Pain perception following different neurosurgical procedures: a quantitative prospective study

Unilateral Biportal Endoscopy for the Resection of Thoracic Intradural Extramedullary Tumors: Technique Case Report and Literature Review

This study describes a patient with an intradural extramedullary (IDEM) tumor removed entirely using the unilateral biportal endoscopic technique (UBE), achieving satisfactory clinical outcomes. A 60-year-old woman had a diagnosis of meningioma with sensations and motor dysfunction in the lower extremities and perineum and gait disturbances for three years, which has worsened over the last month. Preoperative imaging data showed a sizeable IDEM tumor at the T10 level, significantly compressing the thoracic spinal cord to the right side, with 80% intraspinal encroachment. The IDEM tumor was removed entirely by UBE surgery. To the best of our knowledge, this study may be the first to report the application of UBE techniques for IDEM tumor treatment. In this case, UBE provides a magnified and clear surgical field, greater maneuverability, and a less invasive surgical procedure. The procedure objectives were pathological confirmation, spinal cord decompression, and complete tumor removal; all were met. The patient was satisfied with her dramatically improved clinical symptoms. UBE may be an alternative surgical treatment option for benign IDEM tumors presenting with symptomatic, especially the non-giant lateral and posterior tumors.

Incidence, predictors, and impact of acute post-operative pain after cranial neurosurgery: A prospective cohort study

Objectives

Pain is common after craniotomy. Its incidence and predictors in developing nations are not adequately studied. We aimed to assess the incidence, predictors, and impact of acute post-operative pain after intracranial neurosurgeries.

Materials and Methods

This prospective observational study was conducted in adult patients undergoing intracranial neurosurgeries. After patient consent, ethics committee approval, and study registration, we assessed the incidence of post-operative pain using numerical rating scale (NRS) score. Predictors and impact of pain on patient outcomes were also evaluated.

Results

A total of 497 patients were recruited during 10-month study period. Significant (4-10 NRS score) post-operative pain at any time-point during the first 3 days after intracranial neurosurgery was reported by 65.5% (307/469) of patients. Incidence of significant pain during the 1st post-operative h, on the 1st, 2nd, and 3rd post-operative days was 20% (78/391), 50% (209/418), 38% (152/401), and 24% (86/360), respectively. Higher pre-operative NRS score and pain during the 1st h post-operatively, predicted the occurrence of pain during the first 3 days after surgery, P = 0.003 and P < 0.001, respectively. Pain was significantly associated with poor sleep quality on the first 2 post-operative nights (P < 0.001). Patient satisfaction score was higher in patients with post-operative pain, P = 0.002.

Conclusion

Every two in three patients undergoing elective intracranial neurosurgery report significant pain at some point during the first 3 postoperative days. Pre-operative pain and pain during 1st post-operative h predict the occurrence of significant post-operative pain.

Association of preoperative pain beliefs with postoperative pain levels in abdominal surgery patients

AIMS AND OBJECTIVES

This study aimed to analyse the association of preoperative pain beliefs with postoperative pain levels in abdominal surgery patients.

BACKGROUND

Postoperative pain is related to not only clinical and demographic characteristics but also pain beliefs. The perception, intensity and expression of pain as a subjective experience varies among individuals and cultures. Personal beliefs about pain play an important role in pain experiences and responses.

DESIGN

This cross-sectional study consisted of 126 abdominal surgery patients admitted to the General Surgery and Gynecological Surgery Clinics between September 2018-January 2019. The STROBE (Strengthening The Reporting of Observational Studies in Epidemiology) checklist was used as a guideline for this study.

METHODS

Data were collected through descriptive information forms, pain characteristics questionnaires, Visual Analogue Scales and pain beliefs questionnaires. One-way variance analysis and Pearson's correlation and t tests were used for data analysis.

RESULTS

The mean age of the participants was 48.63 ± 14.27 years. A total of 37.3% of the participants experienced moderate pain and 35.7% experienced severe pain at the 8th postoperative hour. Pain intensity significantly decreased at 16, 24 and 32 h postoperatively. In the predischarge interviews, 92.1% of the patients expressed limitations in physical activities due to pain. There was a relationship between 8-16 h postoperatively and sex and pain expectancy. Mean scores obtained from the organic and psychological beliefs subscales of the Pain Belief Questionnaire were 3.12 ± 0.79, and 2.37 ± 1.11, respectively. The psychological beliefs score was negatively associated with the level of education, and the organic beliefs score was higher for those participants who had undergone gynaecological surgery. There was a weak and positive correlation between the organic beliefs and psychological beliefs subscales of the Pain Beliefs Questionnaire.

CONCLUSION

Patients had moderate to severe postoperative pain, and sex and pain expectations affected the experienced level of pain. Most participants believed that the pain was organic in origin. The level of education exerted a significant impact on pain beliefs.

RELEVANCE TO CLINICAL PRACTICE

Characteristics and perception of pain and pain beliefs are important factors that should be determined to personalise pain relief care and maintain effective pain management.

Colloid cysts: Neuropsychological outcome, quality of life and long-term control after endoscopic gross total resection

BACKGROUND

Endoscopy is increasingly being adopted for removing colloid cysts. However, the neuropsychological outcome and quality of life (QOL) have not been studied in detail. This study is to evaluate the efficacy of endoscopic excision on cognitive measures and QOL.

METHODS

Patients with colloid cysts larger than 7 mm, undergoing endoscopy were prospectively studied concerning clinico-radiology, cognitive parameters (age and education adjusted), extent of resection and recurrence. A cross-sectional QOL assessment was additionally performed on endoscopic patients in comparison with cases who underwent microsurgery or standalone ventriculo-peritoneal (VP) shunt.

RESULTS

A total of 22 endoscopic patients with a mean age of 34 years and a mean cyst diameter of 19 mm were studied. Gross total resection(GTR) could be achieved in all. Over a mean follow-up of 53.4 months, none had a recurrence, ventriculomegaly, or retreatment. Among neuropsychological parameters, digit span was the most affected before surgery. There was a broad-based improvement in the mean global cognitive score from 40.63(±10.4) at baseline to 50.25(±5.8) after endoscopy with maximum improvement in 'immediate recall.' The change in scores also had a significant inverse correlation with cyst size, with cysts larger than 18 mm, resulting in lower scores following endoscopy(R=-0.9, P=0.01). QOL was significantly influenced by visual and cognitive impairments and was better among endoscopic patients than similar microsurgery or VP shunt controls, with a significant difference in social and environmental domains(P=0.02).

CONCLUSION

Endoscopy is effective in achieving GTR and long-term control, with neuropsychological improvement correlated with cyst size. This is probably the first report to show QOL is influenced by cognitive parameters and is better following endoscopy than after microsurgery or VP shunt.

Orbital Rim Sparing Single-piece Fronto-orbital Keyhole Craniotomy Through Eyebrow Incision: A Technical Report and Comparative Review

Background

The classical eyebrow supraorbital keyhole craniotomy has limited working volume due to the thick incurving of the frontal bone necessitating generous drilling of the frontal base. However, the basal variant with sectioning of the orbital rim results in increased periorbital edema.

Objective

We describe a novel orbital rim sparing single-piece fronto-orbital keyhole approach, probably the first such report with a comparative review of relevant literature.

Methods

Following eyebrow incision, bidirectional drilling with a ball tip behind the fronto-zygomatic suture exposes the periorbita and frontal dura, with orbital roof in-between. The craniotomy is fashioned with an angled fronto-orbital cut parallel to and sparing the orbital rim with dura-guard over the periorbita, a frontal cut over the dura, and an optional cut along the lateral orbital roof from within the burr hole. A comparative review of this technique with traditional methods is also carried out.

Results

Compared to the classical supraorbital keyhole, this minimally invasive approach yields a wider basal exposure with greater working volume for intracranial and orbital lesions. Compared to the basal variant of keyhole fronto-orbital approach, this technique results in the least disturbance to periorbita's attachment with the orbital margin, maintenance of orbital contour, better cosmesis with use of simple tools and self-fitting flap.

Conclusion

The orbital rim sparing single-piece fronto-orbital keyhole craniotomy is an easy and novel minimally invasive approach with greater working volume without the disadvantages of sectioning the orbital rim.

How Safe and Effective Is Shifting from Pterional to Supraorbital Keyhole Approach for Clipping Ruptured Anterior Circulation Aneurysms? A Surgeon's Transition Phase Comparative Study

Background  Comparative studies between standard pterional and supraorbital keyhole approaches for aneurysms had potential biases with the heterogeneity of patient selection, differences among surgeons, or varying expertise across the surgeon’s learning curve. This is a study of a surgeon’s transition from pterional to keyhole approach for early clipping of selected consecutive ruptured anterior circulation aneurysms.

Methods  Patients more than 18 years, presenting within 72 hours of ictus, in good clinical grades 1 to 3, no midline shift, with saccular aneurysms less than 25 mm at either communicating segment of internal carotid artery, anterior communicating artery, or middle cerebral artery segment till bifurcation were studied between the last 25 cases of pterional and first 25 cases of the keyhole, for the intraoperative and postoperative surgical outcome parameters.

Results  There was no significant difference among baseline parameters, including the location of aneurysms across both groups. While only four cases of pterional had an intraoperative ventricular puncture, the lumbar drain was electively inserted in all keyhole patients. The intraoperative parameters, such as a dural tear, adequate parent vessel exposure, temporary clipping, and intraoperative rupture, did not show any significant difference. None had immediate postoperative deficits. While delayed cerebral ischemia and wound complaints were similar in both groups, temporal hollowing and chewing difficulty were significantly more in pterional patients( p = 0.01).

Conclusion  A surgeon experienced in pterional approach can comfortably and safely shift to the keyhole for early clipping of selected ruptured aneurysms less than 25 mm, with a comparable surgical outcome but better cosmesis and mastication.

Effectiveness of dietary diabetes insipidus bundle on the severity of postoperative fluid imbalance in pituitary region tumours: A randomized controlled trial

AIM

To test the effectiveness of nurse-led dietary diabetes insipidus (DI) bundle on the severity of postoperative fluid imbalance in pituitary region tumours.

DESIGN

Blinded randomized controlled trial.

METHODS

Patients aged 18-65 operated for sellar-suprasellar tumours in an Indian tertiary care centre were enrolled through total enumeration sampling and underwent randomization with allocation concealment during Sep 2018-Feb 2019. Pre-operative DI, postoperative ventilation, renal failure or decompensated diabetes mellitus were excluded. Patients in the intervention group received a nurse-led DI bundle (validated by three Delphi rounds) with four dietary components: intake of only water during thirst and avoidance of the following-added salt, high-protein foods and caffeinated drinks. Treating clinicians and the investigator assessing outcome were blinded about enrolment. Urine output, serum sodium, vasopressin requirement and hospital stay were assessed as primary outcomes. The outcome measures were monitored daily till the 6th postoperative day. Analyses were performed on 'intention-to-treat' basis, irrespective of compliance. Independent t-test and Chi-square test were used.

RESULTS

Of the initial 63 patients, 50 fulfilling criteria were randomized to two groups and assessed over six days yielding 150 patient-days per group. There were no significant baseline differences between groups. The mean daily urine output was significantly lower in the DI bundle group than in control, both overall and among endonasal operated pituitary adenomas [3000.09(462.7) vs. 4095.71(896.4)ml & 2987.14(419.5) vs. 4064.73(1051)ml], with the greatest difference on the second postoperative day. Though hypernatraemia in controls became most prominent during days 2-3 and resolved in a week, it was significantly lower in the intervention group (12.7% vs. 30.7% overall, 11.4% vs. 29.4% endonasal adenomas). The need for vasopressin analogues and hospital stay were also significantly lower with DI bundle (p < 0.001).

CONCLUSION

This is probably the first ever report of dietary DI bundle among operated pituitary patients, which seem to flatten the DI trend with significant benefits in polyuria, hypernatraemia, vasopressin requirement and hospital stay.

TRIAL REGISTRATION

CTRI/2018/07/015127 of ICMR.

IMPACT

The nurse-led dietary DI bundle has effectively reduced the severity of DI among operated pituitary patients with significant benefits in polyuria, hypernatraemia, vasopressin requirement and hospital stay. Its implementation is simple and easy to carry out, especially in resource-constrained institutions, where continuous monitoring and repeated serum sodium estimation are difficult.

Health Problems and Skin Damages Caused by Personal Protective Equipment: Experience of Frontline Nurses Caring for Critical COVID-19 Patients in Intensive Care Units

BACKGROUND

In the event of coronavirus disease-2019 (COVID-19) spread worldwide, frontline healthcare workers play a key role in the containment of this devastating pandemic, and to prevent the cross-transmission and gain confidence in battle with the pandemic, they are wearing personal protective equipment (PPE).

AIM AND OBJECTIVE

To explore the adverse health problems and skin reactions caused by the use of PPEs among the frontline nurses in the ICUs of COVID hospital.

MATERIALS AND METHODS

A cross-sectional study was conducted using an online-based questionnaire assessing the physical problems, and adverse skin reactions of PPEs were sent among the 150 frontline nurses in ICUs of COVID hospital. The collected data were analyzed using descriptive statistics.

RESULTS

We got 137 valid responses from frontline nurses, and the most common adverse health effects expressed by them were headache (73.4%), extreme sweating (59.6%), and difficulty in breathing (36.7%); 91.7% complained about the fogging of the goggle. Majority of frontline nurses expressed nasal bridge scarring (76.64%) and indentation and pain on the back of the ears (66.42%) as the adverse skin reactions after wearing N95 masks. The common skin problems identified due to double gloving of latex gloves were excessive skin soakage with sweat (70.07%) and skin chapping (19%). The protective clothing caused minimal adverse reactions, and excessive sweating (71.53%) was the most reported.

CONCLUSION

The healthcare workers wearing PPE for a prolonged period show significant adverse effects, so appropriate strategies should be taken to prevent the adverse effects by designing effective PPEs and education of preventive measures among healthcare workers.

HOW TO CITE THIS ARTICLE

Jose S, Cyriac MC, Dhandapani M. Health Problems and Skin Damages Caused by Personal Protective Equipment: Experience of Frontline Nurses Caring for Critical COVID-19 Patients in Intensive Care Units. Health Problems and Skin Damages Caused by Personal Protective Equipment: Experience of Frontline Nurses Caring for Critical COVID-19 Patients in Intensive Care Units. Indian J Crit Care Med 2021;25(2):134-139.

Endonasal endoscopic versus microscopic transsphenoidal surgery in pituitary tumors among the young: A comparative study & meta-analysis

PURPOSE

The transsphenoidal approach presents unique challenges in young, with scanty literature. This study compares the outcome of pituitary tumors among young in our center between endoscopic(EES) and microscopic(MTS) transsphenoidal surgery, with a meta-analysis.

METHODS

Patients within 20 years were studied for their surgical approach to a favorable outcome of endocrine remission (ER) (functioning) or Gross/Near-Total resection (nonfunctioning), besides the need for retreatment. Relevant studies were pooled and analyzed according to PRISMA guidelines.

RESULTS

Out of 64 young patients with pituitary tumors, 48 underwent transsphenoidal surgery using MTS(33) or EES(15). Of these, 21, 14, 5, and 8 had Cushing's, somatotropinomas, prolactinomas, and non-secreting tumors, respectively. Mean symptom duration was 28months, with weight gain(50 %) and visual complaints(29 %) most prevalent. Hypogonadism(21 %) was the most frequent endocrinopathy. The mean tumor volume was 3.8 cm³. Over mean follow-up of 4.4years, favorable outcome was significantly higher after EES than MTS(78.6 % vs. 46.7 %)(odds ratio 4.18, p = 0.05). EES's better outcome was homogeneous across subgroups of age and tumor type, with no significant subgroup difference. Symptom duration was significantly higher among those who required retreatment(p = 0.05), while ER had a non-significant association with tumor volume(p = 0.07). Overall, 40 %, 27 %, 17 %, and 8% were on hydrocortisone, thyroxine, sex hormone, and desmopressin, respectively, at follow-up with no significant difference between EES and MTS. In pooled analysis of literature, both favorable outcome(74 % vs. 48 %,p = 0.02) and retreatment rate(8% vs. 37 %,p = 0.004) were significantly better with EES than MTS.

CONCLUSION

Among young patients with pituitary tumors, the favorable outcome and retreatment rates are better with endonasal endoscopy and associated with symptom duration and tumor volume.

Cognitive, Behavioral, and Functional Impairments among Traumatic Brain Injury Survivors: Impact on Caregiver Burden

Background  The burden of cognitive, behavioral, and functional impairments after traumatic brain injury (TBI) is still not highlighted much, but its impact on caregivers is socio-economically relevant. The objectives of the study were to assess cognitive, behavioral, and functional impairments in patients of TBI and its impact on caregiver burden. Materials and Methods  A descriptive cross-sectional study was conducted using a total enumeration sampling technique. Mini-mental status examination, neuropsychiatric inventory and Rappaport's disability rating scale were used to assess patients' cognitive, behavioral, and functional impairments, respectively. Zarit Caregiver Burden Scale was executed to quantify the caregiver burden. Results  Fifty patients of TBI and their caregivers were enrolled. Among these, 24% had moderate cognitive impairments. Among behavioral symptoms, 40% had agitation, 24% had depression, 18% had anxiety, and 16% had irritability. Moderate functional disability was reported by 18% of the patients, while 2% reported severe functional disability. Moderate to severe caregiver burden was reported by 8% of caregivers. Patients' behavioral ( r = 0.507, p < 0.001), functional ( r = 0.473, p = 0.001), and cognitive ( r = -0.438, p = 0.001) impairments had significant correlations with caregiver burden. Conclusion  Patients develop cognitive, behavioral, and functional disability after TBI. The caregiver burden increases significantly with cognitive dysfunction, behavioral symptoms, and impaired functional status of patients. Therefore, appropriate support is to be provided to caregivers as well as patients.

Factors Influencing Pain Dimensions in Patients with Chronic Tension-Type Headache: An Exploratory Survey

BACKGROUND

Chronic tension type headache (CTTH) is one of the common cause of hospital visits among adolescents and adults. Chronic tension type headache produces pain, sleep disturbances, and disability among patients leading to a poor quality of life. Knowledge pattern of headache and various associated factors will aid appropriate management.

AIMS

To identify the headache dimensions and their various influencing factors among patients of chronic tension-type headache.

METHODS

Using consecutive sampling techniques, 169 patients with chronic tension-type headache were recruited in this cross-sectional survey. Approval was obtained from the Institute's Ethics Committee. The Wong-Baker Foundation Pain intensity scale was used to assess the pain severity.

RESULTS

A pain severity score of 6 out of 10 was reported by 56% of the patients, and the mean pain score reported by the patients was 6.62 ± 1.16. The mean weekly headache frequency was 4.95 ± 0.38, and the mean daily headache duration was 8.68 ± 1.68 hours. Significantly more patients who are married, patients who had a duration of illness less than two years, and patients who were treated with only analgesics reported higher headache severity. Higher headache frequency was reported by significantly more patients who were male, married, from a nuclear family, educated, unskilled laborers or employed, urban inhabitants, or only on analgesics, or had illness duration less than two years. Headache duration was significantly higher in patients who were unskilled laborers or only on analgesics, or had illness duration less than two years.

CONCLUSIONS

Patients with chronic tension-type headache experience moderate to high severity of headache, along with substantial duration and frequency, an outcome that was associated with various lifestyle-related factors that can result in stress. Lifestyle modification and nonpharmacological management are thus essential to reduce the severity, frequency, and duration of headache in patients with a chronic tension-type headache and medication overuse.

"Microendoscopic" versus "pure endoscopic" surgery for spinal intradural mass lesions: a comparative study and review

BACKGROUND CONTEXT

Endoscopy is increasingly being used for minimal invasiveness and panoramic visualization, with unclear efficacy and safety among spinal intradural mass.

OBJECTIVE

The present study aims to compare microendoscopic and pure endoscopic surgery for spinal intradural lesions.

MATERIALS AND METHODS

Spinal intradural lesions operated using endoscopic or access ports were categorized into "microendoscopic" (predominant microscope use) or "pure endoscopic" (stand-alone endoscopy) surgery, and were studied with respect to clinico-radiological features, techniques, perioperative course, histopathology, clinical, and radiological outcome at minimum of 3 months.

RESULTS

Among 34 patients studied, the initial 15 had "microendoscopic" surgery, 16 had "pure-endoscopic" surgery, and 3 had "mixed" use. There were 18 nerve sheath tumors, 6 meningiomas, 6 cysts, 2 ependymomas, ranging in size from 1.5 to as large as 6.8 cm (21%≥4 cm), including 4 in craniovertebral junction (CVJ). Intermuscular or paraspinous approach was utilized, followed by small bony fenestration or interlaminar corridor. Even larger tumors could be excised using expandable ports or "sliding delivery" technique. Although visualization of sides and angles was better with endoscope, hemostasis and dural closure had steep learning curve, necessitating the use of microscope in the initial cases. Clinical improvement and radiological resolution could be achieved in all. There was no significant difference between the groups. The change in Nurick grade had significant correlation with only the dimension of lesion (p=.03) and preoperative grade (p=.05).

CONCLUSIONS

This is probably the first report of spinal endoscopy for intradural tumors in CVJ or as big as 7 cm. Endoscopy is effective and safe for even large tumors with better visualization of sides and angles, albeit with hemostasis and dural closure having initial learning curve. Wide heterogeneity of surgical terminologies in the literature on these procedures warrants consensus for uniform reporting.

Quality of Life Among Children Who Had Undergone Ventriculoperitoneal Shunt Surgery

BACKGROUND

Ventriculoperitoneal (VP) shunting is the most common neurosurgical treatment for hydrocephalus. In spite of significant developments in the technology and design of shunt systems, shunt surgery is still associated with morbidity.

AIM

To identify the problems faced by children on VP shunt and assess their quality of life (QOL).

SETTING AND DESIGN

A cross-sectional exploratory study.

MATERIALS AND METHODS

A total of 31 children on VP shunt were selected through consecutive sampling technique, and hydrocephalus outcome questionnaire was used to collect the data, with the converted metric score ranging from 0 to 1. Hydrocephalus due to stroke, hemorrhage, and malignant tumors was excluded.

RESULTS

The mean age of patients was 11.51 ± 4.26 years. Headache and generalized pain were the common problems experienced (42%). The mean score of QOL was 0.67 ± 0.21. Among the three domains, cognitive domain was the most affected. Among the clinicoradiological factors, multiple surgeries (P = 0.02) had the most significant impact on QOL.

CONCLUSION

Children who underwent VP shunt face various health-related problems in different domains and low QOL. Although cognitive domain was the most affected, multiple surgeries had the most significant impact on QOL. Appropriately focused interventions and holistic management are essential to improve the QOL of children undergoing VP shunt.