Search results for: hypobaric unilateral spinal anesthesia

Authors: Ki Hwa Lee, Eunsu Kang, Jae Hong Park

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Background: Interventional neuroradiology (INR) has been a rapidly growing and evolving neurosurgical part during the past few decades. Sevoflurane and propofol are both suitable anesthetics for INR procedure. Monitoring of depth of anesthesia is being used very widely. SEDLine™ monitor, a 4-channel processed EEG monitor, uses a proprietary algorithm to analyze the raw EEG signal and displays the Patient State Index (PSI) values. There are only a fewer studies examining the PSI in the neuro-anesthesia. We aimed to investigate the difference of PSI values and hemodynamic variables between sevoflurane and propofol anesthesia during INR procedure. Methods: We reviewed the medical records of patients who scheduled to undergo embolization of non-ruptured intracranial aneurysm by a single operator from May 2013 to December 2014, retrospectively. Sixty-five patients were categorized into two groups; sevoflurane (n = 33) vs propofol (n = 32) group. The PSI values, hemodynamic variables, and the use of hemodynamic drugs were analyzed. Results: Significant differences were seen between PSI values obtained during different perioperative stages in both two groups (P < 0.0001). The PSI values of propofol group were lower than that of sevoflurane group during INR procedure (P < 0.01). The patients in propofol group had more prolonged time of extubation and more phenylephrine requirement than sevoflurane group (p < 0.05). Anti-hypertensive drug was more administered to the patients during extubation in sevoflurane group (p < 0.05). Conclusions: The PSI can detect depth of anesthesia and changes of concentration of anesthetics during INR procedure. Extubation was faster in sevoflurane group, but smooth recovery was shown in propofol group.

Keywords: interventional neuroradiology, patient state index, propofol, sevoflurane

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Authors: R. Srinivas, K. V. Ramana

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This paper presents a novel method called VESTAL to label vertebrae and inter vertebral discs. Each vertebra has certain statistical features properties. To label vertebrae and discs, a new equation to model the path of spinal cord is derived using statistical properties of the spinal canal. VESTAL uses this equation for labeling vertebrae and discs. For each vertebrae and inter vertebral discs both posterior, interior width, height are measured. The calculated values are compared with real values which are measured using venires calipers and the comparison produced 95% efficiency and accurate results. The VESTAL is applied on 50 patients 350 MR images and obtained 100% accuracy in labeling.

Keywords: spine, vertebrae, inter vertebral disc, labeling, statistics, texture, disc

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Authors: Imdad Ullah Khan, Yongseok Yoon, Kyeung Uk Choi, Kwang Rae Jo, Namyul Kim, Eunbee Lee, Wan Hee Kim, Oh-Kyeong Kweon

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The primary spinal cord injury (SCI) causes mechanical damage to the neurons and blood vessels. It leads to secondary SCI, which activates multiple pathological pathways, which expand neuronal damage at the injury site. It is characterized by vascular disruption, ischemia, excitotoxicity, oxidation, inflammation, and apoptotic cell death. It causes nerve demyelination and disruption of axons, which perpetuate a loss of impulse conduction through the injured spinal cord. It also leads to the production of myelin inhibitory molecules, which with a concomitant formation of an astroglial scar, impede axonal regeneration. The pivotal role regarding the neuronal necrosis is played by oxidation and inflammation. During an early stage of spinal cord injury, there occurs an abundant expression of reactive oxygen species (ROS) due to defective mitochondrial metabolism and abundant migration of phagocytes (macrophages, neutrophils). ROS cause lipid peroxidation of the cell membrane, and cell death. Abundant migration of neutrophils, macrophages, and lymphocytes collectively produce pro-inflammatory cytokines such as tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), interleukin-1beta (IL-1β), matrix metalloproteinase, superoxide dismutase, and myeloperoxidases which synergize neuronal apoptosis. Therefore, it is crucial to control inflammation and oxidation injury to minimize the nerve cell death during secondary spinal cord injury. Therefore, in response to oxidation and inflammation, heme oxygenase-1 (HO-1) is induced by the resident cells to ameliorate the milieu. In the meanwhile, neurotrophic factors are induced to promote neuroregeneration. However, it seems that anti-stress enzyme (HO-1) and neurotrophic factor (BDNF) do not significantly combat the pathological events during secondary spinal cord injury. Therefore, optimum healing can be induced if anti-inflammatory and neurotrophic factors are administered in a higher amount through an exogenous source. During the first experiment, the inflammation and neuroregeneration were selectively targeted. HO-1 expressing MSCs (HO-1 MSCs) and BDNF expressing MSCs (BDNF MSC) were co-transplanted in one group (combination group) of dogs with subacute spinal cord injury to selectively control the expression of inflammatory cytokines by HO-1 and induce neuroregeneration by BDNF. We compared the combination group with the HO-1 MSCs group, BDNF MSCs group, and GFP MSCs group. We found that the combination group showed significant improvement in functional recovery. It showed increased expression of neural markers and growth-associated proteins (GAP-43) than in other groups, which depicts enhanced neuroregeneration/neural sparing due to reduced expression of pro-inflammatory cytokines such as TNF-alpha, IL-6 and COX-2; and increased expression of anti-inflammatory markers such as IL-10 and HO-1. Histopathological study revealed reduced intra-parenchymal fibrosis in the injured spinal cord segment in the combination group than in other groups. Thus it was concluded that selectively targeting the inflammation and neuronal growth with the combined use of HO-1 MSCs and BDNF MSCs more favorably promote healing of the SCI. HO-1 MSCs play a role in controlling the inflammation, which favors the BDNF induced neuroregeneration at the injured spinal cord segment of dogs.

Keywords: HO-1 MSCs, BDNF MSCs, neuroregeneration, inflammation, anti-inflammation, spinal cord injury, dogs

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Authors: Robnier Reyes, Andrew J. P. Marques, Joel Ramjist, Chris R. Pasarikovski, Victor X. D. Yang

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Over the past three decades, surgical robotic systems have demonstrated their ability to improve surgical outcomes. The LBR Med is a collaborative robotic arm that is meant to work with a surgeon to streamline surgical workflow. It has 7 degrees of freedom and thus can be easily oriented. Position and torque sensors at each joint allow it to maintain a position accuracy of 150 µm with real-time force and torque feedback, making it ideal for complex surgical procedures. Spinal fusion procedures involve the placement of as many as 20 pedicle screws, requiring a great deal of accuracy due to proximity to the spinal canal and surrounding vessels. Any deviation from intended path can lead to major surgical complications. Assistive surgical robotic systems are meant to serve as collaborative devices easing the workload of the surgeon, thereby improving pedicle screw placement by mitigating fatigue related inaccuracies. Moreover, robotic spinal systems have shown marked improvements over conventional freehanded techniques in both screw placement accuracy and fusion quality and have greatly reduced the need for screw revision, intraoperatively and post-operatively. However, current assistive spinal fusion robots, such as the ROSA Spine, are limited in functionality to positioning surgical instruments. While they offer a small degree of improvement in pedicle screw placement accuracy, they do not alleviate surgeon fatigue, nor do they provide real-time force and torque feedback during screw insertion. We propose a semi-autonomous surgical robot workflow for spinal fusion where the surgeon guides the robot to its initial position and orientation, and the robot drives the pedicle screw accurately into the vertebra. Here, we demonstrate feasibility by inserting pedicle screws into ex-vivo bovine rib bone. The robot monitors position, force and torque with respect to predefined values selected by the surgeon to ensure the highest possible spinal fusion quality. The workflow alleviates the strain on the surgeon by having the robot perform the screw placement while the ability to monitor the process in real-time keeps the surgeon in the system loop. The approach we have taken in terms of level autonomy for the robot reflects its ability to safely collaborate with the surgeon in the operating room without external navigation systems.

Keywords: ex vivo bovine bone, pedicle screw, surgical robot, surgical workflow

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Authors: D. R. Apoorva

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Ichthyosis follicularis, alopecia, and photophobia (IFAP) syndrome is a rare oculocutaneous disorder of genetic origin. This disorder results from mutations in the membrane-bound transcription factor protease site, two genes that impair cholesterol homeostasis, and the ability to cope with endoplasmic reticulum stress. We report a rare case of IFAP syndrome with an atypical presentation, and it was interesting to note that the child had patchy non-scarring alopecia over the scalp along with unilateral madarosis. To our best knowledge, this unique presentation has not been described earlier. The child presented with photophobia and unilateral ptosis. The child also had short stature and intellectual disability. Skin histopathology was nonspecific and consisted of dilated hair follicles with keratin plugs extending above the skin surface. This rare oculocutaneous disorder requires proper documentation so that identification of its variants may be possible in the future. Early recognition of atypical presentations can help in preventing cardiovascular complications, which remain the major cause of death.

Keywords: alopecia, photophobia, ichthyosis follicularis, IFAP syndrome

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Authors: Delies L. Alejo

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This study explores the psychosocial influences of Spinal Cord Injury (SCI) on patients in the Philippine Orthopedic Center Hospital in the Philippines, examining their social functioning and proposing interventions for reintegration. Quantitative data were collected through surveys using a concurrent triangulation research design, while qualitative insights were obtained via interviews. Findings revealed significant psychosocial challenges among SCI patients, impacting relationships, family dynamics, work, friendships, parenting, education, and self-care. Demographic profiles indicated variations in psychosocial functioning. The study underscores the importance of tailored interventions for SCI patients based on age, marital status, gender, education, and occupation. Triangulation of data enhanced understanding, revealing four themes: ‘Resilient Navigation of Intimacy and Connection,’ ‘Family Dynamics and Care Challenges,’ ‘Occupational Hurdles and Work Engagement,’ and ‘Social and Community Integration Obstacles.’ The study proposes a holistic intervention plan, addressing emotional challenges, creating support networks, implementing vocational rehabilitation, promoting community engagement, and sustaining collaboration with healthcare professionals.

Keywords: spinal cord injury, psychosocial influences, social functioning, concurrent triangulation, intervention plan

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Authors: Nasrin Nejatbakhsh, Anita Kaiser, Sander Hitzig, Colleen McGillivray

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Following spinal cord injury (SCI), many individuals experience anxiety in adjusting to their lives, and its impacts on their sexuality. Research has demonstrated that regaining sexual function is a very high priority for individuals with SCI. Despite this, sexual health is one of the least likely areas of focus in rehabilitating individuals with SCI. There is currently a considerable gap in appropriate education and resources that address sexual health concerns and needs of people with spinal cord injury. Furthermore, the determinants of sexual health in individuals with SCI are poorly understood and thus poorly addressed. The purpose of this study was to improve current practices by informing a service delivery model that rehabilitation centers can adopt for appropriate delivery of their services. Methodology: We utilized qualitative methods in the form of a semi-structured interview containing open-ended questions to assess 1) sexual health concerns, 2) helpful strategies in current resources, 3) unhelpful strategies in current resources, and 4) Barriers to obtaining sexual health information. In addition to the interviews, participants completed surveys to identify socio-demographic factors. Data gathered was coded and evaluated for emerging themes and subthemes through a ‘code-recode’ technique. Results: We have identified several robust themes that are important for SCI sexual health resource development. Through analysis of these themes and their subthemes, several important concepts have emerged that could provide agencies with helpful strategies for providing sexual health resources. Some of the important considerations are that services be; anonymous, accessible, frequent, affordable, mandatory, casual and supported by peers. Implications: By incorporating the perspectives of individuals with SCI, the finding from this study can be used to develop appropriate sexual health services and improve access to information through tailored needs based program development.

Keywords: spinal cord injury, sexual health, determinants of health, resource development

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Authors: Vahid Mehrabi, Iman Sharifi, H. A. Talebi

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The automation of rehabilitation procedure by the implementation of robotic devices can overcome the limitation in conventional physiotherapy methods by increasing training sessions and duration of process. In this paper, the design of a simple rehabilitation robot for forearm-wrist therapy in stroke and spinal cord injuries is presented. Wrist’s biological joint motion is modeled by a gimbal-like mechanism which resembles the human arm anatomy. Presented device is an exoskeleton robot with rotation axes corresponding to human skeleton anatomy. The mechanical structure, actuator and sensor selection, system kinematics and comparison between our device range of motion and required active daily life values is illustrated.

Keywords: rehabilitation, robotic devices, physiotherapy, forearm-wrist

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Authors: Li-Ting Kung, Hui-Zhu Chen, Hsin-Tzu Lee, Wan-Yin Hsu

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Patients with spinal cord injury combined with diabetic nephropathy may under a lot of painful conditions due to complications related to the illness itself or treatments, such as recurrent pressure ulcers, autonomic and peripheral neuropathy, as well as dialysis, for long term. This case report illustrated the nursing experience of transferring a spine cord injure patient who received hemodialysis due to adverse lifestyle-induced diabetic nephropathy to the hospice ward. Nursing care was provided in this patient from July 25th to August 30th, 2015. The tool of 'Gordon’s 11-item functional health assessment' and clinical observation, interviews as well as physical examination were used as data collections. Based on results of health assessment as above, the patient’s health problems were identified as the following: impaired skin integrity, chronic pain, and hopeless. Besides to relieve the symptom of pain due to disease or the treatment of hemodialysis and provide wound care, the first author also played a role to assist the patient to achieve his goal of receiving the hospice palliative care. Finally, with much effort of nurses to communicate with medical teams between the surgical and hospice wards, the patient was transferred to the hospice ward to have fulfilled his last wish of having a good death. We hope this nursing experience can be applied to other similar cases in the future.

Keywords: diabetic nephropathy, hospice care, palliative care, spinal cord injury

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Authors: Kunal K. S., Shwetashri K. R., Keerthan G., Ajinkya R.

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Background: Normal pressure hydrocephalus is a condition caused by abnormal accumulation of cerebrospinal fluid (CSF) within the brain resulting in enlarged cerebral ventricles due to a disruption of CSF formation, absorption, or flow. Over the course of time, ventriculoperitoneal shunt under general anesthesia has become a standard of care. Yet only a finite number of centers have started the inclusion of regional anesthesia techniques for the such patient cohort. Stem Case: We report a case of a 75-year-old male with underlying aortic sclerosis and cardiomyopathy who presented with complaints of confusion, forgetfulness, and difficulty in walking. Neuro-imaging studies revealed disproportionally enlarged subarachnoid space hydrocephalus (DESH). The baseline blood pressure was 116/67 mmHg with a heart rate of 106 beats/min and SpO2 of 96% on room air. The patient underwent smooth induction followed by sonographically guided superficial cervical plexus block and transverse abdominis plane block. Intraoperative pain indices were monitored with Analgesia nociceptive index monitor (ANI, MdolorisTM) and surgical plethysmographic index (SPI, GE Healthcare, Helsinki, FinlandTM). These remained stable during the application of the block and the entire surgical duration. No significant hemodynamic response was observed during the tunneling of the skin by the surgeon. The patient underwent a smooth recovery and emergence. Conclusion: Our decision to incorporate peripheral nerve blockade in conjunction with general anesthesia resulted in opioid-sparing anesthesia and decreased post-operative analgesic requirement by the patient. This blockade was successful in suppressing intraoperative stress responses. Our patient recovered adequately and underwent an uncomplicated post-operative stay.

Keywords: desh, NPH, VP shunt, cervical plexus block, transversus abdominis plane block

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Authors: Robert C. Pritchett, Elizabeth Broad, Kelly L. Pritchett

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Individuals a with spinal cord injuries have been suggested to be at risk for a 25(OH)D insufficiency. However, little is known regarding the relationship between seasonal Vitamin D status and performance in a spinally injured athletic population. Purpose: The purpose of this study was: 1) to examine the seasonal change in 25(OH)D concentrations and 2) to determine whether 25(OH)D status impacts athletic performance in US Paralympic athletes. Methods: 25 (OH)D concentrations were measured in 11 outdoor track athletes ( 5 men/6 females), between fall (October/November) and winter(February). Dietary intake and lifestyle habits were assessed via questionnaire, and performance measurements were assessed using a 20meter sprint test. 25(OH)D concentrations were assessed using a blood spot method (ZRT Laboratory). Results: There was no significant change in 25 (OH) D concentrations across seasons (P=0.505; 31 + 6.35 ng/mL, 29 + 8.72 ng/mL (mean + SD) for Fall and Winter, respectively. In the Fall,42% of the athletes had sufficient levels (>32ng/mL), and 58% were insufficient. (20ng/mL -31ng/mL) where as the winter levels dropped with 33% being sufficient and 58% being insufficient and 1% being deficient (<20ng/mL). There was a weak but significant correlation between a change in 25(OH)D concentrations, and change in 20m sprint time (p<0.05; r=0.408). Conclusion: A substantial proportion of elite athletes with an SCI have low vitamin D status. However, results suggest there was little seasonal variation in 25(OH)D status in elite track athletes with an SCI. Furthermore, any change that was observed demonstrated a very weak relationship with a change in performance.

Keywords: 25(oh)d, performance, spinal cord injuries, elite, sprint, concentration

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Authors: Won Man Park, Dae Kyung Choi, Kyungsoo Kim, Yoon Hyuk Kim

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Traction therapy has been used in the treatment of spinal pain for decades. However, a case study reported the occurrence of large disc protrusion during motorized traction therapy. In this study, we hypothesized that additional local decompression with a global axial traction could be helpful for risk reduction of intervertebral disc damage. A validated three dimensional finite element model of the lumbar spine was used. Two-step traction therapy using the axial global traction (the first step) with 1/3 body weight and the additional local decompression (the second step) with 7 mm translation of L4 spinal bone was determined for the traction therapy. During two-step traction therapy, the sacrum was constrained in all translational directions. Reduced lordosis angle by the global axial traction recovered with the additional local decompression. Stress on fibers of the annulus fibrosus by the axial global traction decreased with the local decompression by 17%~96% in the posterior region of intervertebral disc. Stresses on ligaments except anterior longitudinal ligaments in all motion segments decreased till 4.9 mm~5.6 mm translation of L4 spinal bone. The results of this study showed that the additional local decompression is very useful for reducing risk of damage in the intervertebral disc and ligaments caused by the global axial traction force. Moreover, the local decompression could be used to enhance reduction of intradiscal pressure.

Keywords: lumbar spine, traction-therapy, biomechanics, finite element analysis

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Authors: Jarmila Štěpánová, Martin Kudláček, Lukáš Jakubec

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The people with spinal cord injury are one of the least sport active members of our society. Their hypoactivity is determined by primary injury, i.e., the loss of motor function, the injured part of the body is connected with health complications and social handicap. Study performs one part of the standardization process of semi-structured interview PARA-SCI.CZ (Czech version of the Physical Activity Recall Assessment for People with Spinal Cord Injury), which measures the type, frequency, duration, and intensity of physical activity of people with spinal cord injury. The study focused on persons with paraplegia who use a wheelchair as their primary mode of mobility. The aim of this study was to perform a process to determine the criterion validity of PARA-SCI.CZ. The actual physical activity of wheelchair users was monitored during three days by using accelerometers Actigraph GT3X fixed on the non-dominant wrist, and semi-structured interview PARA-SCI.CZ. During the PARA-SCI.CZ interview, participants were asked to recall activities they had done over the past 3 days, starting with the previous day. PARA-SCI.CZ captured frequency, duration, and intensity (low, moderate, and heavy) of two categories of physical activity (leisure time physical activity and activities of a usual day). Accelerometer Actigraph GT3X captured duration and intensity (low and moderate + heavy) of physical activity during three days and nights. The study presented three potential recalculations of measured data. Standardization process of PARA-SCI.CZ is essential to critically approach issues of health and active lifestyle of persons with spinal cord injury in the Czech Republic. Standardized PARA-SCI.CZ can be used in practice by physiotherapists and sports pedagogues from the field of adapted physical activities.

Keywords: physical activity, lifestyle, paraplegia, semi-structure interview, accelerometer

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Authors: Maryam Kiani, Abdul Basit Kiani

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Simple hydrothermal method to synthesize new nanocomposites consisting of nitrogen-doped graphene and NiFe₂O₄. By analyzing the X-Ray Powder Diffraction (XRD) images, we confirmed that the NiFe₂O₄ phase is pure and has a Face Centered Cubic (FCC) structure. The average size of the NiFe₂O₄ nanoparticles is approximately 40±2 nm. Additionally, we used X-ray photoelectron spectroscopy (XPS) to study the surface chemical composition and cation oxidation states of both the NiFe₂O₄ nanoparticles and the nitrogen-doped graphene/NiFe₂O₄ nanocomposites. A magnetic interaction between nitrogen doped graphene/NiFe₂O₄ was studied. Increases in hydrothermal synthesis temperature lead to the improved crystalline structure of NiFe₂O₄ nanoparticles, which improves the magnetic properties.

Keywords: nickel ferrite spinal, nitrogen doped graphene, magnetic nanocomposite, hydrothermal synthesis

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Authors: William Thomas Worster

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Diplomatic assurances issued by states declaring that they will not mistreat individuals returned to them occupy a strange middle ground between being legal and non-legal obligations. States assert that they are non-binding, yet at other times that they are binding. However, this assertion may not be the end of the discussion. The International Court of Justice and other tribunals have concluded that similar instruments were binding, states have disagreed that certain similar instruments were binding, and the Vienna Convention on the Law of Treaties and its travaux prépératoires do not appear to contemplate non-binding instruments. This paper is a case study of diplomatic assurances but, by necessity, touches on the delicate question of whether certain texts are treaties, promises, or non-binding political statements. International law, and law in general, requires a binary approach to obligation. All communications must be binding or not, even if the fit is not precise. Through this study, we will find that some of the obligations in certain assurances can be understood as legal and some not. We will attempt to state the current methodology for determining which obligations are legal under the law of treaties and law on binding unilateral promises. The paper begins with some background of the legal environment of diplomatic assurances and their use in cases of expulsion. The paper then turns to discuss the legal nature of diplomatic assurances, proceeding to address various possibilities for legal value as treaties and as binding unilateral statements. This paper will not examine the legal value of diplomatic assurances solely under customary international law other than the way in which customary international law might further refine the treaty definition. In order to identify whether any assurances are contained in legal acts, this study identifies a pool of relevant assurances and qualitatively analyzes whether any of those are contained in treaties or binding unilateral statements. To the author’s best knowledge, this study is the first large-scale, qualitative qualitative analysis of assurances as a group of instruments that accounts for their heterogenous nature. It is also the first study to identify the indicators of whether an instrument is a treaty or promise.

Keywords: diplomatic assurances, deportation, extradition, expulsion, non-refoulement, torture, persecution, death penalty, human rights, memorandum of understanding, promises, secret, monitoring, compliance, enforcement

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Authors: Minhyuk Heo, Jihwan Yun, Seonghun Park

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It has been reported that intervertebral fusion surgery, which removes most of the ligaments and muscles of the spine, increases the degenerative disease in adjacent spinal segments. Therefore, it is required to develop a lumbar interspinous process fixation device that minimizes the risks and side effects from the surgery. The objective of the current study is to design an interspinous process fixation device with simple structures in order to minimize soft tissue removal and operation time during intervertebral fusion surgery. For the design concepts of a lumbar fixation device, the principle of the ratchet was first applied on the joining parts of the device in order to shorten the operation time. The coil spring structure was selected for connecting parts between the spinous processes so that a normal range of motion in spinal segments is preserved and degenerative spinal diseases are not developed in the adjacent spinal segments. The stiffness of the spring was determined not to interrupt the motion of a lumbar spine. The designed value of the spring stiffness allows the upper part of the spring to move ~10° which is higher than the range of flexion and extension for normal lumbar spine (6°-8°), when a moment of 10Nm is applied on the upper face of L1. A finite element (FE) model composed of L1 to L5 lumbar spines was generated to verify the mechanical integrity and the dynamic stability of the designed lumbar fixation device and to further optimize the lumbar fixation device. The FE model generated above produced the same pressure value on intervertebral disc and dynamic behavior as the normal intact model reported in the literature. The consistent results from this comparison validates the accuracy in the modeling of the current FE model. Currently, we are trying to generate an abnormal model with defects in one or more components of the normal FE model above. Then, the mechanical integrity and the dynamic stability of the designed lumbar fixation device will be analyzed after being installed in the abnormal model and then the lumbar fixation device will be further optimized.

Keywords: lumbar interspinous process fixation device, finite element method, lumbar spine, kinematics

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Authors: A. K. O’Loughlin

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Identity doesn’t exist in discrete categories as it is defined. Kevin Kumashiro reveals the phrase 'an impossibility of identity' in Troubling Education (2000), an investigation of the intersections of culture and gender and the impact of erasure for queer POC identity. This underscores the essentiality of an insider or an outsider identity and the appearance of 'contradiction' or impossibility of these identities. The contradictions between us as subject in our own stories and in the stories of others are often silenced. This silencing of complex, 'contradicting' identity has unmissable implications in the classroom; the developing student in question is done a serious disservice, from which they may never recover. There is no more important point of contact than the teacher, for willingness to encounter a developing person as they are, not as we already think they are, or 'know' them to be, or think they should be. To decide how to regard them based on our own unilateral identity and its associated exhortations and injunctions is, as Hannah Arendt writes in The Origins of Totalitarianism (1951), to sell off our ability to rise, human-like, to the challenge of investigating things as they are. A re-reading of Kumashiro’s impossibility of identity becomes possible through the investigation of pluralism. Identities become possible and un-paradoxical by the notion that contradictions are not problems that an individual is not unilateral, but plural. In this paper, we investigate how philosophies of pluralism can inform our understanding of impossibility of identity in classroom curriculum and pedagogy.

Keywords: identity, gender, culture, pluralism, education, philosophy of education, queer theory, philosophy of mind, adolescent development

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Authors: Pascale Brasseur, Binu Gurung, Nicholas Halfpenny, James Eaton

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Development of minimally invasive treatments in recent years provides a potential alternative to invasive surgical interventions which are of limited value to patients with spinal metastases due to short life expectancy. A systematic review was conducted to explore the efficacy and safety of radiofrequency ablation (RFA), a minimally invasive treatment in patients with spinal metastases. EMBASE, Medline and CENTRAL were searched from database inception to March 2017 for randomised controlled trials (RCTs) and non-randomised studies. Conference proceedings for ASCO and ESMO published in 2015 and 2016 were also searched. Fourteen studies were included: three prospective interventional studies, four prospective case series and seven retrospective case series. No RCTs or studies comparing RFA with another treatment were identified. RFA was followed by cement augmentation in all patients in seven studies and some patients (40-96%) in the remaining seven studies. Efficacy was assessed as pain relief in 13/14 studies with the use of a numerical rating scale (NRS) or a visual analogue scale (VAS) at various time points. Ten of the 13 studies reported a significant decrease in pain outcome, post-RFA compared to baseline. NRS scores improved significantly at 1 week (5.9 to 3.5, p < 0.0001; 8 to 4.3, p < 0.02 and 8 to 3.9, p < 0.0001) and this improvement was maintained at 1 month post-RFA compared to baseline (5.9 to 2.6, p < 0.0001; 8 to 2.9, p < 0.0003; 8 to 2.9, p < 0.0001). Similarly, VAS scores decreased significantly at 1 week (7.5 to 2.7, p=0.00005; 7.51 to 1.73, p < 0.0001; 7.82 to 2.82, p < 0.001) and this pattern was maintained at 1 month post-RFA compared to baseline (7.51 to 2.25, p < 0.0001; 7.82 to 3.3; p < 0.001). A significant pain relief was achieved regardless of whether patients had cement augmentation in two studies assessing the impact of RFA with or without cement augmentation on VAS pain scores. In these two studies, a significant decrease in pain scores was reported for patients receiving RFA alone and RFA+cement at 1 week (4.3 to 1.7. p=0.0004 and 6.6 to 1.7, p=0.003 respectively) and 15-36 months (7.9 to 4, p=0.008 and 7.6 to 3.5, p=0.005 respectively) after therapy. Few minor complications were reported and these included neural damage, radicular pain, vertebroplasty leakage and lower limb pain/numbness. In conclusion, the efficacy and safety of RFA were consistently positive between prospective and retrospective studies with reductions in pain and few procedural complications. However, the lack of control groups in the identified studies indicates the possibility of selection bias inherent in single arm studies. Controlled trials exploring efficacy and safety of RFA in patients with spinal metastases are warranted to provide robust evidence. The identified studies provide an initial foundation for such future trials.

Keywords: pain relief, radiofrequency ablation, spinal metastases, systematic review

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Authors: S. Öcal, A. Erakgün, E. Yüksel, M. N. Deniz, E. Erhan, A. Çertuğ

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Background: Emergence agitation (EA) is defined as a dissociated state of consciousness during the early post-anesthesia period in which the child is inconsolable, irritable, uncompromising or uncooperative, typically thrashing, crying, moaning, or incoherent, and not recognizing or identifying familiar and known objects or people. Some studies found preoperative parental anxiety to be a predictor of EA. Methods: Seventy-four children, between the ages of 3-12 undergoing adenoidectomy/tonsillectomy at Ege University Hospital, were studied. Anesthesia was induced and maintained using 2% sevoflurane in 50% oxygen and 50% air following a premedicative dose of 0.5mg/kg oral midazolam. After the children were taken into the operating theater, the mothers were given the State-Trait Anxiety Inventory (STAI) questionnaire. To evaluate EA, Post Anesthetic Emergence Delirium (PAED) score of the children were noted every 10min during the first 30min of the postoperative period. EA was defined with a highest PAED score of ≥ 10, and non-EA with a highest PAED score of ≤ 9. Results: In this study, the incidence of postoperative EA was 31% (34% under the age of 6 and 19% over). Mothers of children with EA were found not to be significantly more anxious on STAI compared to mothers of non-EA children. Conclusions: Contrary to some earlier studies, we were unable to find an association between preoperative parental anxiety and postoperative EA.

Keywords: parental anxiety, emergence agittion, Post Anesthetic Emergence Delirium, anesthesia

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Authors: Ahmed Elhussein, Hossam El-Zomor, Adel Alieldin, Mahmoud A. Afifi, Abdullah Elhusseiny, Hala Taha, Amal Refaat, Soha Ahmed, Mohamed S. Zagloul

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Background: A majority of children with retinoblastoma (60%) have a disease in one eye only (unilateral disease). This is a retrospective study to evaluate two different treatment modalities in those patients for saving their lives and vision. Methods: Four hundred and four patients were diagnosed with unilateral intraocular retinoblastoma at Children’s Cancer, Hospital Egypt (CCHE) through the period of July/2007 until December/2017. Management strategies included primary enucleation versus ocular salvage treatment. Results: Patients presented with mean age 24.5 months with range (1.2-154.3 months). According to the international retinoblastoma classification, Group D (n=172, 42%) was the most common, followed by group E (n=142, 35%), group C (n=63, 16%), and group B (n=27, 7%). All patients were alive at the end of the study except four patients who died, with 5-years overall survival 98.3% [CI, (96.5-100%)]. Patients presented with advanced disease and poor visual prognosis (n=241, 59.6%) underwent primary enucleation with 6 cycles adjuvant chemotherapy if they had high-risk features in the enucleated eye; only four patients out of 241 ended-up either with extraocular metastasis (n=3) or death (n=1). While systemic chemotherapy and focal therapy were the primary treatment for those who presented with favorable disease status and good visual prognosis (n=163, 40.4%); seventy-seven patients of them (47%) ended up with a pre-defined event (enucleation, EBRT, off protocol chemotherapy or 2ry malignancy). Ocular survival for patients received primary chemotherapy + focal therapy was [50.9% (CI, 43.5-59.6%)] at 3 years and [46.9% (CI,39.3-56%)] at 5 years. Comparison between upfront enucleation and primary chemotherapy for occurrence of extraocular metastasis revealed that there was no statistical difference between them except in group D (p value). While for occurrence of death, no statistical difference in all classification groups. Conclusion: In retinoblastoma, primary chemotherapy is a reasonable option and has a good probability for ocular salvage without increasing the risk of metastasis in comparison to upfront enucleation except in group D.

Keywords: CCHE, chemotherapy, enucleation, retinoblastoma

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Authors: Sophie Mills, Constantinos Aristotelous, Leila L. Touil, Richard C. W. James

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Objectives: Historical studies of the anatomy of the spinal accessory nerve (SAN) have reported conflicting results regarding its relationship with the internal jugular vein (IJV). A literature review was undertaken to establish the prevalence of anatomical variations of the SAN encountered during routine neck dissection surgery in order to increase awareness and reduce morbidity associated with iatrogenic SAN injury. Materials and Methods: The largest systematic review to date was performed using PRISMA-ScR guidelines, which yielded nine articles following the application of inclusion and exclusion criteria. A case report is also included, which demonstrates the rare anatomical relationship of the SAN traversing a fenestrated IJV, seen for the first time in the senior author’s career. Results: The mean number of dissections per study was 119, of which 55.6% (n=5) studies were performed on cadaver subjects, and 44.4% (n=4) were surgical dissections. Incidences of the SAN lateral to the IJV and medial to the IJV ranged from 38.9%-95.7% and 2.8%-57.4%, respectively. Over half of the studies reported incidences of the SAN traversing the IJV in 0.9%-2.8% of dissections. One study reported an isolated variant of the SAN dividing around the IJV with a prevalence of 0.5%. Conclusion: At the level of the posterior belly of the digastric muscle, the surgeon can anticipate the identification of the SAN lateral to the IJV in approximately three-quarters of cases, whilst around one-quarter are estimated to be medial. A mean of 1.6% of SANs traverses a fenestration of the vein. It is essential for surgeons to be aware of these anatomical variations and their prevalence to prevent injury to vital structures during surgery.

Keywords: anatomical variant, internal jugular vein, neck dissection, spinal accessory nerve

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Authors: Deepthinath Reghunathan, Satheesha Nayak, Sudarshan S., Prasad Alathady Maloor, Prakash Shetty

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Lumbar plexus is formed by the union of ventral rami of T12, L1, L2, L3 spinal nerves and the larger upper division of L4 lumbar spinal nerves. Variations in the normal anatomy of the lumbar and sacral plexus might be seen in some cases and are reported in the literature, but finding such an unusual case comprising of multiple variations which is normally not expected in a clinical setup, proves to be a vital piece of information for clinicians and medical practitioners. During the dissection of the abdomen and pelvis of an approximately 70 year old cadaver, we observed the following variations in the formation of the lumbar and sacral nerves. 1. The genitofemoral nerve bifurcated at a higher level; genital branch of genitofemoral nerve gave branches to the anterior abdominal wall muscles, 2. A communicating branch was given from the lateral cutaneous nerve of thigh to the medial cutaneous nerve of thigh, 3. A muscular branch was given from femoral nerve to psoas major, 4. There was absence of contribution of L4 spinal nerve in the formation of the lumbosacral trunk and 5. Lumbosacral trunk gave communicating branches to the femoral and obturator nerves. Most of the variations found were rare and finding all the above said variations in a single cadaver is even rare. Documentation of such rare cases with multiple variations in the formation of nerves from the lumbar plexus provides vital information on such occurrences. This information would in turn improve the knowledge of clinicians and surgeons dealing with this region. Emphasizing such knowledge of this region would prevent accidental damage to the structures with a variant anatomy.

Keywords: femoral nerve, genitofemoral nerve, lumbar plexus, lumbosacral trunk

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Authors: Michelle Jennett, Jana Dengler, Maytal Perlman

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Background: Cervical spinal cord injury (SCI) is a devastating event that results in upper limb paralysis, loss of independence, and disability. People living with cervical SCI have identified improvement of upper limb function as a top priority. Nerve and tendon transfer surgery has successfully restored upper limb function in cervical SCI but is not universally used or available to all eligible individuals. This exploratory mixed-methods study used an implementation science approach to better understand these factors that influence access to upper limb reconstruction in the Canadian context and design an intervention to increase access to care. Methods: Data from the Canadian Institute for Health Information’s Discharge Abstracts Database (CIHI-DAD) and the National Ambulatory Care Reporting System (NACRS) were used to determine the annual rate of nerve transfer and tendon transfer surgeries performed in cervical SCI in Canada over the last 15 years. Semi-structured interviews informed by the consolidated framework for implementation research (CFIR) were used to explore Ontario healthcare provider knowledge and practices around upper limb reconstruction. An inductive, iterative constant comparative process involving descriptive and interpretive analyses was used to identify themes that emerged from the data. Results: Healthcare providers (n = 10 upper extremity surgeons, n = 10 SCI physiatrists, n = 12 physical and occupational therapists working with individuals with SCI) were interviewed about their knowledge and perceptions of upper limb reconstruction and their current practices and discussions around upper limb reconstruction. Data analysis is currently underway and will be presented. Regional variation in rates of upper limb reconstruction and trends over time are also currently being analyzed. Conclusions: Utilization of nerve and tendon transfer surgery to improve upper limb reconstruction in Canada remains low. There are a complex array of interrelated individual-, provider- and system-level barriers that prevent individuals with cervical SCI from accessing upper limb reconstruction. In order to offer equitable access to care, a multi-modal approach addressing current barriers is required.

Keywords: cervical spinal cord injury, nerve and tendon transfer surgery, spinal cord injury, upper extremity reconstruction

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Authors: Radoslaw Nagay

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The Paulina Project aims to address the challenges faced by immobilized individuals, such as those with multiple sclerosis, muscle dystrophy, or spinal cord injuries, by developing a flexible hardware and software solution. This paper presents the research and development efforts of our team, which commenced in 2019 and is now in its final stage. Recognizing the diverse needs and limitations of individuals with limited mobility, we conducted in-depth testing with a group of 30 participants. The insights gained from these tests led to the complete redesign of the system. Our presentation covers the initial project ideas, observations from in-situ tests, and the newly developed system that is currently under construction. Moreover, in response to the financial constraints faced by many disabled individuals, we propose an affordable business model for the future commercialization of our invention. Through the Paulina Project, we strive to empower immobilized individuals, providing them with greater independence and improved quality of life.

Keywords: UI, human-machine interface, social inclusion, multiple sclerosis, muscular dystrophy, spinal cord injury, quadriplegic

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Authors: Dorsa Rahi, Arghavan Tonkanbonbi, Soheila Manifar, Behzad Jafvarnejad

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Background and Aim: Intraoral manipulation is performed during endotracheal intubation for general anesthesia, which can traumatize the soft and hard tissue in the oral cavity and cause postoperative pain and discomfort. Dental trauma is the most common complication of intubation. This study aimed to assess the prevalence of dental complications due to intubation in patients hospitalized in Imam Khomeini Hospital during 2018-2019. Materials and Methods: A total of 805 patients presenting to the Cancer Institute of Imam Khomeini Hospital for preoperative anesthesia consultation were randomly enrolled. A dentist interviewed the patients and performed a comprehensive clinical oral examination preoperatively. The patients underwent clinical oral examination by another dentist postoperatively. Results: No significant correlation was found between dental trauma (tooth fracture, tooth mobility, or soft tissue injury) after intubation with the age or gender of patients. According to the Wilcoxon test and McNemar-Bowker Test, the rate of mobility before the intubation was significantly different from that after the intubation (P=0.000). Maxillary central incisors, maxillary left canine and mandibular right and left central incisors had the highest rate of fracture. Conclusion: Mobile teeth before the intubation are at higher risk of avulsion and aspiration during the procedure. Patients with primary temporomandibular joint disorders are more susceptible to post-intubation trismus.

Keywords: oral trauma, dental trauma, intubation, anesthesia

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Authors: Susan K. Steele-Moses, Aimee Badeaux

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Background Literature: Nurse anesthesia education placed high demands on students both personally and professionally. High levels of anxiety affect student’s mental, emotional, and physical well-being, which impacts their student success. Whereas more research has focused on the health and well-being of graduate students, far less has focused specifically on nurse anesthesia students (SNRAs), who may experience higher levels of anxiety due to the rigor of their academic program. Current literature describes stressors experienced by SRNAs that cause anxiety and affect their performance, including personal, academic, clinical, interpersonal, emotional, and financial. Sample: DNP-NA 2025 and DNP-NA 2024 cohorts (N = 36). Eighteen (66.7%) students participated in the study. Instrumentation: The DASS-21 was used to measure stress (7 items; α = .87) and anxiety (7 items; α = .74) from the participants. Intervention: The mind-shift meditation app, based on cognitive behavioral therapy, is being used daily before clinical and exams to decrease nurse anesthesia students’ stress and anxiety over time. Results: At baseline, the students exhibited a moderate level of stress, but their anxiety levels were low. The range of scores was 4-21 (out of 28) for stress (M = 12.88; SD = 5.40) and 0-16 (out of 28) for anxiety (M = 6.81; SD = 5.04). Both stress and anxiety were normally distributed [SW = .242 (stress); SW = .210 (anxiety)] without any outliers. There was a significant difference between their stress and anxiety levels (t = 5.55; p < .001) at baseline. Stress and anxiety will be measured over time, with the change analyzed using repeated measures ANOVA. Implications for Practice: The use of purposeful mindfulness meditation has been shown to decrease stress and anxiety in nursing students.

Keywords: mindfulness, meditation, graduate nursing education, nursing education

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Authors: Sylwia Orzechowska, Andrzej Wróbel, Eugeniusz Rokita

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The mineralization is a curious problem of connective tissues. Factors which may play a decisive role in the regulation of the yellow ligaments (YL) mineralization are still open questions. The aim of the studies was a detailed description of the chemical composition and morphology of mineral deposits in the human yellow ligaments. Investigations of the structural features of deposits were used to explain the impact of various factors on mineralization process. The studies were carried out on 24 YL samples, surgically removed from patients suffer from spinal canal stenosis and the patients who sustained a trauma. The micro-computed tomography was used to describe the morphology of mineral deposits. The X-ray fluorescence method and Fourier transform infrared spectroscopy were applied to determine the chemical composition of the samples. In order to eliminate the effect of blur in microtomographic images, the correction method of partial volume effect was used. The mineral deposits appear in 60% of YL samples, both in patients with a stenosis and following injury. The mineral deposits have a heterogeneous structure and they are a mixture of the tissue and mineral grains. The volume of mineral grains amounts to (1.9 ± 3.4)*10-3 mm3 while the density distribution of grains occurs in two distinct ranges (1.75 - 2.15 and 2.15-2.5) g/cm3. Application of the partial volume effect correction allows accurate calculations by eliminating the averaging effect of gray levels in tomographic images. The B-type carbonate-containing hydroxyapatite constitutes the mineral phase of majority YLs. The main phase of two samples was calcium pyrophosphate dihydrate (CPPD). The elemental composition of minerals in all samples is almost identical. This pathology may be independent on the spine diseases and it does not evoke canal stenosis. The two ranges of grains density indicate two stages of grains growth and the degree of maturity. The presence of CPPD crystals may coexist with other pathologies.

Keywords: FTIR, micro-tomography, mineralization, spinal ligaments

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Authors: A. Bruce Janati, Muhammad Umair Khan, Naif Alghassab, Ibrahim Alzeir, Assem Mahmoud, M. Sammour

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Rationale: Lennox-Gastaut syndrome(LGS) is an electro-clinical syndrome composed of the triad of mental retardation, multiple seizure types, and the characteristic generalized slow spike-wave complexes in the EEG. In this article, we report on two patients with LGS whose brain MRI showed dysgenesis of corpus callosum(CC). We review the literature and stress the role of CC in the genesis of secondary bilateral synchrony(SBS). Method: This was a clinical study conducted at King Khalid Hospital. Results: The EEG was consistent with LGS in patient 1 and unilateral slow spike-wave complexes in patient 2. The MRI showed hypoplasia of the splenium of CC in patient 1, and global hypoplasia of CC combined with Joubert syndrome in patient 2. Conclusion: Based on the data, we proffer the following hypotheses: 1-Hypoplasia of CC interferes with functional integrity of this structure. 2-The genu of CC plays a pivotal role in the genesis of secondary bilateral synchrony. 3-Electrodecremental seizures in LGS emanate from pacemakers generated in the brain stem, in particular the mesencephalon projecting abnormal signals to the cortex via thalamic nuclei. 4-Unilateral slow spike-wave complexes in the context of mental retardation and multiple seizure types may represent a variant of LGS, justifying neuroimaging studies.

Keywords: EEG, Lennox-Gastaut syndrome, corpus callosum , MRI

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Authors: Taku Numao, Kazu Amimoto, Tomoko Shimada, Kyohei Ichikawa

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Background: Unilateral spatial neglect (USN) is a common syndrome following damage to one hemisphere of the brain (usually the right side), in which a patient fails to report or respond to stimulation from the contralesional side. These symptoms are not due to primary sensory or motor deficits, but instead, reflect an inability to process input from that side of their environment. Prism adaptation (PA) is a therapeutic treatment for USN, wherein a patient’s visual field is artificially shifted laterally, resulting in a sensory-motor adaptation. However, patients with USN also tend to perceive a left-leaning subjective vertical in the frontal plane. The traditional PA cannot be used to correct a tilt in the subjective vertical, because a prism can only polarize, not twist, the surroundings. However, this can be accomplished using a head mounted display (HMD) and a web-camera. Therefore, this study investigated whether an HMD system could be used to correct the spatial perception of USN patients in the frontal as well as the horizontal plane. We recruited healthy subjects in order to collect data for the refinement of USN patient therapy. Methods: Eight healthy subjects sat on a chair wearing a HMD (Oculus rift DK2), with a web-camera (Ovrvision) displaying a 10 degree leftward rotation and a 10 degree counter-clockwise rotation along the frontal plane. Subjects attempted to point a finger at one of four targets, assigned randomly, a total of 48 times. Before and after the intervention, each subject’s body-centre judgment (BCJ) was tested by asking them to point a finger at a touch panel straight in front of their xiphisternum, 10 times sight unseen. Results: Intervention caused the location pointed to during the BCJ to shift 35 ± 17 mm (Ave ± SD) leftward in the horizontal plane, and 46 ± 29 mm downward in the frontal plane. The results in both planes were significant by paired-t-test (p<.01). Conclusions: The results in the horizontal plane are consistent with those observed following PA. Furthermore, the HMD and web-camera were able to elicit 3D effects, including in both the horizontal and frontal planes. Future work will focus on applying this method to patients with and without USN, and investigating whether subject posture is also affected by the HMD system.

Keywords: head mounted display, posture, prism adaptation, unilateral spatial neglect

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Authors: Simona Capossela, Ramona Schaniel, Singer Franziska, Aquino Fournier Catharine, Daniel Stekhoven, Jivko Stoyanov

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A spinal cord injury (SCI) is a traumatic life event that often results in ageing associated health conditions such as muscle mass decline, adipose tissue increase, decline in immune function, frailty, systemic chronic inflammation, and psychological distress and depression. Psychological, oxidative, and metabolic stressors may facilitate accelerated ageing in the SCI population with reduced life expectancy. Research designs using biomarkers of aging and stress are needed to elucidate the role of psychological distress in accelerated aging. The aim of this project is a feasibility pilot study to observe changes in stress biomarkers and correlate them with aging markers in SCI patients during their first rehabilitation (longitudinal cohort study). Biological samples were collected in the SwiSCI (Swiss Spinal Cord Injury Cohort Study) Biobank in Nottwil at 4 weeks±12 days after the injury (T1) and at the end of the first rehabilitation (discharge, T4). The "distress thermometer" is used as a selfassessment tool for psychological distress. Stress biomarkers, as cortisol and protein carbonyl content (PCC), and markers of cellular aging, such as telomere lengths, will be measured. 2 Preliminary results showed that SCI patients (N= 129) are still generally distressed at end of rehabilitation, however we found a statistically significant (p< 0.001) median decrease in distress from 6 (T1) to 5 (T4) during the rehabilitation. In addition, an explorative transcriptomics will be conducted on N=50 SCI patients to compare groups of persons with SCI who have different trajectories of selfreported distress at the beginning and end of the first rehabilitation after the trauma. We identified 4 groups: very high chronic stress (stress thermometer values above 7 at T1 and T4; n=14); transient stress (high to low; n=14), low stress (values below 5 at T1 and T4; n=14), increasing stress (low to high; n=8). The study will attempt to identify and address issues that may occur in relation to the design and conceptualization of future study on stress and aging in the SCI population.

Keywords: stress, aging, spinal cord injury, biomarkers

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