A snapshot of European neurosurgery December 2019 vs. March 2020: just before and during the Covid-19 pandemic.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or Covid-19), which began as an epidemic in China and spread globally as a pandemic, has necessitated resource management to meet emergency needs of Covid-19 patients and other emergent cases. We have conducted a survey to analyze caseload and measures to adapt indications for a perception of crisis. METHODS: We constructed a questionnaire to survey a snapshot of neurosurgical activity, resources, and indications during 1 week with usual activity in December 2019 and 1 week during SARS-CoV-2 pandemic in March 2020. The questionnaire was sent to 34 neurosurgical departments in Europe; 25 departments returned responses within 5 days. RESULTS: We found unexpectedly large differences in resources and indications already before the pandemic. Differences were also large in how much practice and resources changed during the pandemic. Neurosurgical beds and neuro-intensive care beds were significantly decreased from December 2019 to March 2020. The utilization of resources decreased via less demand for care of brain injuries and subarachnoid hemorrhage, postponing surgery and changed surgical indications as a method of rationing resources. Twenty departments (80%) reduced activity extensively, and the same proportion stated that they were no longer able to provide care according to legitimate medical needs. CONCLUSION: Neurosurgical centers responded swiftly and effectively to a sudden decrease of neurosurgical capacity due to relocation of resources to pandemic care. The pandemic led to rationing of neurosurgical care in 80% of responding centers. We saw a relation between resources before the pandemic and ability to uphold neurosurgical services. The observation of extensive differences of available beds provided an opportunity to show how resources that had been restricted already under normal conditions translated to rationing of care that may not be acceptable to the public of seemingly affluent European countries.

[Progressive Brown-Sequard syndrome secondary to idiopathic spinal cord herniation: clinico-radiological and surgical correlations]. / Síndrome de Brown-Séquard progresivo secundario a hernia medular idiopática: correlación clinicorradiológica y quirúrgica.

INTRODUCTION: Idiopathic medullary herniation is an infrequent disease, which shows up in clinical form as a progressive mielopathy, most commonly known as the Brown-Sequard syndrome. Its anatomical base is a dural defect where a portion of anterior spinal cord gets progressively incarcerated. The MRI and myelo-CT scan show a bending of the spinal cord in the form of a «bell tent¼ towards the anterior dural sheath at the mid-dorsal portion mainly. CASE REPORT: A 37 year old male, who was diagnosed of idiopathic medullary herniation and surgically treated by our own developed technique, reporting its neuroradiological, anatomo-surgical and clinical correlation. CONCLUSION: Treatment should be individualized, as no standard surgical technique has been established up to the present.

TITLE: Síndrome de Brown-Séquard progresivo secundario a hernia medular idiopática: correlación clinicorradiológica y quirúrgica.Introducción. La hernia medular idiopática es una patología infrecuente que cursa clínicamente con una mielopatía progresiva, la mayoría de las ocasiones en forma de síndrome de Brown-Séquard. Su base anatómica es un defecto dural por el que se incarcera progresivamente una porción del cordón medular anterior. La resonancia magnética y la mielotomografía demuestran un acodamiento medular en «tienda de campaña¼ hacia la cara anterior del estuche dural, a nivel dorsal medio fundamentalmente. Caso clínico. Varón de 37 años, diagnosticado de hernia medular idiopática e intervenido quirúrgicamente mediante una técnica propia; se demuestra su correlación neurorradiológica, anatomoquirúrgica y evolutiva. Conclusión. El tratamiento debe ser individualizado, pues no existe una técnica quirúrgica universalmente establecida.

Indirect costs associated with glioblastoma: Experience at one hospital. / Costes indirectos asociados al glioblastoma. Experiencia en un centro.

INTRODUCTION: Glioblastoma is the most common primary brain tumour. Despite advances in treatment, its prognosis remains dismal, with a mean survival time of about 14 months. Many articles have addressed direct costs, those associated with the diagnosis and treatment of the disease. Indirect costs, those associated with loss of productivity due to the disease, have seldom been described. MATERIAL AND METHOD: We conducted a retrospective study in patients diagnosed with glioblastoma at Hospital Universitario Donostia between January 1, 2010 and December 31, 2013. We collected demographics, data regarding the treatment received, and survival times. We calculated the indirect costs with the human capital approach, adjusting the mean salaries of comparable individuals by sex and age and obtaining mortality data for the general population from the Spanish National Statistics Institute. Past salaries were updated to 2015 euros according to the annual inflation rate and we applied a discount of 3.5% compounded yearly to future salaries. RESULTS: We reviewed the records of 99 patients: 46 women (mean age 63.53) and 53 men (mean age 59.94); 29 patients underwent a biopsy and the remaining 70 underwent excisional surgery. Mean survival was 18.092 months for the whole series. The total indirect cost for the series was €11 080 762 (2015). Mean indirect cost per patient was €111 926 (2015). DISCUSSION: Although glioblastoma is a relatively uncommon type of tumour, accounting for only 4% of all cancers, its poor prognosis and potential sequelae generate disproportionately large morbidity and mortality rates which translate to high indirect costs. Clinicians should be aware of the societal impact of glioblastoma and indirect costs should be taken into account when cost effectiveness studies are performed to better illustrate the overall consequences of this disease.

[Surgical management in metastatic squamous cell carcinoma of the larynx to the cavernous sinus. Case report]. / Metástasis de carcinoma escamoso de laringe en seno cavernoso. Presentación de un caso.

The spread to the cavernous sinus in laryngeal cancer means the presence of a disseminated disease and short survival. The aim of this paper is to report a case of laryngeal squamous carcinoma of the larynx. A search was conducted in the databases of Medline and SciELO DOYMA using the words "cavernous sinus metastasis". We found 10 published cases of laryngeal squamous carcinoma with metastasis to the cavernous sinus. The average survival of the 10 cases reported in the literature was 4.1 months; in our case it was 9 months. Patients who received radiotherapy improved symptomatically. In some cases the diagnosis was confirmed only after necropsy. In this type of lesions, surgery is used for diagnosis rather than as a therapeutic tool.

[Remote cerebellar haemorrhage after lumbar arthrodesis: case report and literature review]. / Hematoma cerebeloso como complicación de artrodesis lumbar. A propósito de uncaso y revisión de la literatura.

Remote cerebellar haemorrhage (RCH) is a rare complication of spinal surgery, less frequent than the RCH observed after an intracranial surgery. The patients principally complained of headache or were presented with deterioration in mental status. We report a case of RCH in a 55 years old woman that underwent lumbar arthrodesis with occult dural defect. We review the literature, analysing its causes and therapeutic implications.

Early mortality in spontaneous supratentorial intracerebral haemorrhage.

BACKGROUND: Spontaneous supratentorial intracerebral haemorrhage is a severe, frequent, and poorly understood condition. Despite the publication of 12 randomised controlled trials on this subject, the role of surgery remains controversial and no treatment has proved to be effective. We report on a ten year prospective cohort study based on a defined population treated with or without surgery and their outcome in terms of early survival. METHODS: Population based, ten year prospective observational study directed to patients consecutively admitted to the Intensive Care Unit (ICU) in a tertiary centre with spontaneous supratentorial intracerebral haemorrhage. Patients were distributed in five groups according to the Glasgow Coma Score (GCS) at admission. Haemorrhages were classified as deep-seated or superficial. All patient received standard medical care, and additionally surgery if it was found indicated by the duty neurosurgeon. Primary endpoint was early mortality defined as dead occurred by any cause during the admission in the ICU. FINDINGS: During the ten year period, 1.485 patients were admitted to our centre with primary intracerebral haemorrhage. Of these, 376 were admitted to the intensive care unit and 285 sustained supratentorial haemorrhages. Low GCS was strong predictor of early mortality. Despite the larger size of haematomas in patients undergoing surgical evacuation, surgery was associated with lower early mortality in all GCS subgroups. Maximal benefit was observed in patient with admission GCS of 4-8. Superficial haematomas were operated on more often, and were associated with lower mortality rate than deep-seated cases. CONCLUSIONS: Our findings suggest that craniotomy for haematoma evacuation may reduce early mortality in patients with primary supratentorial intracerebral haemorrhage. Surgery seems specially useful in patients with admission GCS between 4 and 8, and in those with superficial haemorrhages.

[Skull-base plasmacytoma with craniocervical instability]. / Plasmocitoma de base craneal con inestabilidad cráneo-cervical.

INTRODUCTION: Cranio-cervical instability is, in some cases, the main surgical concern in posterior skull base tumors. We report on a case in which a solitary plasmacytoma of the skull base presented with cranio-cervical instability. Vertebral artery was injured during surgery. The surgical anatomy is reviewed, with emphasis in vascular complications avoidance. CASE REPORT: A 66 year-old woman was diagnosed of a cranial base solitary plasmacytoma and treated with radio and chemotherapy with complete remission. After receiving that treatment, she presented with tetraparesis and a cranio-cervical instability was diagnosed. She was operated on, under cranial traction, of posterior occipito-cervical instrumentation with C1 to C2 transarticular Magerl screws. The right vertebral artery was injured during surgery without additional neurological deficit. Two years after the operation she remains independent for daily activities. CONCLUSIONS: Transarticular screws at the C1 to C2 level of the cervical spine may provide rigid fixation in posterior cranio-cervical instrumentation for osteolytic lesions, but there is a risk of injury to the vertebral artery, specially when some variations in the surgical anatomy exist.

[Spinal cord compression due to a epidural lipoma]. / Compresión medular por lipoma epidural dorsal.

INTRODUCTION: The spinal extradural space is normally occupied by adipose tissue and a venous plexus, so it should be not surprising that lipomas arise and reach sufficient size to compress symptomatically the spinal cord. Nevertheless, the spinal epidural lipomas are rare and benign tumours may present as a progressive spinal cord compression syndrome. Magnetic resonance imaging is useful in demonstrating the full extent and characteristics of these lesions, the severity of cord compression and the location in the canal. Usually, the lesion is amenable to total surgical extirpation and the functional prognosis is good. Histopathologically the tumour consists of a mature adipose cells matrix intermixed with vascular endothelial channels, that is the reason why it is also named angiolipomas. CASE REPORT: A 47 year-old woman complained of dorsal and bilateral submamarian pain lasting two years and progressive loss of sensibility and weakness in her legs. Following magnetic resonance studies a posterior spinal cord compression by an extradural tumour at T3-T7 levels was observed. She was operated on and we found an extradural yellow tumour easily to dissect and it was completely removed. One year later she is asymptomatic. CONCLUSIONS: Spinal epidural lipoma is a benign tumour which initially presents itself with local or radicular pain accompanied by progressive spinal cord compression syndrome. The choice treatment is laminectomy and total excision. Probably, this is one of the easiest tumours to remove of the spinal canal and a source of satisfaction because a complete recovery can usually be achieved.

Secondary abdominoplasty.

BACKGROUND: Abdominoplasty is the most frequent excisional body contour procedure performed in aesthetic surgery. Secondary abdominoplasty refers to a new excisional procedure for a patient who has previously undergone an excisional abdominoplasty. In the authors' practice, more than 7% of abdominoplasties are secondary cases and deserve special consideration. METHODS: The authors present a retrospective analysis of their experience with 21 secondary cases among 298 abdominoplasties performed between 2001 and 2006. They have considered as secondary cases only those involving patients who have undergone excisional abdomen contour surgery previously. RESULTS: A total of 17 patients underwent surgery during the first year after the primary procedure, and 4 patients had surgery more than 5 years after that procedure. Following the principles described in this report, it was possible to solve the problem in each particular case and to obtain improvements in both trunk contour and patient satisfaction. CONCLUSIONS: In planning and designing the procedure, a precise diagnosis of the abdominal deformities is essential. The risks in secondary abdominoplasty are similar to those in the primary procedure.

[Effect of the administration of cholecystokinin on the cholestasis associated with total parenteral nutrition in experimental short bowel]. / Efecto de la administración de colescistoquinina sobre la colestasis asociada a la nutrición parenteral total en el intestino corto experimental.

INTRODUCTION: Total parenteral nutrition (TPN) is not free of complications. One of the most serious is cholestasis; the cause of this complication is unclear but it may be due to a lack of an enteral stimulus for cholecystokinin (CCK) production. CCK is essential for contraction of the gallbladder and also stimulates intrahepatic bile flow. Its absence may contribute to cholestasis. After any hepatic aggression, the Kupffer cells respond and release proinflammatory cytokines, such as interleukin-1 (IL-1) and tumour necrosis factor alpha (TNF-alpha), which increase the hepatic damage. The objective of this experimental study has been to observe the effect that the exogenous administration of CCK could have on hepatic damage in experimental short bowel with and without TPN, determined using the serum levels of IL-1 and TNF-alpha. MATERIAL AND METHODS: A resection of 80% of the small bowel was performed on 53 Wistar rats and a continuous infusion of saline or TPN was initiated. The rats were divided into the following groups: SHAM (N = 14): normal saline infusion and free access to food and water. TPN (N = 15): Standard TPN. SHAM-CCK (N = 14): same as the SHAM group but with a daily dose of CCK. TPN-CCK (N = 10): same as the TPN group but with a daily dose of CCK. At the end of the experiment, the animals were sacrificed and blood samples were obtained to determine the IL-1 and TNF-alpha values by ELISA. RESULTS: The IL-1 and TNF-alpha levels were higher in the TPN group (7.537 and 5.899 pg/mL, respectively) than in the SHAM group (6.509 and 4.989 pg/mL, respectively) (p > 0.05). The TNF-alpha values were higher in the SHAM group (4.989 pg/mL) than in the SHAM-CCK group (4.583 pg/mL) (p < 0.001). The IL-1 and TNF-alpha levels were higher in the TPN group than in the TPN-CCK group (6.709 and 4.794 pg/mL, respectively) (p < 0.001 for TNF-alpha). CONCLUSIONS: 1. There is a rise in the serum levels of the pro-inflammatory cytokines IL-1 and TNF-alpha in animals with short bowel on TPN or enteral nutrition. 2. The administration of CCK causes a fall in the IL-1 and TNF-alpha levels, and could be used such as a further measure to prevent TPN-associated cholestasis.

[Selective intestinal decontamination and parenteral nutrition related liver disease. Experimental study]. / Descontaminación intestinal selectiva y hepatopatía asociada a nutrición parenteral: estudio experimental.

Selective intestinal decontamination (SID) has been useful restraining Bacterial translocation (BT) in both animal models and human clinics. The not well known parenteral nutrition-related liver disease is a serious problem associated to short bowel and long-term parenteral nutrition (PN) use, and BT is also frequent in those patients. Germs reach liver through portal vein and activate Kupffer cells, which release cytokines as IL-1 or TNF-alpha. The aim of this study was to test the use of SID restraining BT in a PN undergoing experimental short bowel model, and its possible favourable consequences on hepatic injury determined by IL-1 and TNF-alpha levels. Twenty-five 240-280 g Wistar rats were divided into two groups and maintained in individual metabolic cages for ten days: Resection-PN group (n=15): animals with a bowel resection of the 80% and a continuous PN infusion. Resection-PN-SID (n=10) group: similar to previous group and a daily oral administration of Tobramycine (20mg/kg/day) and Polymyxine-E (25mg/kg/day). Animals were sacrificed and mesenteric lymph nodes (MLN), and both peripheral and portal blood samples were recovered for TB determination in bacterial culture. Determination of both IL-l and TNF-alpha seric levels were carried out by ELISA. Bacterial translocation incidence was higher in RES-NPT group (66.6%) than RES-NPT-SID group (30%) (P>0,05). The relative risk was 2.22 (IC 95% 0,81-6,11) and the number needed to treat was 3 (IC 95% 2-235). Seric levels of IL-1 and TNF-alpha were also higher in RES-NPT group (7,537 and 5,399 pg/ml, respectively) than in RES-NPT-SID group (6,397 and 5,032 pg/ml respectively) (p<0,001). 1. SID reduces TB in a PN undergoing experimental short bowel resection murine model. 2. Parenteral nutrition-related liver disease decreases in DIS receiving animals.

[Necrotizing enterocolitis and bacterial translocation: role of minimal enteral nutrition]. / Enterocolitis necrosante y traslocación bacteriana: papel de la nutrición enteral mínima.

INTRODUCTION: Both necrotizing enterocolitis (NEC) and bacterial translocation (BT) have in common that bacterial overgrowth, a decrease in immunity and intestinal mucosal damage, followed by a barrier failure, can act as trigger factors. The main objectives in NEC treatment are to reduce mortality due to sepsis and to promote feeding tolerance. To achieve that, Minimal Enteral Nutrition (MEN) (less than 25% of the calories provided by enteral route) is a more and more used technique in newborns who receive Parenteral Nutrition (PN) to slow down fasting related villi atrophy and to attenuate its consequences. AIM: To test the hypothesis that MEN decreases BT in an experimental model of PN. METHODS: Twenty-four adult Wistar male rats received a continuous infusion of all-in-one PN solution through a jugular vein catheter. The animals were randomly divided in two groups and maintained in individual metabolic cages for ten days. * Control group (N= 1): fasting rats receiving, standard PN (300 mL/kg/ 24 h, 280 kcall kg/24 h). * MEN group (N=13): standard PN and rat chow (15 g /24 h, 3,1 kcal/g). At the end of the experiment animals were sacrificed and mesenteric lymph nodes (MLN), and both peripheral and portal blood samples were recovered and cultured. Bacterial identification in blood was carried out by conventional methods and MLN culture was considered positive with a growth over 100 Colony Forming Units/g. RESULTS: Weight curve was better in MEN group and BT was also significantly reduced. Translocation was found in 45% of control group and 8% of MEN group (p < 0,05). The relative risk (RR) was 5,9 (IC 95% 0,81-43,71) and the number needed to treat (NNT) was 3 (95% CI 2-20). CONCLUSIONS: 1. MEN reduces the incidence of BT in an experimental model of parenteral nutrition. 2. BT reduction could decrease NEC-related sepsis risk.