of the nerve over the medial epicondyle and recurrent or persistent neuropathy after in situ decompression are indications for transposition.
Radial Neuropathy—Saturday Night Palsy and Posterior Interosseous Neuropathy
Authors: Mansinghani Sethesh , Qi Xiaoming , Huang Jason H.
Published: October 2018

The chapter presents a case of radial neuropathy—specifically, a patient who presented with weakness in his left hand after a fall 2 months earlier. The patient had significant weakness in the fingers of the left hand on physical examination. The assessment process is outlined, along with differential diagnosis of radial nerve entrapment at the spiral groove and posterior interosseous neuropathy. Diagnostic pearls, physical examination findings, and indications for surgical intervention are discussed. A detailed description of the surgical exploration is supplied, along with illustrations of both the surgical incision and intraoperative landmarks.
Neurogenic Thoracic Outlet Syndrome
Authors: Lavergne Pascal , Khuong Hélène T.
Published: October 2018

Neurogenic thoracic outlet syndrome is an entrapment neuropathy involving the brachial plexus along its trajectory from the cervical spine to the axilla. Clinical presentation includes cervical and upper extremity pain as well as neurologic signs and symptoms in the lower trunk territory. Radiologic and electrophysiologic studies are helpful adjuncts in correctly identifying the site of compression. Initial management is usually conservative, with medication, physical therapy, nerve blocks, or botulinum toxin injection. Surgery often consists of brachial plexus neurolysis and removal of compression points through the supraclavicular approach. Good outcomes can be expected with careful patient selection, but available literature is of limited quality.
Tibial Neuropathy—Tarsal Tunnel Syndrome
Authors: Lyons Daniel A. , Brown David L.
Published: October 2018

Tarsal tunnel syndrome (TTS) is caused by compression of the tibial nerve and its branches within the tarsal tunnel at the ankle. The diagnosis of TTS is often made clinically, but imaging and electrodiagnostic studies should be considered when the diagnosis cannot be ascertained from the clinical history and physical examination. Surgical decompression of the tarsal tunnels should be pursued only after conservative measures have failed or when a space-occupying lesion or point of tibial nerve compression has been identified. Surgical intervention requires complete release of the flexor retinaculum at the medial ankle, as well as release of the three distinct tunnels enveloping the medial and lateral plantar nerves and the calcaneal branch. Success rates for tibial nerve decompression vary widely in the literature, ranging from 44% to 96%.
Piriformis Syndrome and Other Nerve Entrapments of the Posterior Pelvis
Authors: Filler Aaron G.
Published: October 2018

Not every case of neurologically based pelvic/genital numbness/incontinence is due to cauda equina syndrome. Pelvic pain, incontinence, and sexual dysfunction can result from treatable peripheral nerve injury or entrapment affecting the pudendal nerves or impar ganglion. Learning the signs, physical exam findings, tests, and surgical options greatly expands a neurosurgeon’s range. The pudendal nerve and nerve to the obturator internus muscle arise after S2, S3, and S4 spinal nerves traverse the piriformis muscle. They exit the sciatic notch with the sciatic nerve but then re-enter the pelvis, where the pudendal nerve then gives off bladder, rectal, and genital branches.
Brachial Plexitis—Parsonage-Turner Syndrome
Authors: Hearn Sandra
Published: October 2018

The chapter provides a case-based review of Parsonage-Turner syndrome. Parsonage-Turner syndrome, also known as neuralgic amyotrophy and idiopathic brachial plexitis, represents immune-mediated inflammation of neural structures within the brachial plexus and peripheral nerves of the upper limb. Classic features include sudden-onset shoulder or upper arm pain, followed by weakness in the forequarter or limb. This pattern, in addition to nonmechanical and nonradicular clinical features, should prompt consideration of Parsonage-Turner syndrome diagnosis. The diagnosis is established on clinical grounds, although electrodiagnostic data and advanced imaging can support the impression. Management is conservative. For neurosurgeons, accurate diagnosis of Parsonage-Turner syndrome can avoid unnecessary and inappropriate surgical intervention when symptoms are erroneously ascribed to another cause.
Peripheral Nerve Biopsy
Authors: Popadich Miriana , Wilson Thomas J.
Published: October 2018

Nerve biopsy is an important part of the diagnostic armamentarium in the evaluation of a number of diseases, including vasculitis, some hereditary neuropathies, toxic and metabolic neuropathies, inflammatory demyelinating conditions (such as chronic inflammatory demyelinating polyneuropathy), and neoplastic and nonneoplastic infiltrative diseases, such as sarcoidosis, amyloidosis, neurolymphomatosis, and other metastatic tumor infiltration. Options for nerve biopsy include whole-nerve biopsy (e.g., biopsy of the sural nerve, superficial peroneal nerve, or superficial sensory radial nerve) or targeted fascicular biopsy. This chapter identifies indications for nerve biopsy, discusses important considerations for choosing the biopsy target, and explains in detail the surgical procedure for common nerve biopsies.
Occipital Neuralgia
Authors: Keifer Orion Paul , Bezchlibnyk Yarema B. , Diaz Ashley , Boulis Nicholas
Published: October 2018

Occipital neuralgia is described as unilateral or bilateral paroxysmal, stabbing pain in the occipital distribution that often is associated with tenderness and occasionally is associated with dysesthesia. Typically, patients are treated conservatively with pharmacologic agents (e.g., NSAIDs, muscle relaxants, antiepileptics); however, conservative treatment has a high failure rate, often resulting in an interventional procedure (e.g., local nerve block, botulinum toxin injection) or surgery (e.g., ganglionectomy, neurectomy, or neuromodulation). The chapter reviews the surgical interventions, with an emphasis on the approach, management, and complications. Further, the expected outcomes and the evidence for each approach are discussed.
Neuropathic Groin Pain
Authors: Wong Stacy N. , Jacques Line G.
Published: October 2018

Chronic neuropathic groin pain may be iatrogenic or posttraumatic and can be disabling or even crippling in some individuals. Patients may have significant sleep disturbances and may experience psychosocial effects along with significant physical limitations. A combination of pharmacologic treatments with physical therapy and local infiltrations may be useful. Neurostimulation techniques, including spinal cord stimulation, peripheral nerve stimulation, and dorsal root ganglion stimulation, have shown promising results in the treatment of chronic neuropathic pain. In certain cases, surgical approaches, including selective neurectomy, can be effective; in other cases, the pain will remain chronic and intractable despite all interventional measures. In summary, patients with neuropathic groin pain can be treated after a thorough pretreatment investigation. Dorsal root ganglion stimulation is a viable option and should be considered when treating this challenging patient population.
Dumbbell Nerve Sheath Tumors
Authors: Abou-Al-Shaar Hussam , Mahan Mark A.
Published: October 2018

A dumbbell tumor is a nerve sheath tumor that arises from a spinal nerve in the neural foramen and grows as a dumbbell-shaped mass. The differential diagnosis for a dumbbell tumor includes schwannoma, neurofibroma, malignant peripheral nerve sheath tumor, and metastases, among others. MR imaging is considered the gold-standard imaging modality for diagnosis of dumbbell tumors. Surgical approaches that are tailored to the individual patient’s case can be utilized. The chapter reviews dumbbell tumors, including a case example and covers the incidence, clinical presentation, imaging features, decision-making strategy, surgical approaches, outcomes, and potential complications associated with their management.
Malignant Peripheral Nerve Sheath Tumors
Authors: Hébert-Blouin Marie-Noëlle
Published: October 2018

Malignant peripheral nerve sheath tumors (PNSTs) are soft tissue sarcomas arising from a peripheral nerve or a pre-existing benign nerve sheath tumor or are sarcomas with features of Schwann-cell differentiation. Differentiating between benign and malignant PNSTs can be challenging. The chapter begins with a case example and then discusses assessment, investigations (including imaging), and diagnosis of malignant PNSTs, as well as the steps involved in decision-making about management of a malignant PNST. The surgical principles and goals for resection of a malignant PNST, the adjuvant therapies used in treatment, and the complications and outcomes of treatment are presented.
Adult Total Brachial Plexus Injury
Authors: Nadi Mustafa , Midha Rajiv
Published: October 2018

Total brachial plexus injury (BPI) typically results from high-energy vehicular accidents, affects mostly young adult males, and produces a flail, insensate limb. Because of the association of total BPI with head and cervical spine injuries, diagnosis might be delayed. Recognizing patients with total BPI and using electrodiagnostic and imaging tests in a timely fashion are critical. Advances in microsurgical techniques, primary nerve transfer, appropriate nerve graft utilization from a remaining intact (often C5) spinal nerve root, and free muscle transfers have improved outcomes. However, limited recovery even after reconstruction and severe deafferentation pain both remain challenging problems that further advancements will need to overcome.
Neonatal Brachial Plexus Palsy
Authors: Tse Raymond , Lipira Angelo B.
Published: October 2018

Neonatal brachial plexus palsy occurs in approximately 1 in 1000 live births. The extent of involvement and severity of injury are variable. The chapter discusses assessment, nonsurgical treatment, and surgical treatment of neonatal brachial plexus palsy. The approach to surgical exploration is detailed and a number of scenarios are presented so that the principles of primary nerve reconstruction (including nerve graft and nerve transfers) can be illustrated. The scenarios include upper plexus injury, pan-plexus injury, multiple root avulsions, isolated deficits, delayed presentation, and failed reconstruction. Technical details of nerve grafting and nerve transfers are described. Secondary musculoskeletal consequences of brachial plexus palsy are also discussed, including strategies for prevention and options for secondary surgical reconstruction.
Facial Nerve Injury
Authors: Socolovsky Mariano , Torino Rafael , Flores Leandro Pretto
Published: October 2018

This chapter focuses on the clinical and surgical management of facial nerve palsy that occurs as a consequence of injury during resection of a vestibular schwannoma. If the facial nerve is damaged during cerebellopontine angle (CPA) tumor resection, a first attempt to repair it at the skull base should be made. Because this is commonly infeasible, a nerve transfer—scheduled as an elective procedure after the patient has completely recovered from the resection procedure—is mandatory. Hemihypoglossal, masseter, and cross-facial nerve transfers are the techniques most widely used. The authors’ preferred technique is hemihypoglossal nerve transfer, and the surgical technique is described. By contrast, when the facial nerve is preserved during surgery, but complete facial palsy develops afterward, postoperative rehabilitation should be started and continued for up to 1 year. If, however, facial palsy persists beyond 1 year, then the patient should be offered the option of a nerve transfer.
Emergent Nerve Injury
Authors: Hanna Amgad S. , Block Lisa M. , Salyapongse A. Neil
Published: October 2018

Injuries to peripheral nerves must be assessed and treated in a thorough and timely manner to achieve optimal outcomes. Physical examination is the cornerstone in diagnosing acute nerve injuries and includes careful inspection as well as precise motor and sensory testing. Nerve conduction studies and electromyography are often more useful in the setting of delayed presentation. Microsurgical repair techniques differ for clean versus ragged lacerations, and resultant nerve gaps will require a conduit or graft to achieve the necessary tension-free closure. The surgeon and patient should be prepared for a lengthy postoperative course and possible complications as the nerve regenerates and function returns.
Moral Suffering
Authors: Rushton Cynda Hylton
Published: October 2018

Moral suffering is common in clinical practice. It can be defined as the anguish that caregivers experience in response to various forms of moral adversity, such as moral harms, wrongs or failures, or unrelieved moral stress, that in some way imperil integrity. There are various types of moral suffering that arise from myriad sources that involve witnessing, participating in, or directly precipitating situations that produce a wide range of negative moral outcomes. Threats to integrity may accompany particular aspects of healthcare professionals’ practice and can contribute to disengagement and alienation from their professions, the people they serve, their organizations, and themselves. Transforming moral suffering will require individual and systemic reforms.
Moral Distress
Authors: Carse Alisa , Rushton Cynda Hylton
Published: October 2018

Moral distress, a response to moral adversity that imperils integrity under conditions of constraint, has been studied for more than three decades. The context of clinical practice, the complexities of healthcare, clinicians’ roles, and broader society, alongside exponential advances in technology and treatment, create circumstances that regularly imperil integrity. These circumstances create the conditions for burnout, disengagement, and imperiled patient care. Specifically, they foster powerlessness, frustration, anger, diminished moral responsiveness, disillusionment, and shame. The cumulative dynamic of moral distress results in myriad detrimental consequences affecting the bodies, emotions, minds, and souls of clinicians. Transforming these experiences requires a shift in orientation toward restoring and preserving integrity by cultivating capacities of moral resilience and strategies to foster systemic ethical practice.
The Many Faces of Resilience
Authors: Rushton Cynda Hylton
Published: October 2018

Resilience allows some clinicians to navigate the inevitable ethical challenges and moral suffering they face without the despair and hopelessness that others experience. It is the ability to withstand, adapt, recover or grow in response to adversity, trauma, or stress. It presumes that humans have an innate resilient potential that can be influenced and includes a process that unfolds in response to diverse types of adversity. Resilience is a multifaceted construct that has been applied in various contexts, including neurobiology, psychology, social ecology, and clinical practice. This chapter examines each of these contexts and highlights their implications for conceptualizing moral resilience.
Designing Sustainable Systems for Ethical Practice
Authors: Rushton Cynda Hylton , Sharma Monica
Published: October 2018

A conceptual basis for designing individual, team, and system interventions to cultivate individual moral resilience and a culture that enables ethical practice is necessary to create sustainable solutions to address moral adversity. It broadens the lens of inquiry to focus on culture, inviting a more robust view of the elements that support ethical practice as well as individual, team, and organizational integrity. Responses to moral adversity are typically partial. In contrast, the Conscious Full Spectrum approach responds to diverse conditions that cause moral adversity to help people innovate, generate breakthroughs, and sustain the specific change that is needed to establish the desired result. This approach helps change-makers recognize patterns, create alternatives, and design tactics, programs, or initiatives that cultivate moral resilience and foster a culture of ethical practice. Individual, team, and organizational interventions are vital in shifting the culture of a healthcare organization.
Creating a Culture of Moral Resilience and Ethical Practice
Authors: Rushton Cynda Hylton , Sharma Monica
Published: October 2018

Large-scale change is not possible without aligning individual and collective values, wisdom, and commitment to the architecture needed to support ethical practice. The process required for designing a system that supports ethical practice on a moment-to-moment basis involves synergistic operational strategies. These include personal transformational learning, information for decision-making, supporting principled change-makers and risk-takers, and creating an enabling work environment. Transformational design and action involve using practices, techniques, and methods that source inner capacity at every step of planning and implementation and embodying foundational values. Transformational design leverages key elements of co-creating new patterns, developing new norms and systems for sustainable change, transcending disempowering patterns, and creating a new narrative.
Preventive Analgesia for the Management of General Surgical Pain
Authors: Qureshi M. A. , Gan J. H. , Kunnumpurath S. , Pau Clara , Kai Alice , Mirsky Zachariah , Park William , Vadivelu Nalini
Published: October 2018

Pain created by surgery has the ability to produce both structural and functional changes in pain pathways. These changes may be reduced if timely and adequate pain relief is delivered to the patient. Poor control of pain can result in remodeling of the “hardwired” pathways involved in pain transmission, which can result in central sensitization and hyperalgesia. Furthermore, poorly controlled pain and delay in its recognition may lead to a chronic pain state, further complicating the patient’s recovery and quality of life. A multimodal approach taking into account psychosocial aspects of the patient is more likely to mitigate the development of chronic postsurgical pain (CPSP).
Perioperative Nonopioid Analgesics of Use in Pain Management for Spine Surgery
Authors: Fomberstein Kenneth , Rubin Michael , Patel Dipan , Truszkowska Ivona , Gabriel Farkas S.
Published: October 2018

This chapter examines the developing role of multimodal analgesia in reducing opioid requirements/dependency in the postoperative period while also facilitating the recovery process without the unwanted adverse side effects associated with opioid use. It reviews a number of medications used in a multimodal regimen including NMDA receptor antagonists, α‎2 agonists, dexamethasone, gabapentinoids, acetaminophen, NSAIDs, COX-2 selective inhibitors, caffeine, and lidocaine. This chapter also discusses the evidence and implications for the use of a specific medication and in which perioperative setting its use has been corroborated. This chapter includes relevant tables and is written for qualified specialist attendings, fellows, residents, and nurses as well as all practitioners involved in the treatment of pain following spine surgery.
Local Anesthetics
Authors: Thomas Donna-Ann
Published: October 2018

Local anesthetics, if utilized properly, can be a powerful tool in perioperative pain control. They are good adjuvants to traditional modes of anesthesia and analgesia while offering unique qualities of their own. Understanding the pharmacodynamics and pharmacokinetics of local anesthetics allows for utilization in the perioperative period that significantly improves patient pain control as well as the patient’s surgical experience. This chapter explores the mechanisms of action, the pharmacology and pharmacodynamics, the pharmacokinetics, and the clinical uses and toxicities for common local anesthetics, especially as these pertain to spinal surgery. In addition, detailed descriptions are given of common local anesthetics, along with dosing guidelines, contraindications, and side-effect profiles.
Susceptibility of Peripheral Nerves in Diabetes to Compression and Implications in Pain Treatment
Authors: Murinova Natalia , Krashin Daniel
Published: October 2018

Diabetes affects a large and growing percentage of the population in most countries of the world. Diabetes causes many different health problems, but among the most severe and disabling is peripheral neuropathy. This progressive, often painful nerve condition causes suffering and disability and also predisposes patients to developing musculoskeletal deformities and foot ulcers that may threaten life and limb. This chapter reviews briefly the significance of this condition, the underlying pathophysiology, and surgical considerations. Surgical decompression is a possible treatment for this neuropathy and may help prevent disastrous complications of diabetic peripheral neuropathy. However, foot surgery in the setting of diabetic peripheral neuropathy also carries significant risks.
Cervical Spine
Authors: Thakur Siddarth , Abdi Salahadin
Published: October 2018

Pain emanating from the cervical spine represents a significant diagnostic and therapeutic challenge for clinicians. The precise etiology of the pain may be difficult to identify because there are many potential pain-generating structures in the cervical spine and surrounding region. It is helpful to delineate the patient’s symptoms as axial- or radicular-predominant in order to guide the investigation prior to initiating treatment. The evidence for many commonly used treatment regimens is variable, and therefore an individualized plan is often necessary. Although it is conceptually accommodating to compartmentalize the etiology of cervical spine pain from a single source, the reality is that multiple structures are often involved, given the complex anatomy of the cervical spine. This chapter discusses cervical spine anatomy and biomechanics, as well as the etiology, pathophysiology, and management options for axial and radicular neck pain.
Sacroiliac Pain
Authors: Przkora Rene , Cleveland Sims Richard , Trescot Andrea
Published: October 2018

The sacroiliac joint (SIJ) is often overlooked as a cause of pain, partially because it is not well visualized on standard imaging and partially because other structures may refer pain to it. This chapter reviews the anatomy of the SIJ as well as the diagnosis and differential diagnosis of SI joint dysfunction and pain, including a multitude of physical exam maneuvers such as the FABER, Gaenslen, extension, Gillet’s, sacroiliac shear, thigh thrust, compression, and distraction tests. In addition, it discusses the evidence-based approach to treat sacroiliac pain, with a focus on both conservative and nonconservative approaches such as image-guided steroid injections and radiofrequency denervation procedures and outcomes.
Sympathetic Pain Syndromes
Authors: Candido Kenneth D. , Kusper Teresa M.
Published: October 2018

This chapter is a brief overview of the major sympathetic pain syndromes and their clinical characteristics, treatment, and preventative measures. It offers a concise overview of distinguishing characteristics, pathogenetic mechanisms, available treatment options for major sympathetic pain syndromes, and in-depth discussion pertaining to complex regional pain syndrome (CRPS) and the influence of specific surgical procedures on the development of this syndrome. Risk factors and pathogenetic mechanisms related to the emergence of CRPS after orthopedic and spine surgeries have been analyzed, as well as therapies and practices used preemptively to prevent new CRPS and worsening of chronic pain and disability in the affected limb. Finally, possible therapies for the postsurgical period are discussed to facilitate rehabilitation and speed up recovery after orthopedic and spinal surgeries in this patient population.
Open Endoscopic Rhizotomy
Authors: Gala Raj J. , Szolomayer Lauren , Yue James
Published: October 2018

The etiology of axial low back pain is multifactorial and includes pain arising from lumbar facet joints. The facet joints, capsules, and surrounding tissues are innervated by the medial branches of the dorsal rami. Rhizotomy of these nerves can provide pain relief in patients with lumbar facetogenic pain. The reported benefits of endoscopic approaches to the spine include minimal disruption of nonpathologic anatomy while simultaneously allowing for improved visualization of pathologic anatomy. Endoscopic techniques have been described for spinal stenosis, disc herniation, interbody fusion, infection, as well as dorsal medial branch rhizotomy. The goal of medial branch rhizotomy is to denervate lumbar facet joints that are contributing to axial back pain. The previous chapter focused on percutaneous techniques, while this chapter will describe endoscopic rhizotomy.
Endoscopically Assisted Lumbar Medial Branch Rhizotomy
Authors: Gala Raj J. , Szolomayer Lauren , Cabrejo Raysa , Yue James
Published: October 2018

For patients with multilevel lumbar spondylosis and back pain without leg symptoms, few surgical procedures exist to provide relief of pain. Axial back pain has been attributed in part to pain generated at the facet joints. The lumbar rhizotomy has emerged as an effective method for treatment of axial lumbar back pain in these patients. By performing a limited surgical approach and using an endoscopic method, patients report quick recovery without the pain that typically follows a larger surgical approach. This method provides effective means of ablating the medial branch of the dorsal root, with limited side effects and complications. The history of selective root rhizotomy is discussed, with focus on medial branch neurotomy for treatment of back pain. An endoscopically assisted rhizotomy technique using a minimally invasive approach to the lumbar spine is described. This technique may be expanded for use in other parts of the spine.
Advances in Dorsal Column Stimulation
Authors: Shah Chirag D. , Rana Maunak V.
Published: October 2018

Spinal cord stimulation (SCS) has been a long established therapy for various pain conditions including low back pain, failed back surgery syndrome, complex regional pain syndrome, and other neuropathic and nociceptive pain states. Since the first report of SCS in 1967 by Shealy, advances have occurred in the technology used to achieve clinical analgesia. Developments in both the hardware and software involved have led to significant improvements in functional specificity, as seen in dorsal root ganglion stimulation, along with increasing breadth and depth of the field of neuromodulation. The patient experience during the implantation of the systems, as well as post-procedurally has been enhanced with improvements in programming. These technological improvements have been validated in quality evidenced-based medicine: what was a static area now is a dynamic field, with neuromodulation poised to allow physicians and patients more viable options for better pain control for chronic painful conditions.