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PubMed2000

Evaluation of core decompression for early osteonecrosis of the femoral head.

Twenty-six hips (19 patients) with osteonecrosis of the femoral head with stage I or II of the disease, according to the Ficat and Arlet classification, underwent core decompression. Osteonecrosis was confirmed histologically in all 26 hips. Of 19 patients, 7 had prognostic factors traditionally associated with poor outcome including collagen vascular disease and continued use of steroids. The follow-up period averaged 7 years 10 months (range: 2 years 5 months-13 years 8 months) for 17 patients with 24 hips. Two patients died secondary to systemic illness. Seventeen hips (65.4%) had very good or good results using the Ficat criteria. Eight hips (30.8%) needed further operation [total hip arthroplasty (THA) for 7 hips, osteotomy for 1 hip]. Of the 12 hips in patients who had used steroids, 6 hips (50%) were converted to THA. Four hips in patients with systemic lupus erythematosus (SLE) needed THA (100%). We conclude that core decompression provides an effective treatment for steroid-associated osteonecrosis other than in cases with SLE, as well as providing effective treatment for non-steroid-associated osteonecrosis in the early stages of the disease.

Adult↗
PubMed2002

Clinical outcome and neuropsychological deficits after right decompressive hemicraniectomy in MCA infarction.

BACKGROUND AND PURPOSE: The purpose of this study was to analyse in detail the functional outcome and the neuropsychological deficits in patients with space-occupying infarction of the non-dominant hemisphere one year after surgery. METHODS: Postoperative complications and retrospective consent to surgery were assessed in a semi-structured interview in 26 patients. Functional outcome was measured with the Barthel-Index (BI) and Rankin-Scale. Neuropsychological tests in 14 patients focused on visuo-spatial and visuo-constructive abilities, attention, spatial span and self-rated mood. RESULTS: The one-year survival rate was 69 % (18 of 26). The functional outcome was good (BI >/= 90) in 3 patients, fairly good (BI 75-85) in 6, moderate (BI 30-70) in 6, and poor (BI 0-25) in 3 patients. Age was an independent predictor of outcome, patients above 52 years had a BI of 50 or below. Neuropsychological tests (14 of 18) showed profound attention deficits in all patients, and visuo-spatial and visuo-constructive deficits in patients with lower formal education. Retrospectively, 4 of 18 patients would not give consent to surgery again, mostly because of the bad quality of life postoperatively. CONCLUSION: Older patients do not seem to benefit from decompressive hemicraniectomy; more than half of the surviving younger patients have a good outcome and live independently. Attention deficits are prominent in all patients; visuo-spatial and constructive deficits are less pronounced in patients with higher formal education. Retrospective agreement to decompressive hemicraniectomy is high in patients with good functional outcome.

Adolescent↗
PubMed1997

Plasticity of the spinal cord contributes to neurological improvement after treatment by cervical decompression. A magnetic resonance imaging study.

To investigate the relationship between morphological plasticity of the spinal cord and neurological outcome after surgery for compressive lesions, we correlated the transverse area of the cervical spinal cord measured by transaxial magnetic resonance imaging (MRI) obtained during the early postoperative period (1-6 months) with neurological function assessed at a median postoperative follow-up period of 2.5 years. Measurements on MRI in 56 patients (35 men and 21 women) included evaluation of the cross-sectional area of the cervical cord and the subarachnoidal space at the level of decompression. The transverse area of the cervical cord increased by 30 to 62% postoperatively and that of the subarachnoidal space by 57 to 95%. Neurological improvement was noted in all patients and averaged 63% in our assessment scale. Expansion of the cervical cord during the early postoperative period correlated significantly with the late postoperative neurological status (P = 0.009). Our results suggest that an increase in the cross-sectional area of the cervical spinal cord, representing spinal cord morphological plasticity, is a significant factor in determining the late neurological improvement following decompressive surgery.

Adult↗
PubMed2003

A predictive model for outcome after conservative decompression surgery for lumbar spinal stenosis.

This study was designed to develop predictive models for surgical outcome based on information available prior to lumbar stenosis surgery. Forty patients underwent decompressive laminarthrectomy. Preop and 1-year postop evaluation included Waddell's nonorganic signs, CT scan, Waddell disability index, Oswestry low back pain disability questionnaire, low back outcome score (LBOS), visual analog scale (VAS) for pain intensity, and trunk strength testing. Statistical comparisons of data used adjusted error rates within families of predictors. Mathematical models were developed to predict outcome success using stepwise logistic regression and decision-tree methodologies (chi-squared automatic interaction detection, or CHAID). Successful outcome was defined as improvement in at least three of four criteria: VAS, LBOS, and reductions in claudication and leg pain. Exact logistic regression analysis resulted in a three-predictor model. This model was more accurate in predicting unsuccessful outcome (negative predictive value 75.0%) than in successful outcome (positive predictive value 69.6%). A CHAID model correctly classified 90.1% of successful outcomes (positive predictive value 85.7%, negative predictive value 100%). The use of conservative surgical decompression for lumbar stenosis can be recommended, as it demonstrated a success rate similar to that of more invasive techniques. Given its physiologic and biomechanical advantages, it can be recommended as the surgical method of choice in this indication. Underlying subclinical vascular factors may be involved in the complaints of spinal stenosis patients. Those factors should be investigated more thoroughly, as they may account for some of the failures of surgical relief. The CHAID decision tree appears to be a novel and useful tool for predicting the results of spinal stenosis surgery

Adolescent↗
PubMed2003

Outcomes of decompression surgery for lumbar spinal stenosis in elderly diabetic patients.

The purpose of this study was to assess and compare the outcome of surgical decompression for spinal stenosis in diabetic and non-diabetic elderly patients. This is a retrospective chart analysis conducted in a university affiliated referral hospital. The participants were consecutive patients, age 65 and older, undergoing laminectomy for spinal stenosis during 1990-2000. We assessed patients' clinical and demographic data, procedures, perioperative complications, preoperative and postoperative pain intensity, basic activities of daily living (BADL), patients' satisfaction, the need for repeated surgery, and overall mortality. A total number of 62 elderly diabetic group (DG) patients undergoing decompression surgery for spinal stenosis were compared with a sex and age-matched non-diabetic control group (CG) at baseline, and a mean of 40.3 months thereafter. We found that the DG patients had more pain ( p=0.042), and suffered more frequently from neurogenic claudication ( p=0.0018), motor weakness ( p=0.021) and numbness of the affected limb ( p=0.0069) than the CG patients. Nocturnal pain was reported in 24% of the DG patients. Pain relief was successfully achieved in both groups ( p<0.001), but the patients' satisfaction was greater in the non-diabetic patients ( p=0.0067). Revision surgery was more frequently performed in the DG than the CG (non-significant difference), and the time interval for such a second intervention was shorter ( p=0.04) in the DG. A higher rate of post-operative complications was observed in the DG ( p<0.0001). It is concluded that surgical treatment of elderly diabetic patients suffering from spinal stenosis improves BADL and ameliorates pain, but the results remain worse than those observed in non-diabetics. The outcome of diabetic patients depends upon the presence of other comorbidities, concurrent diabetic neuropathy, duration of diabetes and insulin treatment. Successful postoperative pain reduction remained the strongest factor associated with patients' satisfaction.

Activities of Daily Living↗
PubMed2000

Can hindbrain decompression for syringomyelia lead to regression of scoliosis?

Scoliosis in childhood develops secondary to syringomyelia in some children. The existing literature does not provide a clear answer as to whether surgical treatment of the syrinx can allow subsequent improvement of the spinal deformity, thus preventing the need for scoliosis surgery. This series comprised 16 patients with syringomyelia who presented with significant scoliosis in the absence of major neurological deficit. All underwent a hindbrain decompression, and follow-up ranged from 1 to 6 years (mean 2.5 years). Subsequent deformity surgery was necessary in eight cases, but the scoliosis was seen to improve or arrest its progression in six (37.5%). Improvement was found to be statistically more likely in children of younger age at the time of syrinx surgery and in those with left thoracic curves. Improvement occurred in 71.4% of those under the age of 10 at the time of hindbrain decompression.

Adolescent↗
PubMed2002

Decompressive craniectomy for the management of patients with refractory hypertension: should it be reconsidered?

INTRODUCTION: The management of refractory post-traumatic cerebral oedema remains a frustrating endeavor for the neurosurgeon and the intensivist. Mortality and morbidity rates remain high, despite refinements in medical and pharmacological means of controlling intracranial hypertension. METHOD AND MATERIAL: In this retrospective study we have evaluated the efficacy of decompressive craniectomy as a last resort therapy, from the data of nine patients with severe brain injury and delayed cerebral oedema (diffuse injury type III), treated between January 1997 and September 1999. The following parameters were considered: age, Glascow Coma Scale, injury severity, intracranial pressure, CT findings, pupil reaction/posturing. Follow-up period was over at least 2 years and outcome measured on the GOS. RESULTS: Patients have been operated on post-trauma median day 3, mean age 26+/-9, GCS 7+/-3.7, mean APACHE II 16+/-6.4, mean ISS 27.8+/-16.1, mean preoperative ICP 37.7+/-10.0, mean postoperative ICP 18.1+/-16.01. Seven patients have been operated by a frontotemporoparietal approach (six of them bilateral, one unilateral) and two patients have been operated on by a bilateral subtemporal approach. Mortality rates 22%, severe disability 11%, good recovery 66%. DISCUSSION: Patients with STBI, developing delayed intracranial hypertension caused by diffuse cerebral oedema, definitely benefit from craniectomy when current medical treatment has failed. The encouraging results of outcome in this and more recent studies, indicate the need for a multi-institutional randomized prospective study evaluating early indicators of raised ICP, timing, efficacy of treatment, operative technique and complications of decompressive craniectomy.

Adolescent↗
PubMed2003

Treatment of failed Adult Chiari Malformation decompression with CSF drainage: observations in six patients.

OBJECTIVE: We report the use of CSF drainage for the management of failed Adult Chiari Malformation (ACM) decompression. METHODS: All patients with more than one year follow-up after treatment of their failed ACM were included in this study. They underwent initial decompression between September 1998 and April 2000. Clinical and radiological data were collected initially and at recurrence. Lumbar punctures (LP) were done at recurrence for diagnostic and therapeutic purposes. Opening pressures and symptomatic relief were recorded. Therapeutic options included intermittent LP and ventriculo-peritoneal shunting (VPS). RESULTS: There were 6 patients (5 females and one male). Their age ranged from 19 to 43 years. Tonsillar descent ranged from 5 to 21 mm. The symptoms recurred 1.5 to 9 months postoperatively (average 5.6 months). Postoperative imaging revealed the presence of CSF flow behind the tonsils and the formation of a retrotonsillar neocistern in all patients. On LP, the opening pressure ranged from 17 to 31 cm of water (average 23 cm). All patients improved after CSF drainage, and four patients underwent VPS. The other patients were treated with repeat LP+/-Acetazolamide. There was significant improvement in all patients, with 18 months follow-up after CSF drainage (range 16-21 months). CONCLUSIONS: Our results suggest a role for CSF drainage in the treatment of some patients with failed ACM surgery. Possible explanations for the failure of ACM surgery in this subgroup include: surgical complications leading to neural hydrodynamic alteration, inadequate initial surgery, and coexistence with another pathology, possibly a mild form of intracranial hypertension. More prospective and hydrodynamic studies are needed to further clarify these issues.

Adult↗
PubMed2003

Extended pterional orbital decompression in severe orbital cellulitis.

BACKGROUND: Bacterial orbital cellulitis is a relatively uncommon infective process, which can threaten the function of orbital structures. Apart from antibiotic therapy, sinus surgery with or without abscess drainage via an orbito-otorhinolaryngological approach might be necessary. CASE DESCRIPTION: We present three cases of severe orbital cellulitis, leading to increasing loss of vision, proptosis, afferent pupillary disturbances and restriction of extra-ocular movements, despite antibiotic therapy. After extended pterional orbital decompression and reducing the orbital pressure by removal of the lateral and superolateral orbital walls, all patients showed distinct improvement of initial symptoms, without any complications related to the operation. INTERPRETATION: Extended pterional orbital decompression represents an effective treatment alternative and supplement in cases of a severe, threat to ocular function due to orbital cellulitis, where acute reduction of pressure on orbital, neural and vascular structures is intended.

Adult↗
PubMed2005

Improved brain protection at decompressive craniectomy--a new method using Palacos R-40 (methylmethacrylate).

A new method is described for protecting the brain after decompressive craniectomy in which a temporary methylmethacrylate flap is formed, somewhat larger than the original bone flap, thus gaining "extra" volume for the oedematous brain in which to expand. The present procedure was developed as a part of ordinary clinical practice particularly in response to demands from the NICU staff and our colleagues at other clinics who were responsible for the care of the patient in the post NICU period. They made us keenly aware that these patients frequently lack optimal co-ordination and balance and therefore run an increased risk of trauma to the unprotected brain when falling. This prompted us to develop a method for brain protection after decompressive craniectomy aiding in the care and rehabilitation until the final installation of the patient's own bone flap can be performed.

Bone Transplantation↗
PubMed2005

Relevance of ICP and ptiO2 for indication and timing of decompressive craniectomy in patients with malignant brain edema.

BACKGROUND: The exact effects of decompressive craniectomy on intracranial pressure (ICP) and cerebral tissue oxygenation (ptiO2) are still unclear. Therefore, we have monitored ICP and ptiO2 intra-operatively and correlated these values to different operative steps during craniectomy. METHODS: ICP and ptiO2 values have been monitored both, simultaneously and continuously, in 15 patients with cerebral edema due to posttraumatic or postischemic brain swelling. Indications for craniectomy were an increase in ICP above 25 mmHg or a decrease in ptiO2 below 10 mmHg resistant to conservative treatment (e.g. mannitol, hyperventilation, adequate arterial blood oxygenation, etc.). In all cases, we performed a fronto-temporo-parietal craniectomy (15 x 12 cm) and dura enlargement with galea-periosteum. During craniectomy, monitoring of ICP and ptiO2 in the affected hemisphere was continued. Values were recorded and correlated with the different operative steps. FINDINGS: We performed craniectomy according to our treatment protocol in 5 patients. Prior to surgery, mean ICP values were 25.6 mmHg (range: 23-29 mmHg), mean ptiO2 values were 5.9 mmHg (range: 2.4-9.5 mmHg), and mean CPP values were 66 mmHg (range: 60-70 mmHg). After removing the bone flap, ICP values dropped to physiological values (mean: 7.4 mmHg), whereas ptiO2 values increased only slightly (mean: 11 mmHg). Opening of the dura resulted in a further decrease of ICP (mean 4.8 mmHg) and an increase of ptiO2 to normal limits (mean: 18.8 mmHg). After skin closure, mean ICP was 6.8 mmHg and mean ptiO2 was 21.7 mmHg, respectively. We found a significant decrease of ICP after craniectomy (p<0.042) and after dura enlargement (p<0.039) as well as a statistically significant increase in ptiO2 after craniectomy (p<0.043) and after dura enlargement (p<0.041). CONCLUSION: As a large bone flap in decompressive craniectomy is essential for adequate ICP reduction, the results of the presented cases suggest that dura enlargement is the crucial step to restore adequate brain tissue oxygenation and that ptiO2 monitoring could be an important tool for timing craniectomy in the future.

Adolescent↗
PubMed2005

Microvascular decompression for primary hemifacial spasm. Importance of intraoperative neurophysiological monitoring.

There is considerable evidence that primary Hemi-Facial Spasm (HFS) is in almost all cases related to a vascular compression of the facial nerve at its Root Exit Zone (REZ) from brainstem, and that Micro-Vascular Decompression (MVD) constitutes its curative treatment. Clinical as well as electrophysiological features plead for mechanisms of the disease in structural lesions at the neural fibers (putatively: focal demyelination at origin of ephapses) and functional changes in the nuclear cells (hyperactivity of the facial nucleus). Lateral Spread Responses (LSRs) elicited by stimulation of the facial nerve branches testify of these electrophysiological perturbations. Monitoring LSRs during surgery is feasible; however the practical value of their intraoperative disappearance as control-test of an effective decompression remains controversial.MVD allows cure of the disease in most cases. Because the VIIIth nerve is at risk during surgery, intraoperative monitoring of Brainstem Auditory Evoked Potentials (BEAPs) is of value to reduce occurrence of hearing loss. Increase in latency of Peak V and decrease in amplitude of Peak I are warning-signals of an excessive stretching of the the cochlear nerve and impairment of the cochlear vascular supply, respectively.

Cochlear Nerve↗
PubMed1998

Transverse microincisions of the outer layer of the dura mater combined with foramen magnum decompression as treatment for syringomyelia with Chiari I malformation.

Numerous surgical procedures have been proposed for treatment of syringomyelia associated with Chiari I malformation, but the optimal treatment has not yet been uniformly standardised. The main aim of the surgical treatment of syringomyelia/Chiari I complex is directed toward restoration of physiological cerebrospinal fluid dynamic at the craniovertebral junction. We report the surgical results of eight patients, affected by syringomyelia and Chiari I malformation, age range from 18 to 62 years, treated by bony foramen magnum decompression combined with transverse microincisions of the outer layer of the dura mater. In an average postoperative follow-up period of two years neurological symptoms and signs improved in seven patients. Postoperative Magnetic Resonance showed a decrease in size of the syrinx in seven patients. These results suggest that foramen magnum decompression combined with transverse microincisions of the outer layer of the dura 1) is an effective and safe treatment option for syringomyelia and Chiari I malformation, 2) corrects the circulatory disturbances of cerebrospinal fluid dynamic, 3) leads to a decrease in size of the syrinx and to a significant improvement in neurological signs and symptoms, 4) avoids complications of intradural approaches and syringosubarachnoid shunting.

Adult↗
PubMed1999

Does additional discectomy and the degree of dural sac compression influence the outcome of decompressive surgery for lumbar spinal stenosis?

The discussion regarding factors that reliably predict the long-term surgical results in patients with lumbar spinal stenosis is still going on. This retrospective study analyses the relation between the dimensions of the dural sac and patients' clinical status before and after decompressive operations performed with or without additional discectomy. The type of surgery performed in 134 patients and the dural sac dimensions measured on postmyelograpic computed tomography in 100 of these patients were related to the Prolo scores before surgery and at follow-up (mean 46 months). The degree of dural sac compression correlated significantly with the patients' postoperative Prolo score and with the difference between the pre- and postoperative scores. The dural sac diameters predicted outcome after surgery more reliably than the preoperative Prolo scores. There was no statistically significant difference in the outcome when comparing patients with and without additional discectomy. The results presented suggest that the relief of symptoms after decompressive surgery for lumbar spinal stenosis correlates with the degree of the dural sac compression and that the simultaneous presence of disc herniation necessitating additional discectomy does not influence the postoperative outcome. However, these results have to be confirmed by prospective studies.

Adult↗
PubMed2000

Microvascular decompression of the facial nerve for the treatment of hemifacial spasm: preoperative magnetic resonance imaging related to clinical outcomes.

BACKGROUND: The objective of this study was to investigate the role of preoperative three dimensional short-range magnetic resonance angiography (3D-TOF MRA) in predicting the clinical outcomes following microvascular decompression for the treatment of hemifacial spasm. METHOD: Preoperative magnetic resonance (MR) imaging was performed on all patients with hemifacial spasm (564 cases) between January 1992 and September 1998. Of the 564 patients, 440 patients were included in this retrospective study. The presence of vascular contact, offenders, and anomalies in the vertebro-basilar system, were determined by 3D-TOF MRA prior to microvascular decompression of the facial nerve. The preoperative findings were compared with the surgical findings and clinical outcomes. Findings. A correlation was found between the clinical outcome (p < 0.01) and the presence of a vascular indentation at the root entry zone (REZ) of the facial nerve. A shift of the vertebrobasilar system to the symptomatic side was found in 214 (48.6%) patients with hemifacial spasm, compared to only 10 (13.5%) patients in the control group (p < 0.01). The unilateral vertebral artery was observed in 43 (9.8%) patients with hemifacial spasm and in 8 (10.8%) of the control patients. A hypoplasia of the artery was found in 8 (1.8%) patients with hemifacial spasm and in 1 (1.4%) control patient. The compressing offenders in the patients, discovered by MRI in conjunction with MRA, were as follows: 45.9% (202 patients) in the anterior inferior cerebellar artery (AICA), 34.8% (153 patients) in the posterior inferior cerebellar artery (PICA), 12.5% (55 patients) in the vertebral artery (VA) and 6.8% (30 patients) in multiple vessels. In contrast to the compressing offenders seen on the MRA, the offenders confirmed during surgery were as follows: 43% (189 patients) in the AICA, 36.4% (160 patients) in the PICA, 1.4% (6 patients) in the VA, 19% (84 patients) in multiple vessels, and 0.2% (1 patient) in the vein. In our long-term follow-up series of the 440 patients with hemifacial spasm, an excellent surgical outcome was obtained in 86.3% of cases and a good outcome was achieved in 6.4% (mean follow-up duration, 45.5 months). INTERPRETATION: Preoperative 3D-TOF MRA can identify the relationship between the facial nerve and adjacent vessels in patients with a hemifacial spasm and assist in preoperative planning. This study suggests that 3D-TOF MRA is useful for selecting appropriate patients for surgical treatment and, to some extent, as an additional role for predicting the clinical outcome.

Adult↗
PubMed2003

Magnetic resonance imaging of spinal involvement by hematopoietic malignancies requiring surgical decompression.

To elucidate magnetic resonance imaging (MRI) findings of the spine with hematopoietic malignancies that require surgery, we retrospectively reviewed the MRI scans in these patients who underwent decompression surgery of the spinal cord or cauda equina. Preoperative MRI scans were obtained from nine patients with spinal involvement by a hematopoietic malignancy who underwent surgery: four with malignant lymphoma and five with multiple myeloma. The marrow involvement pattern, location of signal change of the vertebra, cortical destruction, vertebral fracture, epidural mass formation, paraspinal mass formation, and the wrap-around sign (spread to the extraosseous soft tissues without alteration in the shape of the affected vertebra) were determined by MRI scans. Diffuse marrow involvement (89%), anterior and posterior signal changes of the vertebra (100%), cortical destruction (100%), vertebral fracture (78%), epidural mass formation (78%), and paraspinal mass formation (100%) were commonly observed. The wrap-around sign was seen in only one patient (11%); it was due to vertebral destruction and deformity. Based on these results, we concluded that MRI findings of the spine with a hematopoietic malignancy requiring decompression surgery showed a characteristic diffuse marrow pattern; they also exhibited more expansive and destructive features than previously reported for hematopoietic malignancies without surgery.

Aged↗
PubMed1999

Experience of supraclavicular exploration and decompression for treatment of thoracic outlet syndrome.

The purpose of this study was to assess the symptomatic outcome of patients with thoracic outlet syndrome who underwent decompression of the thoracic outlet. In our unit we prefer the supraclavicular approach, performing anterior scalenectomy with excision of fibrous bands or cervical ribs if present. Operative details were gained by theater logbook and case note review. Over a 6-year period, 31 patients (37 limbs) underwent thoracic outlet decompression. Of the 37 affected limbs, the indications for surgery were a combination of both neurological and vascular symptoms in 24 patients (65%), neurological symptoms in 24 (65%), and 4 patients (11%) had vascular symptoms alone. All patients were assessed for postoperative outcome either at out-patient clinics or by personal contact. From the results of this study we concluded that supraclavicular scalenectomy and cervical rib excision with selective first rib excision is a safe and effective procedure for most patients with thoracic outlet syndrome.

Adult↗
PubMed2004

The incidence of C5-C6 radiculopathy as a complication of extensive cervical decompression: own results and review of literature.

This retrospective study aims to discuss and compare our results with those previously mentioned in the literature with regard to C5-C6 radiculopathy that occurs after decompression carried out for cervical spondylotic myelopathy. There are few reports in the literature referring to the incidence of the C5-C6 radiculopathy following cervical decompression procedures. Some authors believe that the postoperative cord shift is the most likely cause. From January 1994 to November 2002, 121 patients underwent cervical corpectomies for cervical spondylotic myelopathy. The preoperative and the postoperatively discovered paresis have been assessed according to the criteria of the British Medical Council. The Nurick Scale was used to grade the severity of the myelopathic changes. The follow-up period varied from 4 to 111 months with an average of 50 months. Symptoms of C5 and/or C6 radiculopathy appeared in 10 patients (8.2%) postoperatively. Aggravation of a preoperative C5 and/or C6 radiculopathy was seen in 3 patients, while 7 patients developed a new C5 and/or C6 radiculopathy in the immediate postoperative period. These motor deficits resolved completely in 7 patients within 7 months of surgery, whereas a residual motor weakness remained in the other 3 patients. The postoperative C5 motor deficit is not infrequently associated with partial involvement of the C6 root. The lesions can be either unilateral or bilateral with a statistically average frequency of 8%. The prognosis is generally favorable. Our results did not support the hypothesis that the claimed cord shift phenomenon is a possible aetiology.

Adult↗