British Journal of Neurosurgery最新文献

Objective: Case series presentation and literature review of patient group suffering from symptomatic tension subdural extra-arachnoid hygroma following decompressive surgery for degenerative lumbar stenosis or disc disease. The purpose was to better understand this rare post-operative complication with a pathognomic radiological sign to help recommend optimal strategies for clinical management.

Methods: Retrospective case series comprising seven cases from one tertiary Neurosurgical centre spanning a 10-year period from 2011 to 2021. Patients included were those known to have undergone a spinal procedure and subsequently to have developed a symptomatic spinal subdural extra-arachnoid hygroma (SSEH). A literature review was conducted using PubMed, MEDLINE and EMBASE (keywords 'subdural hygroma', 'lumbar CSF hygroma', 'extra arachnoid hygroma', 'extra-arachnoid CSF collection', 'CSF tension hygroma', 'lumbar extra arachnoid hygroma', 'lumbar spinal hygroma', 'post-operating spinal hygroma', 'post-operative spinal CSF collection') and through reading references cited in relevant articles. Articles involving post-operative SSEH following lumbar spinal surgery were included.

Results: Rare complication with only five other cases in the literature. Dural breach described intra-operatively in only 5 of 12 total cases from our series and the literature. 5 patients in our series were managed surgically with 2 being managed conservatively. All patients in our series improved symptomatically and radiologically following surgical or conservative management.

Conclusions: This is a rare post-lumbar surgery complication that can cause rapidly deteriorating lower limb and sphincteric function. Surgical management with wide durotomy and arachnoid marsupialisation can lead to reversal of neurological deterioration and excellent clinical results. A delayed presentation with pseudomeningocele formation may be managed conservatively if neurology is stable or improving. It is a condition that it is important for the clinician to recognise in order to instigate appropriate management in a time-dependent fashion.

Aplasia of the lumbar pedicle is a rare condition, frequently associated with low back pain. Its recognition is fundamental in the definition of the correct treatment. We performed a literature review in order to clarify how to best diagnose and treat this rare anatomical condition. A comprehensive literature search for studies published through October 2020 was performed, using the following algorithm: "aplasia" OR "aplastic" OR "hypoplasia" OR "hypoplastic" OR "absent" OR absence" AND "pedicle" AND "lumbar" OR "sacral" OR "lumbosacral". References from reviewed papers were further evaluated for the inclusion of other relevant studies. Eighteen studies were included in the systematic review for a total of 24 adult patients. Another case of left L5 pedicle aplasia treated at our hospital has been described and included in the present review. This anatomical condition may be suspected in plain x-Ray, but CT scan 3D reconstructions may help to confirm the diagnosis in equivocal cases. Low-back pain and radiculopathy are the main signs and symptoms. The treatment was described in 14 cases. Eight patients underwent surgical intervention. In cases with spondylolisthesis, fusion surgery was performed with different techniques, obtaining an excellent clinical outcome. Pedicular aplasia is a rare condition that must be recognized in patients with a low back. When it is associated with spondylolisthesis, fusion surgery should be the preferred option.

Background: Cerebral syphilitic gummas are rare. However, numerous case reports on them have been published recently, consistent with the resurgence of syphilis and its accompanying atypical manifestations. We here present a patient with a cerebral syphilitic gumma and an unusual clinical course and review recent case reports.

Case presentation: A 49-year-old woman had a generalised seizure and was found by computed tomography and magnetic resonance imaging to have a brain mass that mimicked a brain abscess or malignant tumour. Further imaging with magnetic resonance spectroscopy and positron emission tomography did not contribute further to the differential diagnosis. Because treatment with ceftriaxone was ineffective, the lesion was resected. Serological tests on serum and cerebrospinal fluid were positive for syphilis and histopathological examination of the operative specimen revealed a syphilitic gumma. Antibiotic treatment is preferred over invasive interventions for cerebral syphilitic gumma. However, as in our case, radical resection is required when antibiotic treatment is ineffective.

Conclusions: It has recently been reported that the prevalence of syphilis is increasing in older individuals, including in patients without HIV infection or prior treatment for early syphilis. Though advanced imaging and molecular biological techniques are often used to help make a diagnosis, they are of limited value. Because the clinical and imaging features are nonspecific, some neurosurgeons do not include cerebral syphilitic gummas in their differential diagnoses. It is vital that this possibility be considered when a patient has a tumour-like cerebral mass and serum positivity for syphilis.

Objectives: This study discusses the experience at our centre with treating traumatic thoracolumbar fractures using percutaneous pedicle screw fixation.

Methods: We reviewed the case notes and imaging retrospectively between January 2013 and June 2019.

Results: A total of 257 patients were included, 123 males and 134 females aged between 17 and 70; the mean age was 47.6 years. The majority of injuries were from fall from significant height. The fractures involved the thoracic and lumbar vertebra in 98 and 151 of the cases respectively. Percutaneous pedicle screw fixation was performed either one or two levels above and below the fracture depending on the level of injury. Forty two cases were treated with additional short pedicle screws at the level of fracture. More than 15% (39) of the patients presented with a neurological deficit; more than 80% (32) of those showed post-operative improvement in their neurology as per Frankel Grading system. The mean operative time was 117 min ± 45 min; mean length of hospital stay was 7.2 days ± 3.8 days, with significant improvement in pain.

Conclusions: Percutaneous pedicle screw fixation is a safe surgical option with comparable outcomes to open surgery and a potential reduction in perioperative morbidity.

Purpose: The degree of disability that is acceptable to patients following traumatic brain injury (TBI) continues to be debated. While the dichotomization of outcome on the Glasgow Outcome Score (GOSE) into 'favourable' and 'unfavourable' continues to guide clinical decisions, this may not reflect an individual's subjective experience. The aim of this study is to assess how patients' self-reported quality of life (QoL) relates to objective outcome assessments and how it compares to other debilitating neurosurgical pathologies, including subarachnoid haemorrhage (SAH) and cervical myelopathy.

Method: A retrospective analysis of over 1300 patients seen in Addenbrooke's Hospital, Cambridge, UK with TBI, SAH and patients pre- and post- cervical surgery was performed. QoL was assessed using the SF-36 questionnaire. Kruskal-Wallis test was used to analyse the difference in SF-36 domain scores between the four unpaired patient groups. To determine how the point of dichotomization of GOSE into 'favourable' and 'unfavourable' outcome affected QOL, SF-36 scores were compared between GOSE and mRS.

Results: There was a statistically significant difference in the median Physical Component Score (PCS) and Mental Component Score (MCS) of SF-36 between the three neurosurgical pathologies. Patients with TBI and SAH scored higher on most SF-36 domains when compared with cervical myelopathy patients in the severe category. While patients with Upper Severe Disability on GOSE showed significantly higher PC and MC scores compared to GOSE 3, there was a significant degree of variability in individual responses across the groups.

Conclusion: A significant number of patients following TBI and SAH have better self-reported QOL than cervical spine patients and patients' subjective perception and expectations following injury do not always correspond to objective disability. These results can guide discussion of treatment and outcomes with patients and families.

Objective: Neurosurgical care within the NHS has experienced significant shifts since 2000. Although consultant and national training numbers have risen, waiting lists have remained substantially high. This study aims to examine trends in neurosurgical activity at an NHS institution.

Methods: This is a retrospective study of neurosurgical activity between January 2000 to December 2023 at a single institution. Outcomes included annual inpatient and outpatient caseload, frequencies of cranial/spinal and elective/emergency procedures, staffing and productivity, neurosurgical infrastructure, and effects of the COVID-19 pandemic. The Shapiro-Wilk Test, Mann-Whitney U Test and repeated-measures ANOVA were used for statistical significance. Microsoft Excel and GraphPad Prism were used for data processing.

Results: 23,141 inpatient and 64885 outpatient cases were included. No significant difference was observed in the cumulative annual inpatient procedures over the study period. A significant increase was observed in the cumulative annual outpatient cases (r = 0.584, p < 0.01) and the proportion of elective surgeries performed over the study period (r = 0.6070, p < 0.01), along with a significant increase in the proportion of cranial surgeries performed during 2019 to 2021 (45.0% vs. 36.3%, p < 0.05). A significant surge was observed in the number of consultants employed over time (r = 0.9884, p < 0.0001), coinciding with significant decreases in annual levels of inpatient (r = -0.891, p < 0.0001) and outpatient (r = -0.933, p < 0.0001) activity per-consultant. No significant change was observed in the number of beds/theatres over time. A significant decrease in annual inpatient activity was observed during the COVID-19 pandemic compared to 2018 (592 vs. 787, p < 0.05). Following the pandemic, there was a significant rebound observed in both inpatient (1342 vs. 787, p < 0.01) and outpatient cases (3712 vs. 2355, p < 0.01), exceeding pre-pandemic levels.

Conclusion: Neurosurgical inpatient activity has remained largely stagnant despite an increase in outpatient caseloads, waitlists, and consultant staffing numbers, suggesting the role of other factors including the lack of infrastructural expansion within the NHS.

Case report: A rare case of Klippel-Feil syndrome associated with anterior cervical meningomyelocele is reported, treated successfully using partial cervical corpectomy, spinal cord microsurgical reinsertion into the spinal canal, and vertebral reconstruction. A 71-year-old patient presented with upper limb paraesthesia, chronic neck pain, and progressive motor distal impairment. Cervical spine imaging revealed an anterior cervical meningomyelocele digging into C7 vertebra and underlying adjacent congenital fusion blocks.

Conclusion: An anterior cervical decompression combined with fusion led to excellent recovery in this patient and could be of potential interest for surgical management of spinal malformation combined with embryological neural structure abnormality. The current literature is reviewed, along with the different modes of surgical treatment available for this unusual clinical entity.

Introduction: A chronic subdural haematoma (cSDH) is an encapsulated collection of fluid and blood degradation products in the subdural space. It is increasingly common, affecting older people and those living with frailty. Currently, no guidance exists to define optimal care from onset of symptoms through to recovery. This paper presents the first consensus-built recommendations for best practice in the care of cSDH, co-designed to support each stage of the patient pathway.

Methods: Guideline development was led by a multidisciplinary Steering Committee with representation from diverse clinical groups, professional associations, patients, and carers. Literature searching to identify relevant evidence was guided by core clinical questions formulated through facilitated discussion with specially convened working groups. A modified Delphi exercise was undertaken to build consensus on draft statements for inclusion in the guideline using survey methodology and an in-person meeting. The proposed guideline was subsequently endorsed by the Society for British Neurological Surgeons, Neuroanaesthesia and Critical Care Society, Association of Anaesthetists, British Association of Neuroscience Nurses, British Geriatric Society, and Centre for Perioperative Care.

Results: We identified that high quality evidence was generally lacking in the literature, although randomised controlled trial (RCT) data were available to inform specific recommendations on aspects of surgical technique and use of corticosteroids. The final guideline represents the outcome of synthesising available evidence, consensus-built expert opinion and patient involvement. The guideline comprises 67 recommendations across eight major themes, covering: presentation and diagnosis, neurosurgical triage and shared decision-making, non-operative management, perioperative management (including anticoagulation), timing of surgery, intraoperative and postoperative care, rehabilitation and recovery.

Conclusions: We present the first multidisciplinary guideline for the care of patients with cSDH. The recommendations reflect a paradigm shift in the care of cSDH, recognising and formalising the need for multidisciplinary and collaborative clinical management, communication and decision-making delivered effectively across secondary and tertiary care.

Background: Angiogenesis and nascent blood vessel formation is thought to be important in cerebral arteriovenous malformation (cAVM) development and maintenance, of which little is known. Digital subtraction angiogram (DSA) features of angiogenesis in cAVMs are poorly described and the aim of this study was to describe the frequency of angiogenesis in patients who had a DSA showing a cAVM. We also sought to evaluate the intra- and inter-observer agreement of a diagnosis of angiogenesis and explore which angioarchitectural features were associated with angiogenesis.

Method: Patients that underwent a DSA were identified from the database of referred cAVM patients at the Manchester Centre for Clinical Neurosciences. Data were collected from 100 patients (102 cAVMs). cAVM angioarchitecture, including the presence of angiogenesis, was described after reviewing cAVM patient angiograms. The association of angioarchitectural features with angiogenesis was determined using univariate analysis. Ten cases were distributed amongst two other observers for reporting (inter-observer agreement). Twenty cases (including the previous 10) were reported twice by the first author, after a six-month interval (intra-observer agreement).

Results: Angiogenesis was observed in 39 cAVMs (38.2%), with 12 having a complete border (11.8%). Most intra-observer agreement was strong (ranging from κ = 1 to 0.2), but inter-observer agreement was moderate (κ = 1 to -0.316). There was a significant association between angiogenesis and venous reflux (OR 2.52 [95% CI = 1.08-5.88]), venous congestion (OR 4.47 [95% CI = .671-2.52]), arterial ectasia (OR 16.6 [95% CI = 4.65-59.6]), and artery: vein ratio (4.28 [95% CI = .956-19.15]).

Conclusion: We have demonstrated perinidal angiogenesis can be visualised on angiograms with moderate reliability, and that it may be related to angioarchitectural characteristics associated with venous hypertension.

Introduction: Growing skull fractures are a rare complication of paediatric skull fractures. Despite its rarity, a large proportion of resources go towards detecting this complication. This study aims to identify the factors associated with growing skull fracture development to determine which children require follow-up.

Materials and methods: This was a single-centre retrospective study examining the referral data from all patients under one years old referred with head trauma between 2013 and 2023 (n = 246). Of these patients 189 sustained skull fractures, with two requiring surgery for a growing skull fracture. Referral data for all head injuries between 2008 and 2013 was unavailable but surgical records were accessed for the only case of a child who developed a growing skull fracture in this time period. Each fracture was analysed using the commuted tomography (CT) head for its characteristics, including fracture splay distance and fracture elevation/depression.

Results: A total of 190 cases were reviewed, which showed a male to female ratio of 1.6:1. The majority of patients presented prior to one month of age and the most common mechanism of injury was a fall (80%). The most common fracture sustained was a linear fracture (87.4%). Of all fractures, the most common bone affected was the parietal bone (88.4%). Of those who developed a growing skull fracture, there was a significant difference in both the fracture splay distance (p < .05) and fracture elevation/depression distance (p < .05). All three patients who had growing skull fractures had a fracture splay distance above 5 mm at presentation and an elevation/depression of over 4 mm. 32% of children (n = 61) who had fractures had follow-up, with only nine having a fracture diastasis over 4mm.

Conclusion: Resources and investigations should focus on children with fracture displacement over 4mm and/or elevation/depression distance of over 3mm, as they are at significantly greater risk of growing skull fracture development.