British Journal of Neurosurgery最新文献

Purpose: Head injury is a common presentation to emergency departments, and most patients are discharged with a diagnosis of concussion. Written discharge advice provided to patients serves as a critical tool to communicate signs of surgical deterioration and to convey management principles to reduce long-term morbidity associated with concussion. This study aimed to evaluate the compliance of head injury discharge leaflets with National Institute for Health and Care Excellence (NICE) guidance.

Materials and methods: A cross-sectional, national audit of practice was conducted to assess the adherence of head injury discharge leaflets to NICE head injury guidelines (NG232) across all eligible NHS England trusts. Compliance against each domain was evaluated in duplicate against a standardised, piloted proforma, with overall quality summarised as an average score. Exploratory analysis between domains was performed, with comparative analysis between leaflets for adult and paediatric patients.

Results and conclusions: None of the 99 leaflets reviewed (0/99) complied with all aspects of NICE guidance. The mean score of the leaflets was 0.42 out of 1, falling short of the set target of 0.95. There was no significant difference in mean scores between adult and paediatric leaflets. Safety information based on surgically-relevant deterioration achieved the compliance target of 95%. Advice on concussion management (including symptoms to expect, return to normal activities, and the details about further support and information in case of persistent symptoms) was generally poor. Additionally, 50.5% (50/99) of leaflets advised against returning to activities 'until feeling completely back to normal', which contradicts current guidance. The quality of head injury discharge leaflets currently does not meet satisfactory standards. A centrally curated, regularly updated discharge leaflet, with provision for local modifications, is recommended to standardise practice based on current specialist practice. This is a cost-effective intervention which has considerable potential to improve outcomes after head injury.

Background: Deep brain stimulation (DBS) surgery targeting the ventral intermediate thalamic nucleus (Vim) has proven efficacy in the treatment of tremor.

Aims: The primary aim is to investigate whether there is a statistically significant difference in patient outcomes when CT-guided targeting of the Vim is compared with MRI-guided targeting.

Methods: This is a retrospective study concerning patients undergoing Vim-targeted DBS at the Department of Neurosurgery, Royal Victoria Infirmary in Newcastle (9^th August 2012 to 4^th January 2019). Fahn-Tolosa-Marin Tremor Scale (FTM TS) and EQ-5D scores were collected from patient notes. Statistical analysis was performed using IBM^® SPSS^® Statistics Version 24. Independent samples t-tests were used to compare means.

Results: Independent samples t-test did not reveal a statistically significant difference between CT (n = 10; FTM TS mean = 65.40, SD = 11.40; EQ-5D mean = 39.50, SD = 17.87) and MR (n = 7; FTM TS mean = 60.57, SD = 7.50; EQ-5D mean = 32.14, SD = 9.94) groups in pre-surgery FTM TS (t(15) = 0.977, p = 0.344) and EQ-5D (t(15) = 0.982, p = 0.342) scores. No statistically significant difference between the CT (FTM TS mean = 24.12, SD = 20.47; EQ-5D mean = 75.56, SD = 15.63) and MR (FTM TS mean = 22.86, SD = 6.72; EQ-5D mean = 70.43, SD = 15.48) groups was revealed at 1 year assessment of FTM TS (t(14) = 0.155, p = 0.879) and EQ-5D (t(14) = 0.654, p = 0.524). The median difference between pre- and post-surgery FTM TS and EQ-5D scores in the CT group at 1 year was 43.00 and 35.00, respectively. The MR patient group median difference in pre- and post-surgery at 1 year was 35.00 and 35.00 respectively.

Conclusion: No statistically significant difference between CT and MR image-guided targeting patient groups was detected.

Background: Cervical foraminal stenosis on MRI may be assessed using the Kim, modified Kim or Siller methods. This study aimed to investigate which morphological features of cervical foraminal stenosis in patients with cervical radiculopathy correlated best with pre-operative and post-operative surgical outcome following Anterior Cervical Discectomy (ACD) or a Posterior Cervical Foraminotomy (PCF).

Methods: Pre-operative MRIs of adults with cervical radiculopathy were assessed by six raters. The following measurements were made; uncompressed nerve root diameter, maximal compressed nerve root diameter, anterior & posterior compression, length of the neuroforaminal canal where the diameter was less than the uncompressed nerve root diameter and the distance of maximum compression from the apex of the ligamentum flavum. The Kim, modified Kim and Siller grades were calculated. Neck Disability Index (NDI) was measured pre-operatively and six weeks post-operatively. The radiological measurements and grades were compared to the pre-operative and change in NDI.

Results: Mean NDI was higher in female (58.2) than male patients (45.6) p = 0.05. No other baseline, operative or radiological factors where significantly associated with the pre-operative NDI. The mean [±SD] post-operative NDI was 14.3 [±22.5]. This represents a change of 37.8 (p < 0.001). The pre-operative NDI correlated strongly with the post-operative NDI but no other patient, operation or radiological factors correlated significantly. Neither pre-operative NDI or change in NDI was statistically different in those treated with ACD and those treated with PCF.

Conclusion: There was no association between pre-operative NDI and any of the radiological measurements or radiological grades. Furthermore, whilst surgery significantly improved NDI, for those patients with anterior compression, there was no difference in outcome between those treated with an ACD and those treated with a PCF. Current axial MRIs do not adequately assess the cervical nerve root foramina or predict surgical approach, 3D isotropic acquisition and DTI should be explored.

Deep brain stimulation has been in clinical use for 30 years and during that time it has changed markedly from a small-scale treatment employed by only a few highly specialized centers into a widespread keystone approach to the management of disorders such as Parkinson's disease. In the intervening decades, many of the broad principles of deep brain stimulation have remained unchanged, that of electrode insertion into stereotactically targeted brain nuclei, however the underlying technology and understanding around the approach have progressed markedly. Some of the most significant advances have taken place over the last decade with the advent of artificial intelligence, directional electrodes, stimulation/recording implantable pulse generators and the potential for remote programming among many other innovations. New therapeutic targets are being assessed for their potential benefits and a surge in the number of deep brain stimulation implantations has given birth to a flourishing scientific literature surrounding the pathophysiology of brain disorders such as Parkinson's disease. Here we outline the developments of the last decade and look to the future of deep brain stimulation to attempt to discern some of the most promising lines of inquiry in this fast-paced and rapidly evolving field.

Background and importance: The surgical management of intramedullary spinal cord tumours (IMSCT) poses inherent risk to neurologic function. Direct-wave (D-wave) monitoring is routinely reported to be a robust prognostic measure of spinal cord function via midline recording within the epidural or intradural space in a cranial-caudal montage. We explored the feasibility of bilateral epidural D-wave monitoring with routine evoked potentials in promoting safe and maximal resection in a patient with diminished midline D-wave baselines associated with an eccentric intramedullary cervical astrocytoma.

Clinical presentation: We describe the presentation, surgical management, electrophysiological findings and post-operative outcome of a 46 year-old female patient who underwent two resections for an eccentric intramedullary cervical astrocytoma. During the first procedure we encountered clinically significant motor evoked potential signal change and discontinuation of resection pending further review. Midline D-wave signals showed no change, however peak amplitude was diminutive (7 uV) and overall morphology was characteristic of corticospinal desynchronization. Post-operatively the patient experienced significant but transient left sided weakness. A subsequent revision procedure incorporating ipsilesional and contralesional D-wave monitoring in addition to routinely incorporated evoked potentials was proposed in order to facilitate a safer resection. The ipsilesional D-wave response was considerably lower in amplitude (2.5 uV) in contrast to the contralesional D-wave (20 uV).

Conclusion: To the authors' knowledge this is the first description of bilateral D-wave monitoring as an adjunct to cranial-caudal D-wave montages during IMSCT surgery. In patients with corticospinal desynchronization evidenced by abnormal midline D-wave morphology, bilateral D-wave monitoring in conjunction with routine evoked potentials may be clinically indicated for preservation of motor function and promotion of safe and maximal resection.

Introduction: Hydrocephalus is commonly treated by diverting cerebrospinal fluid (CSF) from the ventricles through a shunt system to a distal site, such as the peritoneum, right atrium, or pleural space. When CSF diversion to these sites is contraindicated, the gallbladder is an alternative terminus. Ventriculo-biliary shunts, in which the distal tip of the shunt catheter is placed into the gallbladder through the cystic duct, are one such alternative. There are a paucity case reports describing the adverse effects of these shunts.

Case presentation: Here, we describe the case of a 3-year-old child with history of a craniopharyngioma who underwent ventriculo-biliary shunt placement and presented with increased seizures, abdominal distention, hydrocephalus, and imaging consistent with development of a subdural collection. Analysis of the subdural collection was consistent with biliary fluid.

Conclusion: The placement of a valveless system between the brain and biliary system should be carefully considered in highly medically unstable patients. We present the first report of this rare adverse event and describe the diagnostic criteria, prevention, and management options for biliary reflux into the intracranial compartment.

Purpose: Neurosurgery training in the UK has undergone significant changes over the past few years, including the new competency-based curriculum and a reduction of elective operating due to the pandemic. We conducted a comprehensive survey to assess UK neurosurgical trainees' experiences and perceptions to develop targeted action plans.

Methods: An online anonymised survey was developed and distributed amongst the BNTA mailing list. Question types included 10-point Likert scales and free text options. Descriptive statistics, non-parametric testing of Likert scores, and Spearman's rank correlation were used to analyse responses. Pearson's chi-squared test was used for subgroup analysis of categorical data.

Results: A total of 75 trainees with a National Training Number (NTN) responded. Overall trainees feel they are well trained, well supported, and have caught up with training emerging out of COVID. Funding for training varied between deaneries. There is significant concern amongst trainees regarding the workforce crisis. This, as well as financial concerns are leading to more than a quarter of trainees considering quitting. Half of the trainees are considering going OOP. More than one third of the trainees and more than half of the female trainees are considering working Less Than Full Time (LTFT). Most important supportive mechanisms towards completion of training were social support, along with personal satisfaction from work. An independent mentoring scheme is a preferred additional support mechanism.

Conclusions: Overall training experience for neurosurgery trainees in UK and Ireland was positive. There are significant concerns regarding the workforce crisis and costs of training, with a large proportion of neurosurgery trainees considering resigning. OOP and LTFT are popular means of becoming more competitive for consultant posts and to spend time with their families. Deanery experience, senior and peer support does, and will improve trainee experience and protect against attrition.

Introduction: Skull base pathologies in the paediatric population are rare and require treatment by multiple qualified specialists. The endoscopic endonasal approach has revolutionized surgical treatment because it is less invasive than existing treatments.The goal of this study was to retrospectively review our experience with the reconstruction of paediatric skull middle base defects and associated complications.

Materials and methods: We analysed medical records from patients aged ≤ 18 years who were treated at our centre between 2013 and 2021. Patients treated with an endoscopic skull base approach and reconstruction, and who had complete clinical and radiological documentation and a minimum follow-up of 12 months, were included in the analysis. Personal data, reconstructive techniques, and complications were analysed.

Results: A total of 78 patients met the inclusion criteria and were enrolled in the study. Of these patients, 32 were male and 46 were female, and the mean age was 11.5 years. The main signs and symptoms were as follows: bitemporal hemianopsia in 53 cases, visual impairment in 23 cases, and headache in 30 cases. The most frequent aetiologies were craniopharyngioma (38 cases), pituitary adenoma (23 cases), and clivus chordoma (4 cases). All patients were treated via a pure endoscopic approach. For reconstruction, a multilayer technique was used in 18 cases, naso-septal flap in 43 cases, Gasket-Seal technique in 12 cases, and heterologous reconstruction in 5 cases. Only six patients presented a major complication: two had a postoperative cerebral spinal fluid leak, one developed a brain abscess, and three had diabetes insipidus.The mean follow-up period was 23.4 months.There were no statistically significant differences in postoperative CSF leak in relation to different reconstructive techniques.

Conclusion: Endoscopic endonasal skull base surgery is a safe and effective treatment for paediatric middle skull base pathologies. Reconstruction techniques have a high success rate of 96.5-100%, and the rate of associated complications is < 3%.

Although glioblastoma is the commonest primary brain tumour in adults, its location in the cerebellum is extremely rare. We present thirteen cases (3 female, 10 male; median age at presentation 56 [age range 21-77]) of surgically managed, histologically confirmed, primary cerebellar glioblastoma (cGB) over a 17 year period (2005-2022). Pre-operative radiological diagnosis was challenging given cGB rarity, although MRI demonstrated ring enhancement in all cases. Surgical management included posterior fossa craniectomy and debulking in 11 cases and burr hole biopsy in two. CSF diversion was necessary in four cases. No evidence of IDH or ATRX gene mutations was found when tested. Survival ranged from 1 to 22 months after diagnosis (mean 10.9 months). We also seek to understand why glioblastoma is rare in this location and discuss potential reasons for this. We hypothesise that increasing anatomical distance from germinal regions and decreased local endogenous neural stem cell activity (which has been associated with glioblastoma) may explain why glioblastoma is rare in the cerebellum. We hereby seek to add to the limited literature on cGB as this is the largest UK cGB series to date.