British Journal of Neurosurgery最新文献

Objective: To present a new technique for the management of subdural empyema to promote resolution and prevent recurrence.

Background: Classic treatment for subdural empyema (SDE) has consisted of antibiotics and surgical treatment with either craniotomy or burrholes. There are still several complications that persist after current treatment, including relatively high rates of morbidity and mortality. In this case report, we present a technique that utilises a novel irrigating-draining catheter to provide a minimally invasive approach for empyema resolution with continuous antibiotic irrigation.

Methods: In this example case, a 24-year-old male presented to the hospital for new onset headache, lethargy, confusion, and extremity tremors. Initial imaging demonstrated a left frontal extra-axial collection, treated with emergent craniotomy for evacuation of subdural empyema. The subsequent hospital course was complicated by the development of bilateral subdural empyemas which were surgically treated with use of novel irrigating-draining catheters.

Results: The patient tolerated the procedure well without any complications. He was subsequently discharged to rehab with no deficits or recurrence at a 4-month follow-up visit.

Conclusions: This minimally invasive novel approach for SDEs can be both safe and effective. Future work should further elucidate the effect of this technique on empyema recurrence and long-term outcomes compared to traditional surgical approaches.

Background: The climate crisis is one of the greatest threats to public health and surgery is a significant contributor to carbon emissions generated by the NHS. In this paper, we describe our experience of sustainable operating by using evidence-based methods to reduce our carbon footprint across three neurosurgical theatres during our 'Green operating day'.

Methods: The Green operating day was run at a single site over a 12-hour operative day and included 10 neurosurgical cases. Following discussions with the theatre, anaesthetic and sustainability team, each operative case was reviewed and changes in the consumables, surgical instruments and utilities recorded. Carbon footprint was calculated using an environmentally extended input-output model for baseline and Green operating day. Qualitative data was collected on the participants of the Green operating day to assess attitudes and behaviours towards sustainability in neurosurgery.

Results: There was a total reduction of carbon emissions by 31%, equivalent to 1.04 tonnes CO₂e. Reductions were seen across different aspects of surgery including anaesthetics, surgical instruments, waste and utilities.

Discussion: This study demonstrates the feasibility of carbon footprint reduction within neurosurgical theatres which was not associated with increases in operative duration or adverse patient outcomes. This study advocates for environmentally conscious decision making in neurosurgical procedures.

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.

Purpose: The legal interpretation of consent has transitioned over the last decade. Surgeons must identify what patients value to individualise surgical consent. This presents a considerable challenge during busy ward rounds or outpatient clinics. We aimed to develop and evaluate a novel risk tolerance tool to aid surgical consent.

Methods: This prospective, longitudinal cohort study evaluated the views of adult, elective surgical patients from a single centre. Attitudes to the existing surgical consent process were assessed (n = 48) and responses underwent thematic analysis. From these responses and a stakeholder focus group, a novel risk tolerance tool was developed. The risk tool was evaluated using questionnaires in 25 pre-operative patients. Post-operatively, the same cohort were followed-up with a telephone clinic 6-8 weeks after discharge.

Results: Overall patients were satisfied with the current consent process, but negative themes emerged including that it is generalised, impersonal, and time pressured. The developed risk tool contained six domains: death, pain, loss of physical function, loss of cognitive function, need for repeat medical interventions, and social disability. Loss of physical function (mean = 34.0, SD = 12.8) and loss of cognitive function (mean = 34.0, SD = 6.1) had lowest risk tolerance, and need for repeat medical interventions (mean = 18.8, SD = 10.9) had the highest risk tolerance. Thirteen (93%) patients had a positive experience of the consent process vs 85% of patients in pre-consent tool cohort.

Conclusions: The tool demonstrated good patient acceptability and patient reported experience. The tool gathered data that may enhance understanding of patient risk tolerance and personalise the surgical consent process.

Background: Chiari malformation type 1 (CM1) pathophysiology remains uncertain. One theory involves small posterior fossa volumes leading to tonsillar herniation. Craniosynostosis causes suture fusion, which can limit skull growth, and has been investigated in paediatric CM1 cohorts. We aimed to identify the prevalence of concurrent craniosynostosis in adult CM1 patients.

Methods: Surgically managed CM1 patients were identified from a pre-existing Edinburgh neurosurgical centres database spanning 10 years. Patients aged 16 years of age or older had their case notes reviewed retrospectively. Cross sectional imaging identified and classified craniosynostosis, tonsillar herniation and the presence of hydrocephalus or syrinxes.

Results: 35 cases met inclusion criteria. Seven cases (20%) had craniosynostosis, all of which were sagittal synostosis. There was no significant association between the presence of craniosynostosis and the degree of tonsillar herniation, presence of hydrocephalus or syrinx formation.

Conclusion: This is the first study to evaluate the prevalence of craniosynostosis in a cohort of surgically managed adult CM1 patients. Future studies should potentially investigate whether conservatively managed adult CM1 patients have similar rates of craniosynostosis and also lack significant associations to known CM1-related complications.

Objective: This study aimed to evaluate the demographics and outcomes of major paediatric head trauma managed in our Paediatric Intensive Care Unit (PICU) in South Wales and comparison is made with the existing published literature.

Design and setting: A retrospective review of medical records and imaging of patients identified from the paediatric neurosurgical trauma database at University Hospital Wales (UHW) from March 2013 to July 2021. We assessed the GCS at admission, mechanism of injury, CT scan, type of surgery required and GOS after 12 months.

Patients: A total of 46 children (<16 years old) who were admitted to intensive care secondary to a traumatic brain injury were identified. Mean age was 7.6 years (range 0 days-15.7 years).

Results: Road traffic accidents (RTA) were the predominant mechanism of injury (56.5%), followed by falls (32.6%). Neurosurgical intervention, including stand-alone ICP monitoring was required in 69.6% of patients. Post discharge outcome was defined using the Glasgow Outcome Score (GOS), with a good functional outcome (GOS ≥4) accounting for 86.4% at 12 months follow-up. Survival rate was 93.4%.

Conclusion: Demographics in South Wales are similar to the published literature, except falls had a higher mortality than RTA in our cohort. Head injury mechanisms, surgical interventions and outcomes show variation between patients from the pre-covid and lockdown periods. Outcomes are good for surgically and conservatively treated patients and very comparable to the published literature.

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.

Purpose of article: The role of immediate precipitating activities in aneurysmal subarachnoid hemorrhage (aSAH) remains unclear, lcontributing to uncertainty regarding activity restriction. This systematic review and meta-analysis examined the relative strain of activities preceding spontaneous aSAH using metabolic equivalents of task (METs).

Materials and methods: A systematic search identified studies reporting activities preceding aSAH (categorised as nonstrenuous, MET 1-4, and strenuous, MET ≥5). Associations between activity category and aSAH occurrence were assessed using chi-squared testing, with Fisher's combined method evaluating overall association. Odds of aSAH were evaluated using sleep or rest (MET 1) as the reference.

Results: Six studies (3,285 aSAH cases) were included. aSAH mostly preceded nonstrenuous activities (43.2%) compared with strenuous activities (23.5%). Heavy strain activities (MET 6-8) , preceded 8.9% of cases ,while Valsalva maneuversaccounted for 7.9%. Fisher's combined method showed aSAH occurred less frequently after strenuous activities (p <0.001). Compared with sleep or rest, odds of aSAH were comparable or lower across all other activity categories.

Conclusion: Routine nonstrenuous activities most often preceded aSAH, suggesting high physical exertion may not be a dominant immediate trigger of aneurysm rupture. Other factors, including circadian blood pressure fluctuations and impaired autoregulation, may contribute to rupture risk.

Purpose: Awake craniotomy (AC) is a procedure often performed concomitantly with direct electrical cortical stimulation (DES) and electrocorticography (ECoG) during functional brain mapping. Patients undergoing AC are at risk of acute symptomatic seizures, including intraoperative (IS) and early postoperative seizures (EPS) which can lead to higher risk of morbidity. Predicting those who are at risk of IS and EPS could alert clinicians and provide the ability to closely monitor and consider management changes in the acute setting to prevent seizures.

Materials and methods: This is a narrative review of previous studies on IS and EPS during awake craniotomy, including a summary of studies from our center using a novel circular grid electrode.

Results and conclusions: There are a number of clinical features with variable association with a higher risk of EPS and IS. Surgeries involving the anterior and central head regions are a risk factor for IS. EPS is more likely to occur in patients with perioperative intracranial hemorrhage. Improving grid/electrode technology for ECoG can allow for better sensitivity of detecting epileptiform activity which can help to diagnose and predict perioperative seizures.