British Journal of Neurosurgery最新文献

Introduction: Cervical torticollis is a relatively common presentation in infants and children, but its broad differentials necessitate thorough evaluation to exclude more serious underlying pathology. Congenital muscular torticollis is the most frequent cause and acquired torticollis may arise from trauma, inflammation, infection or even neoplastic conditions.

Case report: We present a case of a 10-month old female who developed cervical torticollis without any systemic signs of infection. Inflammatory markers and white cell count were within normal limits. MRI imaging demonstrated T2 hyperintensity at the C3/4 intervertebral disc and adjacent vertebral bodies which was suggestive of cervical discitis, a rarer and under-recognised cause of torticollis in infants. After multidisciplinary discussion empirical oral antibiotics were commenced, resulting in rapid clinical improvement. The patient was reviewed in 6 weeks with a follow-up MRI, showing improvement in their condition and completed the 12 week course of antibiotics without any further issues.

Study design: A retrospective case analysis of patients aged 75 and above with C2 odontoid peg fractures at a large UK teaching hospital/major trauma centre.

Objective: This review was conducted to evaluate the outcome of isolated odontoid peg fracture management in elderly patients. Many studies have examined odontoid peg fractures in patients aged 65 years and older, evaluating both surgical and non-surgical management. Considering our ageing population and related comorbidities, our hospital now considers those over 75 years old to be elderly. We aimed to evaluate the management outcome in this specific group of patients treated conservatively.

Methods: Case records of isolated odontoid peg fractures in patients aged 75 years or older, between October 2011 and April 2017, were reviewed, along with the outcome of planned clinical follow-up at 8-12 weeks. The mechanism of injury, fracture classification, comorbidities, fall risk, compliance, complications, and outcomes were recorded. All patients were treated with a hard collar initially, and none had neurological deficits.

Results: 112 patients aged 75 and older with isolated odontoid peg fractures were identified in case records. The majority (88.4%) suffered C2 odontoid peg fractures after falling from less than 6 feet, with a mortality rate of 22.3% during treatment. The most common types of fractures were Anderson and D'Alonzo type 2 (79.5%) and Roy-Camille type 2 (59.8%). 18 out of 112 patients (16.1%) had complications from hard collar treatment, including pain, pressure sores, and dysphagia. Older patients and those with Anderson and D'Alonzo type 2, and Roy-Camille type 2 fractures had lower rates of bony union and more fibrous union. 15 out of 112 patients (13.4%) were non-compliant with hard collar treatment. The main reason for not tolerating the hard collar was pain, with 8 patients (7.2%) complaining of intolerable pain and discomfort from the collar. Despite non-compliance, these patients achieved similar union rates to those who completed their treatment, and we found that fibrous union was the most common outcome in both groups.

Conclusions: Although a small cohort of 11 patients were treated without a hard collar (10 of whom used soft collars), the outcomes in terms of union rates were comparable to those of patients managed with hard collars. This suggests that soft collar immobilisation may represent a viable alternative in terms of both radiological and clinical bone healing, as well as fibrous healing, compared to the traditional treatment option of hard collar immobilisation. With the high mortality associated with these injuries, C2 odontoid peg fractures in elderly patients require a personalised treatment approach, considering age, fracture type, and patient compliance. We also advise a broader scope of practice in terms of recognising falls as a risk factor f

Background: Decompressive craniectomy (DC) is a well-established intervention for refractory intracranial hypertension. Autologous bone flaps are commonly preserved by cryopreservation or subcutaneous abdominal storage.

Objective: To report a novel, life-threatening complication of abdominal bone flap storage: haemorrhagic shock secondary to abdominal wall haematoma.

Methods: We describe three cases (2 males, 1 female; ages 46-73) from two tertiary centres. Two patients underwent DC for traumatic brain injury, one for malignant MCA infarction. Each developed a large subcutaneous haematoma at the abdominal pocket site - analogous to a device pocket haematoma - precipitating haemorrhagic shock.

Results: Haematomas developed between <6 hours and 14 days postoperatively. Anticoagulation varied: therapeutic heparin (n = 1), prophylactic LMWH (n = 1), none (n = 1). CT angiography and operative findings demonstrated focal arterial bleeding, likely from superficial rectus sheath branches of the superficial epigastric artery, attributed to abrasion by the bone flap edge. Despite moderate haematoma volumes (800-1000 mL), all patients developed ATLS class III-IV shock, reflecting physiological vulnerability after major surgery, trauma or advanced age. Urgent surgical exploration, flap removal, and electrocautery achieved haemodynamic stabilisation. This Clavien-Dindo grade IV complication appears rare - estimated incidence ∼0.5% (3/600 cases).

Conclusion: Abdominal bone flap storage, though considered safe, can cause focal vascular injury and life-threatening haemorrhage. Preventive measures - meticulous haemostasis, appropriate pocket sizing, and vigilant monitoring - are essential to enhance safety.

Introduction: Cyproterone acetate (CPA) is an antiandrogen that may be used in combination with estradiol in gender reaffirmation therapy. Whilst CPA is associated with an increased risk of meningioma in cisgender women, literature on its risks and optimal management in cases of meningioma in transgender women remains sparse.

Case presentation: The authors present the case of a 67-year-old transgender female who presented acutely with meningiomatosis. The patient had been on long term, high dose CPA and estradiol gender reaffirming therapy. CPA and estradiol therapy were held and the large, left sided lesions causing peritumoural oedema and significant mass effect were surgically resected. Histology confirmed atypical meningiomatosis with diffuse but weak progesterone receptor expression. Post-operative MRI scans demonstrated delayed regression of the remaining lesions following CPA and estradiol cessation at 12-months. Volumetric analysis revealed a mean tumour volume reduction of 21% at 12-months. Minimal change in tumour volume was seen on imaging at both 4-weeks and 6-months after cessation.

Conclusions: CPA cessation alone may be an effective way to halt and even regress meningioma progression. However, its effect appears to be delayed, indicating that cessation alone is suboptimal in cases causing significant mass effect and symptomatology. In such cases, early surgical intervention should be considered.

We present a case of aneurysmal subarachnoid haemorrhage in a preadolescent teenage patient from a right posterior inferior cerebellar artery origin aneurysm rupture. During coiling they had a re-rupture event with cerebral anoxia which necessitated decompressive craniectomy on bleed day three due to medically refractory intracranial hypertension. The patient then developed severe bilateral V4 and basilar vasospasm. In addition to blood pressure control and fluids, 4mg of intrathecal nicardipine was administered every eight hours into the ventriculostomy for 5 days. Vasospasm was markedly improved within 24 hours and resolved within two days. MRI did not show any focal vasospasm-related stroke. At 6-month follow up, the only neurological deficit was short-term memory loss. The outcome of this case highlights the potential for IT nicardipine to safely and effectively reduce paediatric vasospasm and avoid detrimental injury resulting from cerebral ischemia.

Introduction: This study aimed to assess the feasibility as well as the clinical and radiological outcomes of posterior percutaneous pedicle screw fixation (PPSF) combined with anterior monosegmental column reconstruction in unstable thoracolumbar burst fractures.

Methods: From January 2015 to August 2022, 65 consecutive patients with unstable thoracolumbar burst fractures were enrolled in this study. The patients underwent posterior PPSF combined with anterior monosegmental reconstruction, utilising titanium mesh cages. Primary outcomes included patient reported outcomes defined by the visual analog scale (VAS) score of low back and leg and ability to return to work. Secondary outcomes included radiological parameters, and treatment-related complications.

Results: The mean age of the patients was 48.2 ± 12.3 years. These patients were followed up for a period of 28.2 ± 14.1 months The VAS pain score significantly improved postoperatively (P = 0.028), and this improvement was maintained until the final follow-up. 32 (49.2%) patients returned to work within 6 months and a further 33 (50.8%) returned to work subsequently. At the time of the final follow-up, 42 of 65 (64.6%) patients had returned to a similar job, and 23 (35.4%) patients changed to a less physically demanding job. In 39 patients with neurologic dysfunction, 34 (87.2%) had improvement after surgery. Radiologically, the mean sagittal kyphosis was corrected from 16.3 ± 12.7 preoperatively to 2.2 ± 1.8 postoperatively (P < 0.001), which remained stable at the final follow-up. No obvious subsidence of the titanium mesh cage and no dislodgement, loosening or breakage of the instrumentation was observed in any patient during the follow-up period. Solid bony fusion was achieved in all patients.

Conclusions: Combined posterior PPSF with anterior monosegmental column reconstruction for unstable thoracolumbar burst fractures is safe and can achieve good clinical and radiological outcomes.

Purpose: Chronic subdural haematoma (cSDH) is a prevalent neurosurgical condition with an increasing incidence. Most cSDH occur in patients with complex perioperative needs and emerging clinical practice guidelines could provide substantial benefit. This study sought to understand current and future health service costs to inform guideline implementation.

Materials and methods: Using data from the Cambridge University Hospital neurosurgical network, national audit reports, and UK unit cost data, we modelled the total national cost of operative cSDH treatment in 5-year intervals to 2040. Estimates were adjusted for inflation (2.5%) and demographic change (Office for National Statistics). We also modelled potential savings from reductions in hospital length of stay (5 - 40%) and post-discharge care costs (2.5 - 10%).

Results: In 2025, operative cSDH is estimated to cost £15,100 per case and £42,150,000 across the UK, rising by 45% and 88% by 2040, respectively. A 20% reduction in neurosciences unit length-of-stay and 5% reduction in post-discharge costs could save £1,220 per case and £3,395,000 UK wide in 2025. This will rise approximately two-fold by 2040.

Conclusion: cSDH has a significant, and increasing, economic impact. Implementing integrated multidisciplinary care could yield monetary savings as well as additional benefits, such as increased operative capacity.

Study design: Retrospective cohort study.

Objectives: Previous studies have identified diagnostic clinical coding inconsistencies within the Hospital Episode Statistics (HES) database for England. We aimed to explore the appropriateness of diagnostic clinical coding for cervical decompression procedures.

Methods: Extracted anonymous HES data included age, sex, frailty, deprivation, surgical procedure and diagnostic details between April 2017-March 2024. The primary outcome was the use of 'non-specific' or 'inappropriate' diagnostic clinical codes.

Results: Data were available for 44,623 patients (54% males, n = 24,030) . The mean age was 56.5 years (SD 15.8 years). The most common diagnosis was myelopathy or radiculopathy (n = 26,764; 60%), however 32% of patients (n = 14,257) were assigned ICD-10 codes that were neither myelopathy, radiculopathy nor another appropriate code. Undergoing revision surgery (OR 1.21), and posterior surgical approach (OR 4.06) were associated with greater odds; while increasing age > 40 years, male sex (OR 0.88), emergency surgery (OR 0.55) and 3-level surgery (OR 0.74) deceased the odds of non-specific or inappropriate coding.

Conclusions: Inappropriate or non-specific clinical diagnostic coding information was recorded for almost a third of cervical decompression surgery in the HES patient record. We recommend the use of the most widely used codes for cervical radiculopathy (M50.1) or cervical myelopathy (M50.0).

Background: Ventriculoperitoneal shunts (VPS) remain the standard of care for cerebrospinal fluid (CSF) diversion in hydrocephalus and idiopathic intracranial hypertension (IIH). Despite their efficacy, they carry a risk of distal catheter migration, which can result in repeated revisions and increased morbidity.

Methods: Three patients with recurrent distal catheter migration, two with IIH and one with hydrocephalus secondary to residual intraventricular tumour, underwent laparoscopic revision. All patients had a high body mass index (BMI) > 40 and multiple prior shunt revisions. The distal catheter was externalised, CSF flow confirmed, the catheter thread through a Parietex composite mesh patch in a zigzag pattern. The mesh-catheter construct was introduced laparoscopically into the peritoneal cavity and anchored to the abdominal wall with tacks under direct visual guidance.

Results: Postoperative follow-up showed no further catheter migration or shunt malfunction in any of the three cases. Neurological and visual symptoms resolved or improved, and imaging demonstrated stable shunt function without new complications. No mesh-related infections or adverse events were observed during this follow-up period.

Conclusion: Laparoscopic surgical mesh anchoring appears to be a safe and effective technique for preventing recurrent distal catheter migration in VPS, particularly in high-risk populations such as patients with obesity. By securing the catheter to the abdominal wall with a mesh scaffold, this approach provides enhanced mechanical stability and reduces the need for repeated revisions.

Background: Glioblastoma (GBM) is an aggressive primary brain tumour that carries a great deal of symptom burden, placing significant stress on caregivers. The purpose of this current study is to capture realities of bereaved loved ones of patients with GBM throughout the illness journey and to understand family beliefs and experiences regarding a post-mortem whole brain analysis study, the Spatial Heterogeneity Challenge (SHC).

Methods: This qualitative description study utilized semi-structured interviews with 16 bereaved loved ones of previous SHC donors. Data was analyzed using thematic analysis.

Results: Experiences were temporally categorized into phases of the illness journey (diagnosis, standard therapy, 'honeymoon period', clinical trials, end of life, and donation). Within these categories, participants reported inadequate support in caring for their loved one and accessing clinical trials. Regarding the SHC, participants felt proud of the patient's participation, and reported alleviated stress and meaning provided to an otherwise devastating loss.

Conclusions: The illness journey of patients with GBM and their families is unique from other cancers and requires additional support from our healthcare system with a streamlined approach to care. Providing the opportunity to participate in studies like the SHC after death allows families to gain meaning from this devastating experience.