British Journal of Neurosurgery最新文献

Introduction: Intracranial aneurysms (IA) are a common complication of autosomal dominant polycystic kidney disease (ADPKD). Screening protocols that exist for IA in ADPKD patients are an important component of disease monitoring to enable appropriate preventative measures and precautions to avoid IA rupture with its associated morbidly and mortality.

Aims: The aims of this review are to analyse the different types of screening protocols that exist by referencing the lead time between IA diagnosis and rupture in ADPKD patients, the purpose and importance of screening, the types of imaging modalities used, and patient outcomes. We will also consider cost-effectiveness and its relation in establishing a screening protocol as this is an important factor.

Methodology: A literature search was conducted in April 2022 using PubMed, BMJ electronic databases, Dynamed, NICE guidelines and Cochrane databases for articles published between 1990 and 2022 with special interest in IA, ADPKD and screening protocols. The only exclusion criteria were patients who were diagnosed with ADPKD <30 years of age.

Results: Our findings suggest that if a patient with ADPKD presents with either a positive family history of IA and/or cerebrovascular events and/or is above 40 years of age, then they should have a magnetic resonance angiography (MRA) scan every 5 years to monitor IA formation and growth with annual follow-ups. This may contribute to decreased patient morbidity and mortality in ADPKD-positive patients.

Conclusion: While there is some evidence proving that screening protocols decrease the morbidity and mortality of ADPKD patients, none have been recommended. The screening protocol suggested in this review should be used as a guideline for future studies that will try and establish a national or international guidelines that can be used by nephrologists and neurosurgeons worldwide.

Purpose: The aim of this study is to investigate the clinical outcomes of transforaminal lumbar endoscopic discectomy (TLED) in patients with L5-S1 lumbar disc herniation (LDH).

Materials and methods: Seventy-five consecutive individuals with diagnosed foraminal/extraforaminal L5-S1 LDH were included in this study. All patients underwent TLED, being subsequently evaluated in a 2-year follow-up period. Assessment was performed preoperatively and at 6 weeks and 3, 6, 12 and 24 months postoperatively. Visual Analogue Scale (distinctly applied for lower limb - VAS-LP and low back - VAS-BP pain) and Short-Form 36 (SF-36) Medical Health Survey Questionnaire were implemented to assess pain and health-related quality of life (HRQoL) of enrolled individuals, respectively.

Results: No major perioperative complications were observed. Recorded values of all studied indices were demonstrated to feature a clinically and statistically significant amelioration at 6 weeks, presenting lesser improvement at 3 months with subsequent stabilisation. VAS-LP and VAS-BP values were displayed to reach a plateau in 6 months postoperatively, whereas all parameters of SF-36 continued to present a statistically significant improvement until the end of follow-up at 2 years.

Conclusions: TLED represent a safe and efficient technique in terms of diminishing perceived pain and improving HRQoL in patients with L5-S1 LDHs. However, specific patient- and technique-related circumstances on the ground of low surgical experience may limit its effectiveness in these patients.

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.

Background: The informed consent process in neurosurgery aims to support patient autonomy and provide comprehensive information for decision-making. However, gaps in communication and understanding between patients and surgeons persist, that need to be addressed. This systematic review examined the interventions and strategies which to enhance the process of consent in neurosurgery.

Methods: A comprehensive search of databases and relevant sources to identify relevant studies for inclusion. Systematic review of prospective and retrospective studies that assess the effect of interventions which improve the consent process. Data collection and analysis involved independent reviewers assessing eligibility, study quality, and risk of bias. Findings from the included studies were used to write the review.

Main results: The reviewed identified seven studies notably revealed an educational and interactive consent process involving strategies like booklets, videos, multiple interviews, and interactive websites showed improvements in patient knowledge. Recall of risks decreased over time, and factors like age, education, and timing of consent influenced recall.

Authors’ conclusions: To maximise informed consent, neurosurgeons should consider various strategies. Tailoring communication-based on patient's health literacy and treatment knowledge, involving their support system, and using a bullet-point consent form is essential. Utilising multiple modalities like verbal, static, and dynamic visuals improve information retention. Creative and memorable visual aids enhance comprehension. Allowing time for questions and team approach is superior.

Background: The guidance for clinicians on who requires further investigation when suspecting cauda equina syndrome has become clearer in England following the publication of the national recommendations. This does not have specific advice for those patients who have had recent imaging with no compression, returning to a healthcare provider with a change in symptoms. These cases can cause difficulty for clinicians with limited access to imaging who can often be reassured by previous imaging.

Method: This study presents a retrospective review of the case notes of 45 patients presenting on two occasions to the same Emergency Department who underwent magnetic resonance imaging due to the clinical diagnosis of cauda equina syndrome. Those with compression of the cauda equina on the second visit were compared to those without a compressive cause for their symptoms.

Results: Patients presenting with an increased number of clinical symptoms associated with cauda equina syndrome on their return visit were more likely to have compression of the cauda equina on imaging.

Conclusion: The small numbers in this study would suggest caution, however, if patients present with an increasing number of symptoms further imaging should be considered, even with previous reassuring scans.

Background: Patients with glioma often report language complaints with devastating effect on daily life. Analysing spontaneous speech can help to understand underlying language problems. Spontaneous speech monitoring is also of importance during awake brain surgery: it can guide tumour resection and contributes to maintaining language function. We aimed to investigate the spontaneous speech of patients with glioma in the perioperative period and the additional value of spontaneous speech analyses compared to standardised language testing.

Methods: We elicited and transcribed spontaneous speech of eight patients with glioma elected for awake brain surgery preoperatively, intraoperatively and 2.0-3.5 months postoperatively. Linguistic errors were coded. Type Token Ratio, Mean Length of Utterance of words, minimal utterances, and errors were extracted from the transcriptions. Patients were categorised based on total error patterns: stable, decrease or increase during surgery. Reliable Change Index scores were calculated for all spontaneous speech variables to objectify changes between time points. Language performance on language tests was compared to spontaneous speech variables.

Results: Most errors occurred in lexico-syntax, followed by phonology/articulation, syntax, and semantics. The predominant errors were Repetitions, Self-corrections, and Incomplete sentences. Most patients remained stable over time in almost all spontaneous speech variables, except in Incomplete sentences, which deteriorated in most patients postoperatively compared to intraoperatively. Some spontaneous speech variables (total errors, MLUw, TTR) gave more information on language change than a standard language test.

Conclusions: While the course of spontaneous speech over time remained relatively stable in most patients, Incomplete sentences seems to be a robust marker of language difficulties patients with glioma. These errors can be prioritised in spontaneous speech analysis to save time, especially to determine intra- to postoperative deterioration. Importantly, spontaneous speech analyses can give more information on language change than standardised language testing and should therefore be used in addition to standardised language tests.

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.

Aims: After the relocation of paediatric spinal surgery services between specialist centres within the same region, monetary rebates for spinal procedures declined, despite consistent case volumes. A long-term quality improvement initiative was undertaken to enhance coding accuracy and ensure correct remuneration.

Method: A five-year quality improvement project, consisting of three cycles, was undertaken to assess paediatric spinal procedures and related coding practices. Procedures were reviewed and given "optimal" codes by clinicians from the spinal deformity team, and mock rebates were generated. These were compared to actual codes and rebate values from the new site. Meetings were held with lead coders at the new site, and instruction was provided on how to more accurately code spinal procedures. A spinal coding operation manual with lay descriptions of spinal procedures and coding advice was developed.

Results: Rebate accuracy rose from 82.16% to 98.40% over the course of the project (p = 0.007). The mean difference between actual and optimal coding rebate fell from -£4,243.16 to -£264.42. The overall accuracy of clinical coding rose from 37.8% to 70.0% (p = 0.003).

Conclusions: This long-term quality improvement project significantly increased the accuracy of clinical coding for paediatric spinal procedures and, when extrapolated to a mean of 150 cases per year, has generated an annual saving of approximately £596,811.00 for the site. This methodology can be easily replicated in institutions facing similar issues.

Objective: Pituitary neuroendocrine tumours (PitNETs) are the second most common type of intracranial tumour. Several studies have explored the prognostic factors for PitNETs. However, prognostic factors for postoperative PitNET recurrence remain not fully understood. This study aimed to explore potential prognostic factors for PitNET recurrence, such as surrounding tissue invasion and the extent of surgical resection in patients with postoperative PitNETs.

Methods: We included 106 patients who underwent PitNET surgery between 2013 and 2018, dividing them into two groups: those with recurrence and those without recurrence. Tumours were classified based on demographics, neuroradiological, and immunohistological characteristics. Univariate and multivariate analyses were used to determine factors predicting recurrence. Kaplan-Meier plots and log-rank tests were used to analyse each independent factor based on the cumulative 5-year recurrence rate.

Results: During the 5-year follow-up period, 29.2% of the patients (n = 31) had disease recurrence. Univariate analysis showed that predictors of recurrence included cavernous and sphenoid sinus invasions, optic chiasm compression, larger tumour volume, giant adenoma >4 cm, and gross total resection (GTR). Multivariate analysis showed that lactotroph tumour type, sphenoid sinus invasion, and GTR were independent predictors. Kaplan-Meier analysis revealed significant differences in the 5-year recurrence rate among the three independent predictors, with significantly lower recurrence rate in patients with lactotroph tumours and GTR, and a significantly higher recurrence risk in patients with sphenoid sinus invasion.

Conclusions: Lactotroph tumour type, sphenoid sinus invasion, and GTR are independent predictors of postoperative PitNET recurrence. This study provides insights into the factors affecting postoperative PitNET recurrence.

Background: Despite the availability of safe and effective surgical treatments for chronic SI joint pain, many clinicians find the diagnosis of SI joint pain challenging. Misdiagnosis can lead to misdirected surgery, which has important consequences. The study's goal was to determine whether a combination of clinical examination, joint block, and selected radiographic imaging can distinguish patients with SI joint pain from those with other causes of chronic low back pain.

Methods: Prospective diagnostic accuracy study with evaluation of 364 consecutive patients seeking advice in a neurosurgical clinic for chronic low back pain. Participating patients underwent comprehensive clinical examination (medical history items, specific physical examination manoeuvres, and selected radiographic tests) followed by SI joint block. Block was used to confirm or exclude SI joint pain. Logistic regression with LASSO (least absolute shrinkage and selection operator) penalty was used to calculate the accuracy of diagnosis when looking at (1) medical history items only, (2) medical history plus radiographic testing, and (3) medical history, radiographic testing, and physical examination testing.

Results: 150 patients had a positive response (>50% acute pain relief) to SI joint block, 214 had no response to SI joint block, and 37 had minimal (<50% improvement) in pain. Diagnostic accuracy for SI joint pain was lowest with medical history only (85-86%), slightly higher when radiographic testing was added (87%), and highest when physical examination testing was included (96%).

Conclusion: Comprehensive clinical examination (including SI joint block where relevant and selected imaging procedures) is accurate in distinguishing the SI joint from non-SI joint causes of chronic low back pain.

Trial registration: https://www.clinicaltrials.gov/study/NCT04381208.