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Cervical myelopathy is a clinical entity resulting from external compression of the cervical medulla. The clinical course can be divided into the acute form (secondary to trauma) versus subacute (progression within weeks to months) and chronic cervical myelopathy (months to years). The clinical picture of myelopathy is that of unsteady gait with long-tract signs, such as hyperreflexia, spasticity and extensor plantar responses. Between 1997 and 2000, 359 consecutive patients have been operated on in our department presenting with a variety of symptoms related to compression of the cervical medulla. Beside of standard MRI for all patients we applied SSEPs, gait analysis and dynamic MRI studies as additional helpful tools in evaluating selected patients pre- and postoperatively. We prefer the anterior approach as first-line approach because in the majority of patients the osteophytic spurs are more dominant anteriorly, and after anterior decompression and stabilization the posterior approach appears safer. We also favor the more extended approach of spondylectomy versus multilevel decompression in patients with bisegmental or multisegmental spinal canal stenosis. However it seems to be that radicular decompression is better achieved through multilevel decompression than through spondylectomy.

Sacral pressure sore treatment requires a multidisciplinary approach, the surgical procedures following nutritional and medical status rehabilitation, spasticity control and sepsis treatment. Serial surgical debridement might also precede flap coverage. Gluteal flaps design such as rotation, transposition or V-Y advancement is selected according to the shape and size of the sore. Our experience with 74 patients with 95 flaps includes 38 rotation flaps, 28 V-Y and 8 transposition flaps. Twenty one patients had bilateral gluteal V-Y flaps. Only 2 transposition flaps had marginal necrosis that healed per secundam. Delayed healing occurred in 12 cases due to sepsis, that healed spontaneously in 10 cases and required surgical reintervention for excision and flap reposition in 2. Prolonged bed immobilization, postoperative antibiotic therapy and late suture removal are important factors in surgical success.

The meaning of a disturbance of consciousness is completely different in an acute as opposed to a chronic stage. In the acute stage, the grade of arousal is the most essential component in order to assess the changes of the level of intracranial pressure in neurosurgical emergency room. A new coma scale called Emergency Coma Scale has been proposed, which represents a combination of the Glasgow Coma Scale and the Japan Coma Scale. In the chronic stage, however, contents of consciousness or mental function deserve phenomenological and holistic investigations, keeping the difference between consciousness and mind in consideration, in order not only to treat and care for patients following cerebral injuries, stroke and mild cognitive impairment in aged people. We propose the difference in conception between consciousness and mind; that is, consciousness consists of psycho-sensory afferent system, mind of psycho-motor efferent and afferent system, and memory and language as liaison officers between them. This proposal would play a role to understand mental change in the natural aging processes, when memory and cognition are deteriorating gradually, but is still in evolution in the field of culture.

My work in Neurotraumatology was initiated in 1961, when I as a neuropsychologist got a position in a neurosurgical University department. The tasks were to evaluate the mental state of patients, give advices to family members regarding the mental and social prognosis of the patients and to support nurses in the initial care of the patients. Initially the methods that were made use of were tests developed by the German neurologist Kurt Goldstein [ 8 ] and traditional psychometric tests, but it was not until the theories of A. R. Luria and his investigation method were applied that a true position as a member of the treatment team was secured. Reading Luria’s book “Higher Cortical Functions in Man” [ 9 ] made me aware of his theories. The skill to perform the investigation was acquired during visits to Luria’s laboratory at the Bourdenko Neurosurgical Institute in Moscow in the nineteen-seventies. Text and material to “Luria’s Neuropsychological Investigation” was published in 1974 [ 1 ]. The early work was further stimulated by the development in the neurosciences regarding brain plasticity and brain repair [ 6 ] and experiences from visits to rehabilitation centres in the US, Yehuda Ben-Yishay’s center at New York Medical School, George Prigatano’s centre at the time in Oklahoma, and Lance Trexler’s center at Community Hospital, Indianapolis led in 1985 to the establishment of the first post acute rehabilitation center in Europe: the Center for Rehabilitation of Brain Injury (CRBI) at the University of Copenhagen, DK [ 2 ]. The main program was a holistic day program, six hours a day for four months in accordance with the university semesters, and an eigth months follow-up. Groups of 15 persons started together, collaborating in smaller groups. The present director of the CRBI is neuropsychologist Frank Humle. A thorough follow-up of the patients’ state and improvement through the course of treatment towards social integration, including getting back to work was performed, and studies have indicated that successful integration of the traumatized patient is possible, provided that an early intensive care is succeeded by a comprehensive, individualized post-acute rehabilitation program, of which follow-up is a part, all within the frame of multidisciplinary collaboration.

In severe brain injury patients few studies have examined the role of early clinical factors emerging before recovery of consciousness. Patients suffering from vegetative state and minimally conscious state in fact may need variable periods of time for recovery of the ability to follow commands. In a previous study we retrospectively examined a population of very severe traumatic brain injury patients with coma duration of at least 15 days (prolonged coma), and we found, as significant predictive factors for the final outcome, the time interval from brain injury to the recovery of the following clinical variables: optical fixation, spontaneous motor activity and first safe oral feeding. Psychomotor agitation and bulimia during coma recovery were also favourable prognostic factors for the final outcome. In a further study, also as for the neuropsychological recovery, the clinical variable with the best significant predictive value was the interval from head trauma to the recovery of safe oral feeding. In the present study the presence of psychomotor agitation diagnosed by means of LCF (score 4 = confused-agitated) at the admission time in rehabilitation predicted a statistically significant better outcome at the discharge time in comparison with patients without agitation.

Predicting long-term clinical outcome for patients with traumatic brain injury (TBI) at the beginning of rehabilitation provides essential information for counseling of the family and priority-setting for the limited resources in intensive rehabilitation. The objective of this study is to work out the probability of the one-year outcome at the beginning of rehabilitation. Sixty-eight patients with moderate-to-severe TBI and known one-year outcome were employed for outcome prediction using the logistic regression model. A large number of prospectively collected data at admission (age, Glasgow Coma Scale [GCS] Score, papillary response), during intensive care unit (ICU) management (duration of coma, intracranial pressure [ICP] and its progress) and at the beginning of rehabilitation (baseline Functional Independence Measure [FIM], Neuro-behavioral Cognitive Status Examination [NCSE] and Functional Movement Assessment [FMA]) were available for preliminary screening by univariate analysis. Six prognostic factors (age, GCS, duration of coma, baseline FIM, NCSC and FMA) were utilized for the final logistic regression model. Age, GCS and baseline FIM at the beginning of rehabilitation have been found to be independent predictors for one-year outcome. The accuracy of prediction for a good Glasgow Outcome Score is 68% and an outcome for disability (either moderate or severe) is 83%. Validation of this model using a new set of data is required.

Authors present a seven years retrospective study on 85 cases of severe brain injuries (SBI) in children (GCS </= 8) treated in the Pediatric and ICU Departments of the Clinic Hospital “Bagdasar-Arseni” Bucharest, Romania. The relationship between ICP, GCS on admission, the CT-scan/MRI alteration and the outcome evaluated by the Glasgow Outcome Scale (GOS) were studied in order to highlight the most important factors to improve prognosis. An overall mortality of 25.9% was found in this series. Authors concluded that the ICP values at admission >/= 20 mmHg, the Diffuse Axonal Injury (DAI) on MRI and the GCS on admission are factors of prognosis in SBI in children. The politrauma context is an aggravating factor for SBI in this age group. Other factors which influence GCS on admission may have prognostic importance i.e.: prehospital care, transport time and adequate transport conditions.

The locked-in syndrome (LIS) is a severe condition originated by a ventral pons lesion causing quadriplegia and anarthria but with a preserved consciousness. LIS seems to be a well defined clinical picture, although different problems still persist, such as the diagnosis as it is usually mistaken for akinetic mutism and a vegetative state; the unclear prognosis, because of the patient’s psychological state and the lack of information and data concerning the different types of available treatment and the need for results. Rehabilitation is a challenge for physicians, new methods and techniques of specialized treatments for these patients are opening a new future that will allow us to abandon the initial pessimism. A more efficient rehabilitation of these patients depends on the intensity of the rehabilitation, the multidisciplinary approach, and duration of the treatment.