The use of e-consent in surgery and application to neurosurgery: a systematic review and meta-analysis

INTRODUCTION

The integration of novel electronic informed consent platforms in healthcare has undergone significant growth over the last decade. Adoption of uniform, accessible, and robust electronic online consenting applications is likely to enhance the informed consent process and improve the patient experience and has the potential to reduce medico-legal ramifications of inadequate consent. A systematic review and meta-analysis was conducted to evaluate the utility of novel electronic means of informed consent in surgical patients and discuss its application to neurosurgical cohorts.

METHODS

A review of randomised controlled trials, non-randomised studies of health interventions, and single group pre-post design studies in accordance with the PRISMA statement. Random effects modelling was used to estimate pooled proportions of study outcomes. Patient satisfaction with the informed consent process and patients' gain in knowledge were compared for electronic technologies versus non-electronic instruments. A sub-group analysis was conducted to compare the utility of electronic technologies in neurosurgical cohorts relative to other surgical patients in the context of patient satisfaction and knowledge gain.

RESULTS

Of 1042 screened abstracts, 63 studies were included: 44 randomised controlled trials (n = 4985), 4 non-randomised studies of health interventions (n = 387), and 15 single group pre-post design studies (n = 872). Meta-analysis showed that electronic technologies significantly enhanced patient satisfaction with the informed consent process (P < 0.00001) and patients' gain in knowledge (P < 0.00001) compared to standard non-electronic practices. Sub-group analysis demonstrated that neurosurgical patient knowledge was significantly enhanced with electronic technologies when compared to other surgical patients (P = 0.009), but there was no difference in patient satisfaction between neurosurgical cohorts and other surgical patients with respect to electronic technologies (P = 0.78).

CONCLUSIONS

Novel electronic technologies can enhance patient satisfaction and increase patients' gain in knowledge of their surgical procedures. Electronic patient education tools can significantly enhance patient knowledge for neurosurgical patients. If used appropriately, these modalities can shorten and/or improve the consent discussion, streamlining the surgical process and improving satisfaction for neurosurgical patients.

Spinal anaplastic ganglioglioma

Anaplastic gangliogliomas of the spinal cord are extremely rare with only four cases reported in the literature. Here we present the case of a 22-year-old female who presented acutely with quadraparesis and urinary retention. Radiographic imaging demonstrated an intramedullary lesion within the cervical spine. She underwent a cervical laminectomy and resection of the lesion under neurophysiological monitoring. Post-operatively, she regained some function, but remained paraparetic. Histopathology demonstrated an anaplastic ganglioglioma (WHO Grade 3). She subsequently underwent radiotherapy. Following surgery, she remained stable and had MRC Grade 3 Power in all four limbs. Herein, we describe a previously undescribed case of cervical anaplastic ganglioglioma and review the existing literature.

Protocol for the development of a multidisciplinary clinical practice guideline for the care of patients with chronic subdural haematoma

Introduction: A common neurosurgical condition, chronic subdural haematoma (cSDH) typically affects older people with other underlying health conditions. The care of this potentially vulnerable cohort is often, however, fragmented and suboptimal. In other complex conditions, multidisciplinary guidelines have transformed patient experience and outcomes, but no such framework exists for cSDH. This paper outlines a protocol to develop the first comprehensive multidisciplinary guideline from diagnosis to long-term recovery with cSDH. Methods: The project will be guided by a steering group of key stakeholders and professional organisations and will feature patient and public involvement. Multidisciplinary thematic working groups will examine key aspects of care to formulate appropriate, patient-centered research questions, targeted with evidence review using the GRADE framework. The working groups will then formulate draft clinical recommendations to be used in a modified Delphi process to build consensus on guideline contents. Conclusions: We present a protocol for the development of a multidisciplinary guideline to inform the care of patients with a cSDH, developed by cross-disciplinary working groups and arrived at through a consensus-building process, including a modified online Delphi.

Intradural extramedullary meningeal melanocytoma: a case report and literature review

Primary meningeal melanocytomas are extremely rare, benign tumours arising from the leptomeninges. While they are considered to be benign lesions, there is potential for their growth and transformation into malignant melanomas. They are commonly found in the cervical spine, with a decreased incidence in the thoracic and lumbar regions. We present a case report of a 56-year-old man who presented to our unit with a 4-month history of lower limb weakness and a sensory level at T6. Magnetic resonance imaging shows an intradural extramedullary tumour. The patient underwent a thoracic debulking of the lesion with neurophysiological monitoring. Histopathology confirmed the diagnosis of melanocytoma of meningeal origin, with a low mitotic count. Our patient recovered well post-operatively with no complications. Surgical resection is an effective method to manage this tumour; however, adjuvant radiotherapy is advised due to the risk of recurrence and malignant transformation.

Presentation, management, and outcomes of cauda equina syndrome up to one year after surgery, using clinician and participant reporting: A multi-centre prospective cohort study

Background

Cauda equina syndrome (CES) results from nerve root compression in the lumbosacral spine, usually due to a prolapsed intervertebral disc. Evidence for management of CES is limited by its infrequent occurrence and lack of standardised clinical definitions and outcome measures.

Methods

This is a prospective multi-centre observational cohort study of adults with CES in the UK. We assessed presentation, investigation, management, and all Core Outcome Set domains up to one year post-operatively using clinician and participant reporting. Univariable and multivariable associations with the Oswestry Disability Index (ODI) and urinary outcomes were investigated.

Findings

In 621 participants with CES, catheterisation for urinary retention was required pre-operatively in 31% (191/615). At discharge, only 13% (78/616) required a catheter. Median time to surgery from symptom onset was 3 days (IQR:1–8) with 32% (175/545) undergoing surgery within 48 h. Earlier surgery was associated with catheterisation (OR:2.2, 95%CI:1.5–3.3) but not with admission ODI or radiological compression. In multivariable analyses catheter requirement at discharge was associated with pre-operative catheterisation (OR:10.6, 95%CI:5.8–20.4) and one-year ODI was associated with presentation ODI (r = 0.3, 95%CI:0.2–0.4), but neither outcome was associated with time to surgery or radiological compression. Additional healthcare services were required by 65% (320/490) during one year follow up.

Interpretation

Post-operative functional improvement occurred even in those presenting with urinary retention. There was no association between outcomes and time to surgery in this observational study. Significant healthcare needs remained post-operatively.

Funding

DCN Endowment Fund funded study administration. Castor EDC provided database use. No other study funding was received.

930 Cauda Equina Syndrome Referrals: A Single Centre Experience

Aim

Cauda Equina Syndrome (CES)is a neurosurgical emergency that requires prompt surgical intervention. History and examination performed by referring departments play an imperative role in the triaging of these patients for onward radiological investigation. We aimed to compare radiologically confirmed cauda equina syndrome to the CES referrals to our tertiary unit to elucidate the true regional incidence of CES.

Method

All CES referrals over a 4 year period (2018–2021) made using the electronic patient referral portal, referapatient.orgtm, were collated. The incidence of radiological confirmed CES was identified.

Results

2018: 231 CES referrals of which 26 were radiological CES and accepted (14 female and 12 male).

2019: 151 referrals of which 20 were radiological CES and accepted (14 female and 6 male).

2020: 257 referrals of which 28 were radiological CES accepted (16 female and 12 male).

2021 (first 6 months): 89 referrals of which 16 were radiological CES and accepted (7 female and 9 male).

Conclusions

In 2018–2021 we received 728 CES referrals of which 90 were radiologically CES and required surgical management. There were 51 female and 39 male patients.

211 referrals were from our own Hospital (Hub) while 517 referrals were from 6 other (Spoke) Hospitals. 12.36% had radiological CES.

This represents just over 1 in 10 referrals from secondary care facilities. A greater understanding of the condition via the utilisation of large electronic datasets may facilitate the formulation of novel scoring systems to more accurately appraise cases of putative CES to avoid unnecessary transfers to tertiary centres.

Potential Surgical Implications of Internal Jugular Stenosis in a Craniocervical Junction Meningioma

We report a case of a 61-year-old lady presenting with several weeks of progressive left-sided weakness, and found to have a foramen magnum meningioma. She was counselled on surgical resection of the tumour, and a preoperative computed tomography angiogram (CTA) was obtained for operative planning purposes. CTA demonstrated incidental bilateral internal jugular vein (IJV) stenosis, with enlarged extracranial collateral vessels and elongated styloid processes. The main surgical concern was potential injury of the extracranial collateral vessels during operative exposure, which may compromise her intracranial venous outflow in light of the IJV stenosis. A doppler ultrasound scan of the IJVs was performed, which demonstrated that blood flow was still present through both vessels. Through careful soft tissue dissection during surgery, potential complications and injury to the extracranial collaterals were avoided.

We performed a literature review of the incidence of IJV stenosis, its associated conditions, and potential surgical implications. Complications from injury to vital collateral extracranial vessels should be considered during preoperative planning in patients with anatomical variants or risk factors for IJV stenosis, as seen in this case.

Presentation and management of spinal meningioma and its association with breast carcinoma-case series and systematic review

OBJECTIVE

Benign spinal intradural tumors are rare entities and there have been relatively few case series describing the epidemiology and characteristics of these tumors. Here, we evaluate the presentation, demographics, pathology and outcomes associated with the surgical management of spinal meningioma in our unit over a 6-year period.

RESULTS

A total of 68 cases presented to the operating surgeon during a 6-year period. Of these, over 80% (n = 55) were in females. Seventy-nine percent of the meningiomas were observed in the thoracic region (n = 54). Weakness and gait disturbance were the most common presenting complaints. Surgery significantly improved both motor outcome (p < 0.001) and health related qualities of life (SF36, p < 0.01).Seventeen percent of spinal meningioma cases (n = 12) had a preceding cancer diagnosis. Of these 75% (n = 9/12) were attributable to breast cancer. Overall, breast cancer preceded a diagnosis of a spinal meningioma in 16.4% of female cases (9/55). This is higher than expected number of breast cancer based on UK population and those reported in literature for breast cancer and intracranial meningioma.

CONCLUSION

Spinal meningioma is disproportionately over-represented in females. Patients present with neurological deficits and surgery improved both neurology and patient reported quality of life. Relative to the known UK prevalence of breast cancer, there is a significantly higher than expected association between spinal meningioma and a preceding history of breast cancer.

Spinal Fractures Incurred by Sports-Related Injuries

BACKGROUND

Sports-related injuries are the third commonest cause of spine fractures. Spinal fractures incurred as a result of partaking in sport by their nature are different from those associated with frailty and road traffic accidents. The patient demographics and nature of fractures associated with sports activities are not well documented. We aim to describe the management and outcome of patients with a sports-related spine fracture in a single U.K. major trauma center in a 6-year time period.

METHODS

Patients with sports-related spinal fractures were identified from the Trauma Audit and Research Network database at a U.K. major trauma center between January 2011 and December 2016. Patient notes were retrospectively reviewed for demographics, injury severity score, treatment, complications, and outcomes.

RESULTS

In the study period, 122 patients were admitted with a sports-related spinal fracture, sustaining a total of 230 fractures. Of these, 48 (20.9%) were in the cervical, 79 (34.3%) in the thoracic, and 103 (44.8%) in the lumbar regions. The sports most commonly associated with spinal fractures were horse riding (n = 55), cycling (n = 36), and boating (n = 10). Of the 230 fractures, 32 (13.9%) were associated with neurologic injury. Forty-five of the 230 fractures (19.6%) were managed surgically, and the remainder were managed conservatively.

CONCLUSIONS

Within our population, sports most commonly associated with spinal fractures were horse riding, cycling, and boating. The majority of cases were managed nonoperatively. Further research is required to establish evidence-based guidelines on the management of sports-related spinal fractures.

Perioperative Optimization of Patients With Neuromuscular Disorders Undergoing Scoliosis Corrective Surgery: A Multidisciplinary Team Approach

STUDY DESIGN

Narrative review.

OBJECTIVE

The high rate of complications associated with the surgical management of neuromuscular spinal deformities is well documented in the literature. This is attributed to attenuated protective physiological responses in multiple organ systems.

METHODS

Review and synthesis of the literature pertaining to optimization of patients with neuromuscular scoliosis undergoing surgery. Our institutional practice in the perioperative assessment and management of neuromuscular scoliosis is also described along with a clinical vignette.

RESULTS

Respiratory complications are the most common to occur following surgery for neuromuscular disorders. Other categories include gastrointestinal, cardiac, genitourinary, blood loss, and wound complications. A multidisciplinary approach is required for perioperative optimization of these patients and numerous strategies are described, including respiratory management.

CONCLUSION

Perioperative optimization for patients with neuromuscular disorders undergoing corrective surgery for spinal deformity is multifaceted and complex. It requires a multidisciplinary evidence-based approach. Preadmission of patients in advance of surgery for assessment and optimization may be required in certain instances to identify key concerns and formulate a tailored treatment plan.

Surgical Treatment of Chronic Subdural Hematomas in Nonagenarians: Who to Treat?

OBJECTIVE

Although chronic subdural hematomas (cSDH) are often treated surgically it remains plausible that invasive treatment in elderly patients may have a negative effect on survival. The aim of this study was to characterize survival following neurosurgical intervention for cSDH in a selected cohort aged >90 years and to identify prognostic factors that may inform clinical decision-making.

METHODS

In total, we identified a cohort of 548 consecutive patients who had undergone burr hole drainage for cSDH in a 5-year period between 2009-2013. Of these patients, 41 were aged >90 years. For each patient, information was gathered from local hospital records, general practice records, and the patients directly. Long-term survival was compared with actuarial data obtained from the National Life Tables.

RESULTS

Overall mortality at the time of discharge was 2%. Mortality was 26.8% at 6 months, 36.8% at 1 year, and 47.9% at 2 years. Interestingly, there was no significant difference between the actuarial curve and the survival curve following surgery (hazard ratio, 1.17; confidence interval, 0.67-2.05; P = 0.57). Despite initially departing from the actuarial curve, the survival curve becomes parallel at approximately 1 year. Multivariate analysis showed that preadmission residence and the number of comorbid conditions were significant predictors of survival.

CONCLUSIONS

We advocate that neurosurgical intervention for cSDH in selected nonagenarians can be a safe and beneficial procedure. Patients living independently at home and with a limited past medical history were most likely to benefit from the surgery.

Differences in management of isolated spinal fractures between neurosurgery and orthopaedics: a 6-year retrospective study

INTRODUCTION

The acute management of spinal fractures is traditionally split between neurosurgeons and orthopaedic surgeons and the specialities have varying approaches to management. This study investigates differences between neurosurgeons and spinal orthopaedic surgeons in the management of spinal fractures at a single trauma centre in the United Kingdom.

METHODS

A retrospective study at a single trauma centre of patients identified using the Trauma Audit and Research Network (TARN). Case notes and radiological investigations were reviewed for demographics, fracture classification, clinical management and outcomes. Polytrauma cases and patients managed by non-neurosurgical/orthopaedic specialties were excluded.

RESULTS

A total of 465 patients were included in this study (neurosurgery n = 266, orthopaedics n = 199). There were no significant differences between groups for age, gender, Charlson co-morbidity score or distribution of fractures using the AO spine classification. Patients admitted and managed under the orthopaedic surgeons were more likely to undergo a surgical procedure when compared to those admitted under the neurosurgeons (n = 71; 35.7% vs n = 71; 26.8%, p = 0.042, OR 1.56 95%CI 1.056 to 2.31). The median overall length of stay was 8 days and there was no significant difference between teams; however, the neurosurgical cohort were more likely to be admitted to an intensive care unit (24.3% vs 16.2%, p = 0.04).

CONCLUSION

This study is the first in the United Kingdom to compare neurosurgical and orthopaedic teams in their management of spinal fractures. It demonstrates that differences may exist both in operating rates and outcomes.

Neurosurgical management of head injuries incurred during sports: a single centre experience

Introduction: Accidents during sporting activities are a common cause of head injury, particularly in children and young adults. Whilst most sporting head injuries are minor, there remains a proportion which is associated with high morbidity and mortality. The epidemiology of sports associated head injuries is variable based on geographical region so the aim of this study was to review the management and outcomes of sporting head injuries managed by a single neurosurgical unit in the South of England.Method: A retrospective review of the Trauma Audit and Research Network database was conducted for all patients admitted to a tertiary neurosurgical centre over a six-year period (January 2011-December 2016). Case notes were reviewed for demographics, mechanism of injury, injury severity score, intensive care admission, surgical interventions and Glasgow Outcome Score at discharge.Results: Seventy-six patients (mean age: 37.6 ± 18.4 years, male gender n = 43; 56.6%) were eligible for inclusion in this series. Horse riding accidents were identified as the most common cause of head injury (n = 31; 40.8%). Fifteen patients (19.7%) in this series had a severe head injury (GCS 3-8 on admission). Twenty-eight (36.8%) patients required admission to an intensive care unit and 26 (34.2%) patients underwent neurosurgical intervention. At discharge, 68 (89.5%) patients had a Glasgow Outcome Score 4-5.Conclusion: The majority of patients with head injuries admitted to a neurosurgical unit can expect a good functional outcome despite the need for intensive care or neurosurgical intervention. The range of sports resulting in head injury is likely influenced by geographic location; however, further national study is required for wider comparison.

P86 Surgical management of spinal cavernous malformations

Objectives

Evaluation of the presentation, demographics, pathology and outcomes associated with the surgical management of spinal cavernous malformations [sCM].

Design

A retrospective single-centre case series of surgically managed cavernous malformations over a 3 year period.

Subjects

Ten patients were identified to have a diagnosis of sCM.

Methods

Cases were identified from electronic and theatre records at a single centre. All patients underwent pre-operative assessment and radiographic evaluation.

Results

10 patients with a mean age of 52.6 years [SD ±14.1] and a male to female ratio of 1:1 with a mean follow-up of 14.1 months [SD ±7.9] were identified. Spinal CM spanned two vertebral levels in 9 out 10 cases with 3 cervical, 1 cervico-thoracic and 6 within the thoracic region. Duration of the symptoms prior to surgical intervention was 17 months [SD ±24], with three cases presenting with an acute [<2 week] history. Of those that underwent surgery [n=7] pain [85%, n=6], sensory/motor changes [85% n=6] and sphincteric disturbance [43%, n=3] were the commonest presenting signs and symptoms. Acute haemorrhage was a presenting factor in 3 cases. Post-operatively motor and sensory scores improved in 4 patients, 2 patients remained unchanged and 1 patient was worse. Recent haemorrhage was associated with increased likelihood in improvement in motor scores following resection.

Conclusions

In selected cases surgical management of sCM is associated with improvement in motor and sensory function postoperatively.

Spinal fractures incurred by a fall from standing height

OBJECTIVE

Falls from standing are common, particularly amongst the aging population, due to declining mobility, proprioception and vision. They are often complicated by fragility fractures, including vertebral fractures, that are associated with significant morbidity and may represent a pre-terminal condition with high one-year mortality rates.

PATIENTS AND METHODS

A retrospective review of the Trauma Audit and Research Network database for a major trauma centre was conducted for all patients admitted between January 2011 and December 2016. Patients with a spinal fracture and a confirmed fall from standing height were eligible for inclusion. Case notes were reviewed for demographics, Injury Severity Score, Charlson co-morbidity score, treatment, complications and outcomes.

RESULTS

Of 1408 patients with a spine fracture admitted during the study period, 229 (16.3%) were confirmed to be secondary to a fall from standing height. The average age of this cohort was 76.6 ± 14.5 years and 134 (58.5%) cases were female. The average ISS score was 9.7 ± 5.4. The 229 patients sustained 283 fractures with a distribution of: cervical (n = 140), thoracic (n = 65) and lumbar (n = 78) spine. Fifty-six (24.5%) patients underwent surgical intervention. Forty-three patients (18.7%) died within 6 months of admission and all-cause mortality was significantly higher in patients with increasing age and Charlson co-morbidity score.

CONCLUSION

Spinal fractures due to a fall from standing height represent one sixth of the fracture workload of the emergency spinal service at a major trauma centre. Whilst the majority of patients can be managed conservatively there are still considerable implications for hospital bed usage and patient mortality.

AMPA receptors and seizures mediate hippocampal radial glia-like stem cell proliferation

Neurogenesis is sustained throughout life in the mammalian brain, supporting hippocampus-dependent learning and memory. Its permanent alteration by status epilepticus (SE) is associated with learning and cognitive impairments. The mechanisms underlying the initiation of altered neurogenesis after SE are not understood. Glial fibrillary acidic protein-positive radial glia (RG)-like cells proliferate early after SE, but their proliferation dynamics and signaling are largely unclear. We have previously reported a polarized distribution of AMPA receptors (AMPARs) on RG-like cells in vivo and postulated that these may signal their proliferation. Here, we examined the acute effects of kainate on hippocampal precursor cells in vitro and in kainate-induced SE on proliferating and quiescent clones of 5-bromo-2-deoxyuridine prelabeled hippocampal precursors in vivo. In vitro, we found that 5 μM kainate shortened the cell cycle time of RG-like cells via AMPAR activation and accelerated cell cycle re-entry of their progeny. It also shifted their fate choice expanding the population of RG-like cells and reducing the population of downstream amplifying neural progenitors. Kainate enhanced the survival of all precursor cell subtypes. Pharmacologically, kainate's proliferative and survival effects were abolished by AMPAR blockade. Functional AMPAR expression was confirmed on RG-like cells in vitro. In agreement with these observations, kainate/seizures enhanced the proliferation and expansion predominantly of constitutively cycling RG-like cell clones in vivo. Our results identify AMPARs as key potential players in initiating the proliferation of dentate RG-like cells and unravel a possible receptor target for modifying the radial glia-like cell response to SE.

Image guidance and improved accuracy of external ventricular drain tip position particularly in patients with small ventricles

OBJECTIVEExternal ventricular drain (EVD) insertion is one of the most common emergency neurosurgical procedures. EVDs are traditionally inserted freehand (FH) in an emergency setting, but often result in suboptimal positioning. Image-guided surgery (IGS) is selectively used to assist placement. However, the accuracy and practicality of IGS use is yet to be reported. In this study, the authors set out to assess if IGS is practical and improves the accuracy of EVD placement.METHODSCase notes and images obtained in patients who underwent frontal EVD placement were retrospectively reviewed. Ventriculomegaly was determined by the measurement of the Evans index. EVD location was classified as optimal (ipsilateral frontal horn) or suboptimal (any other location). Propensity score matching of the two groups (IGS vs FH) for the Evans index was performed. Data were analyzed for patient age, diagnosis, number of EVDs, and complications. Those without postoperative CT scans were excluded.RESULTSA total of 607 patients with 760 EVDs placed were identified; 331 met inclusion criteria. Of these, 287 were inserted FH, and 44 were placed with IGS; 60.6% of all unmatched FH EVDs were optimal compared with 75% of the IGS group (p = 0.067). The IGS group had a significantly smaller Evans index (p < 0.0001). Propensity score matching demonstrated improved optimal position in the IGS group when compared with the matched FH group (75% vs 43.2%, OR 4.6 [1.5-14.6]; p = 0.002). Patients with an Evans index of ≥ 0.36 derived less benefit (75% in IGS vs 66% in FH, p = 0.5), and those with an Evans index < 0.36 derived more benefit (75% in IGS vs 53% in FH, p = 0.024). The overall EVD complication rate was 36% in the FH group versus 18% in the IGS group (p = 0.056). Revision rates were higher in the FH group (p = 0.035), and the operative times were similar (p = 0.69). Long intracranial EVD catheters were associated with tip malposition irrespective of the group.CONCLUSIONSImage guidance is practical and improves the accuracy of EVD placement in patients with small ventricles; thus, it should be considered for these patients.

Choroid Plexus in the Central Canal of the Spinal Cord Causing Recurrent Syringomyelia

BACKGROUND

Syringomyelia is a fluid-filled cavitation within the substance of the spinal cord. This condition usually follows a primary pathology that disrupts the normal cerebrospinal fluid circulation or disturbs the microcirculation and cytoarchitecture of the spinal cord parenchyma. However, an etiology of recurrent syringomyelia resulting from an ectopic choroid plexus (CP) has not been discussed. Ectopic CP rests may be found within the central nervous system. Although there has been a single report, describing ectopic intramedullary spinal cord CP, to our knowledge, extra-cranial nonmalignant CP in the central canal of the spinal cord has not been reported.

CASE DESCRIPTION

We report CP in the central canal of the spinal cord in a 23-year-old male patient who had developmental delay and diabetes mellitus type I who presented with dissociated sensory changes and muscle wastage predominantly on the right upper and lower limbs. Magnetic resonance imaging demonstrated a multiloculated spinal cord syringomyelia stretching from cervical (C3) to the conus medullaris causing recurrent neurologic deficits. A biopsy of the central canal spinal cord lesion revealed CP. Decompression and syringosubarachnoid shunt insertion stabilized the patient's neurology.

CONCLUSIONS

Our illustrative case reveals the presence of CP in the central canal of the spinal cord that may suggest a role in the etiology of recurrent syringomyelia. Although management poses a challenge to neurosurgeons, prompt decompression and shunting of the syringomyelia remains a favorable approach with acceptable outcomes. Further investigation into the pathophysiology of central canal CP ectopic causing recurrent syringomyelia and its correlation with spinal cord development may help future treatments.

An Evaluation of Commonly Used External Ventricular Drain Securement Methods in a Porcine Model: Recommendations to Improve Practice

BACKGROUND

External ventricular drain (EVD) dislodgement is common and leads to significant morbidity and mortality. Many securement techniques to prevent this are described. There are, however, no objective studies comparing them. This study aimed to determine the most secure method of securing an EVD.

METHODS

A survey was distributed through the British Neurosurgical Trainee Research Collaborative to determine common EVD securement methods and select techniques for testing. Securement methods were tested in a pig cadaver model. Peak pull force before EVD failure was measured. Failure was defined as catheter displacement 1 cm from the insertion site, catheter fracture, or suture fracture.

RESULTS

Twenty-three neurosurgical units responded. Five basic EVD securement methods were in common use. These were tested in isolation and in combination so that in total 15 common methods were tested. The most secure method was a triple construct, consisting of an anchoring suture, sutures around a coil of the catheter, and either a soft plastic flange (25.85 N, 95% confidence interval 24.95 N-26.75 N) or a hard plastic flange (29.05 N, 95% confidence interval 25.69 N-32.41 N). Of the individual methods, single anchoring sutures, soft flanges, VentriFix, and staples were found to be the least secure, whereas multiple sutures and hard flanges were the most secure.

CONCLUSIONS

An anchoring suture followed by a coil of the catheter and finally a flange is the most secure method for securing EVDs. This simple technique can withstand up to 8.2 times the force of a single anchoring suture, is easily used, and decreases the likelihood of EVD dislodgement and associated complications.

Lumbar intravertebral disc herniation secondary to idiopathic calcific discitis

Calcific discitis is a well recognized entity in the paediatric population but more recently has been increasingly reported in adults. It typically involves the lower thoracic vertebrae and is of unknown aetiology. Herniation of the calcified fragment is rare but typically occurs out through the annulus fibrosus into the canal space. Herein we describe the first reported case of calcific discitis involving the lumbar vertebrae with subsequent herniation of the calcified disc into and through the anterior aspect of the L5 vertebra. The patient first presented with a history of right back pain and leg sciatica. Radiographic imaging demonstrated calcification within the L4/5 interspace, which was managed with simple analgesia. She subsequently re-presented 24-months later with worsening sciatica, right leg weakness and faecal incontinence. No evidence of cord or root compression was noted on MRI. However, an abnormality was noted at the anterior body of L5 with evidence of superior endplate depression and marrow signal change. Subsequent radionucleide bone studies confirmed a solitary focus of increased linear activity extending across the width of the L4-L5 interspace. Her symptoms were managed medically. Serial radiographic imaging demonstrated regression of the disc space calcification and healing of the L5 fracture. Despite its sinister presentation this condition was self-limiting. We describe the radiographic evolution of this pathology and postulate a putative hypothesis through which it may have arisen.

Ventral Lumbar Synovial Cyst Causing Cauda Equina Compression: Case Report and Literature Review

BACKGROUND

Juxtafacet spinal cysts are cystic synovial lesions that often are indistinguishable clinically or radiologically and require histopathology analysis to confirm the diagnosis. Lumbar synovial cysts usually arising from the synovium of the facet joints. They have been described posterolaterally or rarely in the posterior midline. However, we describe the first synovial cyst ventral to the dural sac.

CASE DESCRIPTION

We report a lumbar 3-4 lesion causing cauda equina compression in a 57-year-old man who presented with a 3-month history of low back pain and bilateral sciatica, intermittent urinary incontinence, and erectile dysfunction. Preoperative magnetic resonance imaging suggested prolapsed disc, after decompression, histological analysis of the fragment confirmed a synovial cyst.

CONCLUSIONS

Hitherto synovial cysts have not been reported anterior to the dural sac. We describe a lumbar ventral cystic mass with cauda equina compression that mimicked a disc prolapse due to synovial metaplasia. The patient had urgent decompression with subsequent resolution of the symptoms.

The role of neurosciences intensive care in trauma and neurosurgical conditions

The creation of neurosciences intensive care units was born out of the awareness that a group of neurological and neurosurgical patients required specialized intensive medical and nursing care. This first of two articles describes the role of neurosciences intensive care in the management of trauma and neurosurgical conditions.

The role of neurosciences intensive care in neurological conditions

The neurosciences intensive care unit provides specialized medical and nursing care to both the neurosurgical and neurological patient. This second of two articles describes the role it plays in the management of patients with neurological conditions.

Polarized distribution of AMPA, but not GABAA , receptors in radial glia-like cells of the adult dentate gyrus

Glial fibrillary acidic protein (GFAP)-positive astrocytes with radial processes [radial glia (RG)-like cells] in the postnatal dentate gyrus share many of the characteristics of embryonic radial glia and appear to act as precursor cells for adult dentate neurogenesis, a process important for pattern separation and hippocampus-dependent learning. Although much work has delineated the mechanisms underlying activity-neurogenesis coupling via gamma-amino butyric acid (GABA)ergic neurotransmission on GFAP-negative transient-amplifying cells and neuroblasts, little is known regarding the effects of neurotransmitters on RG-like cells. Conflicting evidence exists for both GABA and glutamate receptors on these cells. Here, using GFAP reporter mice, we show that the somatic membrane of RG-like cells carries GABAA receptors and glutamate transporters but not ionotropic glutamate receptors, whereas 2-amino-3-(hydroxyl-5-methylisoxazole-4-yl) propionic acid (AMPA) and GABAA receptors are expressed on the processes of these cells. Almost all RG-like cells expressed the GluA2 subunit, which restricts the Ca(2+) permeability of AMPA receptors. The glial GABAA receptors mainly comprised α2/α4, β1, and γ1/γ3. The selective presence of AMPA receptors on the radial processes may be important for sensing and responding to local activity-driven glutamate release and supports the concept that RG-like astrocytes are composed of functional and structural domains.

Decompressive Craniectomy in Acute Brain Injury – Lifting the lid on Neurosurgical Practice

Decompressive craniectomy (DC) is an effective method of controlling rising intracranial pressure (ICP) refractory to medical treatment in a range of conditions: traumatic brain injury in both adults and children, malignant middle cerebral artery infarction and following subarachnoid haemorrhage. Herein, we describe its indications, prognosis, current operative methods and postoperative management.

Posterior reversible encephalopathy syndrome: a case following reversible cerebral vasoconstriction syndrome masquerading as subarachnoid haemorrhage

Posterior reversible encephalopathy syndrome (PRES) is a neurotoxic clinico-radiological diagnosis typically presenting with headache, encephalopathy and visual disturbance accompanied by a unique neuroradiological pattern of symmetrical parieto-occipital vasogenic oedema. Here we present the case of a 51-year-old woman who presented to hospital following a thunderclap headache, initially thought to be secondary to a subarachnoid haemorrhage (SAH). A tiny anterior choroidal artery aneurysm was demonstrated on cerebral angiogram. At surgical clipping, no evidence of haemorrhage was observed. Post-operatively, the patient developed delayed right-sided hemiparesis, managed with aggressive hypertensive treatment, and later, with onset of septicaemia, central visual loss. Computed tomography (CT) brain scans demonstrated oedematous changes within the parieto-occipital regions bilaterally and later areas of infarction. The initial diagnosis of SAH was revised to reversible cerebral vasoconstriction syndrome (RCVS), which gave rise to PRES. To our knowledge, this is the first reported case of RCVS with concomitant PRES and cerebral infarction.

Spontaneous upper limb monoplegia secondary to probable cerebral amyloid angiopathy

Cerebral amyloid angiopathy is a clinicopathological disorder characterised by vascular amyloid deposition initially in leptomeningeal and neocortical vessels, and later affecting cortical and subcortical regions. The presence of amyloid within the walls of these vessels leads to a propensity for primary intracerebral haemorrhage. We report the unusual case of a 77-year-old female who presented to our emergency department with sudden onset isolated hypoaesthesia and right upper limb monoplegia. A CT scan demonstrated a peripheral acute haematoma involving the left perirolandic cortices. Subsequent magnetic resonance imaging demonstrated previous superficial haemorrhagic events. One week following discharge the patient re-attended with multiple short-lived episodes of aphasia and jerking of the right upper limb. Further imaging demonstrated oedematous changes around the previous haemorrhagic insult. Cerebral amyloid angiopathy is an overlooked cause of intracerebral haemorrhage; the isolated nature of the neurological deficit in this case illustrates the many guises in which it can present.

Seizure-induced miosis

Ictal autonomic pupillary dilation is common; however, miosis is rare. We describe a case of focal seizures secondary to cortical dysplasia presenting with bilateral pupillary miosis, rendered seizure free by resective surgery. The seizure-onset zone was localized within the left middle parietal gyrus by intracranial electrographic recording. Seizure onset was coincident with focal left centroparietal fast spike activity on electroencephalography (EEG). A large region of the left frontocentral cortical dysplasia was demonstrated on magnetic resonance imaging (MRI). Complete resection of the area of cortical dysplasia and additional cortical regions of ictal activity, identified using intracranial EEG, rendered the patient seizure free.

Pituitary apoplexy can mimic acute meningoencephalitis or subarachnoid haemorrhage

Pituitary apoplexy is an uncommon but life-threatening condition that is often overlooked and underdiagnosed. We report a 45-year-old man who presented to our emergency department with a sudden onset headache, acute confusion, signs of meningeal irritation and ophthalmoplegia. An initial diagnosis of acute meningoencephalitis was made, which was amended to pituitary apoplexy following thorough investigation within the emergency department.

A 45-year-old man was brought to our emergency department by ambulance with a history of sudden onset of frontal headache and acute confusion. His wife provided the history. There was no significant past medical history of diabetes, hypertension, recent travel abroad, exposure to sick contacts, involvement in outdoor pursuits such as hiking/cave diving, or trauma. He worked in a bank and had been well until 24 h prior to the onset of sudden headache, which was gradually worsening in nature and associated with increasing confusion. The patient's wife reported that he had neither experienced any fevers, night sweats, or coryzal symptoms nor received any recent vaccinations. He was not on any regular medications. He was a non-smoker and occasionally consumed alcohol. There was no significant family history. On examination in the ED, his temperature was 37.6°C, his pulse was 110/min, and he was normotensive and normoglycaemic. A macular blanching rash was noted over the patient's trunk. The patient was disoriented to time and place. Neurological examination revealed reduced GCS (11/15-E3, M6, V2), marked neck stiffness, a positive Kernig's sign and a right sixth nerve palsy.

A provisional diagnosis of acute meningoencephalitis was made and the patient was started on a course of intravenous antibiotics with benzyl penicillin 1.2 g, cefotaxime 2 g and acyclovir 750 mg. Baseline blood investigations revealed hyponatraemia (122 mmol/l), a white-cell count of 11 × 10⁹/l and a C-reactive protein > 250. Due to the sudden onset of the symptoms and lack of prodrome, an urgent CT head scan was performed to rule out a cerebrovascular event. The scan demonstrated an enlarged pituitary gland (3 cm in diameter) with impingement of the optic chiasm. The centre of the enlarged pituitary gland was noted to be hypodense in comparison to its periphery, which was consistent with a diagnosis of pituitary apoplexy. A subsequent MRI confirmed the diagnosis (Figure 1) of an enlarged sella containing abnormal soft tissue with increased signal intensity suggestive of haemorrhage (Figure 1A).

Post-MRI a lumbar puncture was performed revealing glucose 3.4 mmol/l, protein 1.0 g/l, red cells of 53/mm³ and white cells of 174/mm³ with predominant neutrophilia. No organisms were seen, and CSF cultures and HSV DNA tests were found to be negative. Endocrinological investigations demonstrated low concentrations of thyroid hormones [TSH: 0.14 mIu/l (0.35-5.5 mlU/l), FT3: 1.1 nmol/l (1.2-3.0 nmol/l), FT₄: 9.6 pmol/l (8-22 pmol/l)], gonadal hormones (LH: < 1 u/l) and prolactin: 16 u/l (<450 u/l). Serum FSH was 2.9 u/l (0.8-11.5 u/L) and cortisol 575 nmol/l (450-700 nmol/l). The patient was treated for hypopituitarism based on clinical and radiological findings with intravenous fluids, hydrocortisone (100 mg) and thyroxine (50 μg) as loading doses in the ED.

Within 24 h of commencement of therapy the patient's GCS rose to 15, and within 48 h there was marked improvement in the right sixth cranial nerve palsy. Formal visual field assessment demonstrated temporal visual field loss in the left eye. The patient was discharged to his usual residence a week later and follow-up was organised with both the endocrinologists and ophthalmologists. Follow-up MRI demonstrated that there was no significant change in either size or signal characteristics of the pituitary fossa mass (Figure 1B).

Variability in selecting patients to manage in the community: a service evaluation of community matron's case-finding strategies

BACKGROUND

Community-based case management of high-frequency health service users, also termed 'high-intensity users' may reduce the demand on secondary care. In the UK, experienced senior nurses 'community matrons' have been appointed to provide more care in the community and to case manage high-intensity users and prevent unnecessary hospital admission. Computerized scoring systems have been developed to help with case finding.

OBJECTIVE

To evaluate how community matrons select their caseload, in particular the impact of a case finding tool, and access to computer-based systems.

METHODS

We used direct observation and the think aloud protocol during case selection and a series of workshops. Analysis was based on the Framework Approach (familiarization, coding, charting, mapping and interpretation) using verbatim transcripts analysed by N-Vivo software.

RESULTS

Community matrons within the same locality have different and sub-optimal caseloads. Although common elements exist in case selection, processes are modified by individuals depending on the influence of their interpersonal relationships, accessibility of computer systems and personal experience and expertise. The supporting IT system often produced data too late and while predicting admission did not identify cases amenable to community intervention.

CONCLUSIONS

Inter-professional networks, personal experience and training influence the patients identified for case management. The combination of an improved case finding tool and a better defined role for community matrons could lead to more standardized and equitable case selection.

Electroconvulsive therapy: a novel hypothesis for the involvement of purinergic signalling

It is proposed that ATP is released from both neurons and glia during electroconvulsive therapy (ECT) and that this leads to reduction of depressive behaviour via complex stimulation of neurons and glia directly via P2X and P2Y receptors and also via P1 receptors after extracellular breakdown of ATP to adenosine. In particular, A(1) adenosine receptors inhibit release of excitatory transmitters, and A(2A) and P2Y receptors may modulate the release of dopamine. Sequential ECT may lead to changes in purinoceptor expression in mesolimbic and mesocortical regions of the brain implicated in depression and other mood disorders. In particular, increased expression of P2X7 receptors on glial cells would lead to increased release of cytokines, chemokines and neurotrophins. In summary, we suggest that ATP release following ECT involves neurons, glial cells and neuron-glial interactions acting via both P2 and after breakdown to adenosine via P1 receptors. We suggest that ecto-nucleotidase inhibitors (increasing available amounts of ATP) and purinoceptor agonists may enhance the anti-depressive effect of ECT.

Emphysematous cystitis with clinical subcutaneous emphysema

Emphysematous cystitis (EC) is the presence of intramural gas, with or without luminal gas, within the bladder as a result of a primary infection of the lower urinary tract with a gas-producing organism. It is a well-recognised complication of urinary tract infections involving Escherichia coli in diabetic patients. Clinical subcutaneous emphysema is a rare complication of EC that appears to have poor prognosis. Only careful clinical judgement, and a high degree of suspicion, will lead to its early diagnosis and treatment. Here, we report a case of subcutaneous emphysema due to EC based on a clinical diagnosis confirmed using computed tomography (CT).