Neurocirugía en el paciente mayor: neurocirugía geriátrica

Complex Multidisciplinary Cranial and Scalp Reconstruction for Patient Salvage

OBJECTIVE/BACKGROUND

Patients can develop scalp and cranial defects as a result of neoplasm, trauma, or infection. Reconstruction of these defects can be difficult in some patients and may require a multidisciplinary approach using creative solutions usually used for disease processes in other areas of the body, such as severe burns.

METHODS

A series of 9 patients were treated using multidisciplinary techniques for reconstruction of complex cranial and scalp defects. Data on patient characteristics, initial treatment, and preparatory and definitive reconstructive treatment were retrospectively collected. Outcomes were measured as full solution, partial solution, or failure.

RESULTS

Three patients had a full solution/wound closure, 5 had a partial solution, and 1 failed reconstructive attempt. Full solution patients tended to be younger, received reconstruction treatment modalities for longer periods of time, and had more definitive surgeries. Initial and preparatory surgeries did not tend to promote a full solution, though having fewer preparatory surgeries that were not related to wound vacuum-assisted closure use tended to be associated with a better outcome. Infection of the scalp or cranium did not tend to change the result.

CONCLUSIONS

Reconstructive salvage of complex cranial and scalp defects takes time, so patience and earlier recognition of need for atypical reconstruction is beneficial. Patient characteristics may influence outcomes, but judicious choice of materials and techniques is more critical to patient success. Use of a multidisciplinary approach to complex cranial and scalp reconstruction is a beneficial option for many patients for whom standard reconstruction methods are not viable.

Multimorbidity and Critical Care Neurosurgery: Minimizing Major Perioperative Cardiopulmonary Complications

With increasing prevalence of chronic diseases, multimorbid patients have become commonplace in the neurosurgical intensive care unit (neuro-ICU), offering unique management challenges. By reducing physiological reserve and interacting with one another, chronic comorbidities pose a greatly enhanced risk of major postoperative medical complications, especially cardiopulmonary complications, which ultimately exert a negative impact on neurosurgical outcomes. These premises underscore the importance of perioperative optimization, in turn requiring a thorough preoperative risk stratification, a basic understanding of a multimorbid patient’s deranged physiology and a proper appreciation of the potential of surgery, anesthesia and neurocritical care interventions to exacerbate comorbid pathophysiologies. This knowledge enables neurosurgeons, neuroanesthesiologists and neurointensivists to function with a heightened level of vigilance in the care of these high-risk patients and can inform the perioperative neuro-ICU management with individualized strategies able to minimize the risk of untoward outcomes. This review highlights potential pitfalls in the intra- and postoperative neuro-ICU period, describes common preoperative risk stratification tools and discusses tailored perioperative ICU management strategies in multimorbid neurosurgical patients, with a special focus on approaches geared toward the minimization of postoperative cardiopulmonary complications and unplanned reintubation.

[The joint management of Geriatrics-Neurosurgery of patients older than 75 years reduces the average stay, morbidity, hospital readmissions and mortality per year]

OBJECTIVE

Population ageing is a reality for which national health systems are not adapted. The World Health Organisation has already raised awareness about the implementation of specific measures, from undergraduate training to dedicated elderly care units, to tackle this situation. In this article, the aim is to analyse the potential benefits of geriatric monitoring on elderly neurosurgical patients.

MATERIAL AND METHODS

A descriptive analysis was performed in this medical centre, comparing the information collected from elderly patients (over 75 years of age) admitted into the neurosurgical department during 2periods: June 2015 to February 2017, in which a shared geriatric monitoring was implemented, and between October 2013 and May 2015, equivalent period, in which only the geriatrician performed the evaluation of the patients' general condition, before referring them to other social-healthcare units. A number of factors were considered, including mean age, gender, the neurosurgical condition that led to admission, mean stay, infectious complications, acute confusional syndrome, admission into an intensive care unit, need for support from other medical departments, reoperations, mortality during hospitalisation, referral to social-health units, readmission within a month, and mortality within a year.

RESULTS

A total of 173 patients on shared monitoring were compared to 189 patients from the previous period. Both groups had similar demographic characteristics. During the analysis, a significant reduction was observed in shared monitoring as regards, mean hospitalisation, infectious complications, admissions into an intensive care unit, the need for support from other medical departments, readmissions within a month, and mortality within a year.

CONCLUSIONS

On patients of over 75 years of age, shared geriatric-neurosurgical monitoring reduces mean hospitalisation, morbidity, the need for support from other medical departments, early readmission, and mortality within a year. This strategy prioritises patient care, reduces costs, and rationalises resources.