British Journal of Neurosurgery最新文献

Background: Shunt surgery remains the gold standard of treatment for hydrocephalus. Ventriculoperitoneal (VP) shunt systems represent the most commonly used technique, and the increasing use of programmable valves allows the neurosurgical team to easily and non-invasively adjust shunt settings where indicated. However, their safety in specific clinical scenarios can be a common source of uncertainty due to potential interactions between parametric shunt components and external electromagnetic fields.

Case presentation: We report the case of electroconvulsive therapy being used successfully in a 64-year-old presenting with treatment-resistant depression, on a background of a programmable VP shunt system in situ for congenital hydrocephalus. To our knowledge, this is the first individual report which presents the successful use of ECT in a patient with a programmable shunt valve.

Background: Major trauma networks were introduced in 2012 onwards with a major trauma centre (MTC) linked to district general hospitals (DGH). Most traumatic brain injuries (TBI) are managed in DGHs, without on-site neurosurgical services. It is unclear whether the characteristics of TBIs at DGHs have differed since the network was introduced. We compare outcomes of TBI patients pre- (2008-2012) and post-MTC (2013-2021) network implementation.

Methods: We conducted a retrospective analysis of TBI patients admitted to a 500-bedded DGH, before and after the introduction of a trauma network. We compared the characteristics of patients, including age, mechanism of injury, imaging findings, and length of stay. All statistical analyses were carried out in SPSS v29 (IBM).

Results: Overall, 876 patients (males = 56.1%; median age 67 years) were included. Mean yearly cases pre-MTC was 76 compared to 55 in the post-MTC period. Mean age was significantly higher, and patients had more co-morbidities, in the post-MTC period (p < 0.001). Mean GCS at presentation was not significantly different between the pre- and post-MTC periods (13.7 vs 13.8, respectively). Referrals to the regional neurosurgical centre were significantly higher in the post-MTC period. The overall mortality rate was 33.7%. Increasing age (OR = 1.072), higher comorbidities (OR = 1.243) and intracerebral haematoma (OR = 6.269) were associated with a higher risk of death. The post-MTC period was associated with a lower risk of death (OR = 0.501).

Conclusions: Fewer patients with less severe mechanisms of injury, and a more elderly population are now being managed at our DGH in the post-MTC period. Mortality was similar to published literature but the introduction of the trauma system was associated with lower risk of death. Although fewer TBIs help to optimise service delivery by maintaining orthopaedic bed capacity, the reduced exposure to these patients may lead to lowered expertise in managing these complex cases.

Background: Patients with traumatic brain injury are at high risk for venous thromboembolism. Therefore, pharmacological prophylaxis for venous thromboembolism has become critical in managing trauma patients. Unfortunately, the decision to initiate prophylaxis in patients with radiographic progression must be carefully weighed against the risk of further progression of intracranial haemorrhage, with little evidence to support decision-making.

Methods: A retrospective review was performed at a Canadian Level 1 Trauma Centre from 2011-2017. Included adult patients had evidence of radiographic intracranial haemorrhage progression on repeat CT, and patients receiving prophylaxis were compared with those not having received prophylaxis. Regression analyses were performed to determine the decision-making process for providers when caring for these patients.

Results: 242 patients were included in the study, with 33.1% of these patients not receiving pharmacological prophylaxis during admission. Of those without prophylaxis, 1.2% developed deep vein thromboses, no patients with pulmonary emboli, compared with five patients in the prophylaxis group with pulmonary emboli. The probability of not receiving prophylaxis was higher if abbreviated injury score is greater or equal to 4, decreased in cases of pelvic fracture or solid organ injury, or if the patient required an operative procedure.

Conclusion: Patients with isolated, non-operative severe traumatic brain injury may be at risk of not receiving pharmacologic prophylaxis for venous thromboembolism during hospital admission. This decision may place patients at greater risk of venous thromboembolism, and thereby increased morbidity and mortality. As such, further investigation and initiatives to improve pharmacologic prophylaxis in this patient population is warranted.

Introduction: DISH is an ankylosing disease, when fractured can be challenging to manage. A retrospective radiological study was conducted to evaluate the natural history and radiological characteristics of DISH on Computed tomography (CT).Methods: Paired CT scans with DISH that are separated at least two years apart were used to perform the following radiological measurements: Degree of disc space fusion, Osteophyte and vertebral body linear attenuation coefficients (LAC), and Osteophyte axial area size and location.Results: 164 patients were analysed with a mean duration of 4.49 years between scans. 38.14% (442/1159) of disc spaces had at least partial calcification. Most osteophytes were right sided before becoming more circumferential over time. The average fusion score was 54.17. Most of the changes in fusion occurred in the upper and lower thoracic regions. The thoracic region when compared to the lumbar region had a greater proportion of its disc spaced being fully fused. Disc level osteophyte areas were larger than Body level osteophytes. Disc osteophytes size growth rate drops over time from 10.89mm²/year in Stage 1 to 3.56mm²/year in Stage 3. Stage 3 disc spaces (-11.01HU/year) was also found to have had a reduction in their LAC over time when compared to Stage 1 disc spaces (17.04HU/year). This change in osteophyte LAC was not mirrored in the change in vertebral body LAC. We predict that the age of onset and complete thoracolumbar ankylosis of DISH to be 17.96 years and 100.59 years, respectively.Conclusion: DISH ankylosis of the spine a slow process that starts in the mid to lower thoracic region before extending cranially and caudally. After the bridging osteophyte has fully formed, remodelling of the osteophyte occurs.

Cranioplasty is a neurosurgical procedure that repairs a defect in the skull Coupled with the underlying pathology cranioplasty associated morbidity can have a large impact on patient quality of life, which is often poorly explored. The objective of this systematic review was to identify patient-reported outcomes evaluating health-related quality of life following cranioplasty. The review protocol was registered on PROSPERO (CRD42021251543) and a systematic review was conducted in accordance with the PRISMA statement. PubMed, Embase, CINAHL Plus, and the Cochrane databases were searched from inception to 1 May 2022. All studies reporting HRQoL following cranioplasty were included. Reporting was assessed using the ISOQOL checklist and risk of bias was assessed using the Newcastle-Ottawa Scale or the Johanna-Briggs Institute Scale, as appropriate. A total of 25 studies were included of which 20 were cross-sectional and 2 longitudinal. Most studies utilized study specific questionnaires and Likert scales to assess HRQoL. The studies found a significant improvement in physical functioning, social functioning, cosmetic outcome, and overall HRQoL following cranioplasty. Further longitudinal studies utilising validated measurement tools are required to better understand the effect of cranioplasty at a patient level.

Background: The authors report an Australian experience of lateral lumbar interbody fusion (LLIF) with respect to clinical outcomes, fusion rates, and complications, with recombinant human bone morphogenetic protein-2 (rhBMP-2) and other graft materials.

Methods: Retrospective cohort study of LLIF patients 2011-2021. LLIFs performed lateral decubitus by four experienced surgeons past their learning curve. Graft materials classified rhBMP-2 or non-rhBMP-2. Patient-reported outcomes assessed by VAS, ODI, and SF-12 preoperatively and postoperatively. Fusion rates assessed by CT postoperatively at 6 and 12 months. Complications classified minor or major. Clinical outcomes and complications analysed and compared between rhBMP-2 and non-rhBMP-2 groups.

Results: A cohort of 343 patients underwent 437 levels of LLIF. Mean age 67 ± 11 years (range 29-89) with a female preponderance (65%). Mean BMI 29kg/m² (18-56). Most common operated levels L3/4 (36%) and L4/5 (35%). VAS, ODI and SF-12 improved significantly from baseline. Total complication rate 15% (53/343) with minor 11% (39/343) and major 4% (14/343). Ten patients returned to OR (2-wound infection, 8-further instrumentation and decompression). Most patients (264, 77%) received rhBMP-2, the remainder a non-rhBMP-2 graft material. No significant differences between groups at baseline. No increase in minor or major complications in the rhBMP-2 group compared to the non-rhBMP-2 group respectively; (10.6% vs 13.9% [p = 0.42], 2.7% vs 8.9% [p < 0.01]). Fusion rates significantly higher in the rhBMP-2 group at 6 and 12 months (63% vs 40%, [p < 0.01], 92% vs 80%, [p < 0.02]).

Conclusion: LLIF is a safe and efficacious procedure. rhBMP-2 in LLIF produced earlier and higher fusion rates compared to available non-rhBMP-2 graft substitutes.

Brain Tumour Related Epilepsy (BTRE) has a significant impact on Quality of Life with implications for driving, employment, and social activities. Management of BTRE is complex due to the higher incidence of drug resistance and the potential for interaction between anti-cancer therapy and anti-seizure medications (ASMs). Neurologists, neurosurgeons, oncologists, palliative care physicians and clinical nurse specialists treating these patients would benefit from up-to-date clinical guidelines. We aim to review the current literature and to outline specific recommendations for the optimal treatment of BTRE, encompassing both Primary Brain Tumours (PBT) and Brain Metastases (BM). A comprehensive search of the literature since 1995 on BTRE was carried out in PubMed, MEDLINE and EMCARE. A broad search strategy was used, and the evidence evaluated and graded based on the Oxford Centre for Evidence-Based Medicine Levels of Evidence. Seizure frequency varies between 10 and 40% in patients with Brain Metastases (BM) and from 30% (high-grade gliomas) to 90% (low-grade gliomas) in patients with PBT. In patients with BM, risk factors include number of BM and melanoma histology. In patients with PBT, BTRE is more common in patients with lower grade histology, frontal and temporal tumours, presence of an IDH mutation and cortical infiltration. All patients with BTRE should be treated with ASMs. Non-enzyme inducing ASMs are recommended as first line treatment for BTRE, but up to 50% of patients with BTRE due to PBT remain resistant. There is no proven benefit for the use of prophylactic ASMs, although there are no randomised trials testing newer agents. Surgical and oncological treatments i.e. radiotherapy and chemotherapy improve BTRE. Vagus Nerve Stimulation has been used with partial success. The review highlights the relative dearth of high-quality evidence for the management of BTRE and provides a framework for further studies aiming to improve seizure control, quality of life, and indications for ASMs.

Purpose: Treatment of craniopharyngiomas (CP) is challenging due to their proximity to critical neural structures, risk of serious complications and impaired quality of life after treatment. Recurrences may occur many years after surgical resection. However, long-term outcome data are still scarce. The purpose of this retrospective study was therefore to assess the long-term results after treatment of patients with CP.

Material and method: Patients surgically treated for a histologically verified CP at Oslo University Hospital between 1992 and 2015 and with at least a 5-year follow-up were included. Patients' medical records and radiological studies were reviewed.

Results: Sixty-one patients (mean age 35.8 ± 22.2 years) were included; 18 patients (30%) were children <18 years of age. The incidence for the study period and the referral population was 1.1 cases/million/year, with trimodal peak incidence at 6, 32 and 59 years of age. The commonest presenting symptoms were visual disturbances (62%), headache (43%) and endocrine dysfunction (34%). The transcranial approach was utilized in 79% of patients. Gross total resection (GTR) was achieved in 59%. The surgical complication rate was 20%. Three patients (5%) received radiotherapy or radiosurgery after primary resection. The mean follow-up was 139 ± 76 months, with no patients lost to follow-up. Postoperatively, 59% of patients had panhypopituitarism and 56% diabetes insipidus. Eighteen patients (30%) developed tumour recurrence after a mean follow-up of 26 ± 25 months. The 10-year overall survival (OS) rate was 75%, whereas the disease-specific survival (DSS) rate was 84%, and recurrence-free survival (RFS) 61%. Subtotal resection (STR) (p = .01) and systemic comorbidity (p = .002) were associated with worse DSS.

Conclusion: Surgical treatment of CP, even though combined with adjuvant radiotherapy in only selected cases, provides good long-time OS and DSS, and relatively good functional outcome in long-term survivors despite postoperative morbidity, particularly endocrine dysfunction. Systemic comorbidity and STR are individual negative prognostic factors.