An Approach to the Examination of the Lumbar Plexus for Neurosurgical Residents: A Video Manuscript

The lumbar plexus provides innervation to the lower limbs and is essential in enabling motor movement and sensation in the lower limbs. Some of its branches also innervate the muscles in the pelvic girdle. Compared to the brachial plexus in the upper limbs, the lumbar plexus appears to garner less recognition among physicians and surgeons. However, it is important to understand the anatomy of the lumbar plexus and its branches along with the innervation they enable, as injury to them can cause plexopathies and pathologies that should be recognised by any treating clinician. Lumbar disc herniation, trauma and entrapment by muscles or hypertrophic ligaments are common causes of lumbar plexus or nerve injuries. A video was produced to demonstrate the examination techniques explained in this article. To provide comprehensive examination of the lower limbs, the sciatic nerve and its branches are also included in the examination video.

Neuroanaesthetic challenges in a pregnant patient with a huge cerebellopontine angle meningioma

Intracranial malignancy among pregnant women is extremely rare. Neuroanaesthesia for such high-risk patients demands extreme precautions. Our patient presented with a huge right cerebellopontine angle meningioma during the first trimester of her pregnancy. We share our valuable perianaesthetic challenges in managing her tumour-debulking surgery and a brief review of intracranial neoplasm during pregnancy.

Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

BACKGROUND

Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.

METHODS

We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

FINDINGS

Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49).

INTERPRETATION

Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

FUNDING

National Institute for Health Research Global Health Research Group.

Optimisation of topical antibacterial preparation from Malaysian kelulut honey by using xanthan gum as polymeric agent

The study aims to formulate and optimise topical antibacterial preparation by using Malaysian kelulut honey as the active ingredient and xanthan gum as the polymeric agent. Response surface methodology was used to optimise the preparation. The acidity, honey concentration and xanthan gum concentration were the independent variables. The zone of inhibitions on S. aureus ATCC6538 and E. coli ATCC8739 were the response variables. The optimal preparation was evaluated on its physicochemical properties, viscosity, antibacterial efficacy and stability. The antibacterial efficacy of the optimal preparation was compared to the commercially antibacterial gel (MediHoney™, Comvita). The optimal preparation was formulated at pH of 3.5, honey concentration of 90% (w/v) and xanthan gum concentration of 1.5% (w/v) with the inhibition zones measured on S. aureus ATCC6538 was 16.2 mm and E. coli ATCC8739 was 15.8 mm respectively. The factors of acidity and honey concentration have significantly influenced the inhibition zone on S. aureus ATCC6538 and E. coli ATCC8739. The utilisation of xanthan gum as the polymeric agent was fit for the preparation which showed by adequate physicochemical properties and retained of the antibacterial effects. This was supported by constant viscosity and efficacy of the preparation within the six months of stability study indicating stable and reliable preparation. Xanthan gum is a potential polymeric agent due to its effective use in preparing stable preparation with effective antibacterial properties.

Demographic study of brain tumour in a neurosurgical department in Terengganu, Malaysia

INTRODUCTION

Brain tumour (BT) is a tremendous burden on patients, families as well as the surrounding communities, especially the healthcare services. It can be classified into either a benign slow growing tumour (non-cancerous) and malignant tumour (cancerous). The purpose of this study was to determine the incidence and pattern of brain tumour admitted to the Neurosurgery Department in Hospital Sultanah Nurzahirah (HSNZ), Terengganu, Malaysia.

METHODS

This is a retrospective study of incidence and pattern of BT admitted to the Neurosurgery Department in HSNZ. Data was collected from the yearly census of BT registered from 2013 to 2018.

RESULTS

A total number of 386 new cases of primary BT were registered. The number of cases of BT was found to be lowest among children (0 to 10 years old) with only 4.4% but at peak among elderly aged between 51 to 60 years old (26.2%). As for gender, males constituted about 44.5% (n=172) whereas females accounted for 55.5% (n= 214) of the cases. In total, meningioma was found to have the highest incidence (27.2%) followed by metastases brain tumour (18.1%) and glioma (17.4%).

CONCLUSIONS

This study has shown that the incidence of BT was led by meningioma which had a high prevalence among the elderly population, followed by metastasis BT and gliomas.