Identifying functional cortical plasticity after spinal tumour resection using navigated transcranial magnetic stimulation.

Our aim was to investigate the effectiveness of navigated transcranial magnetic stimulation (nTMS) brain mapping to characterise preoperative motor impairment caused by an intradural extramedullary (IDEM) tumour and postoperative cortical functional reorganisation. Preoperative and 1-year follow-up clinical, radiological and nTMS data from a case of thoracic spinal meningioma that underwent surgical resection of the lesion were collected and compared. A 67-year-old patient presented with severe progressive thoracic myelopathy (hypertonic paraparesis, clonus, insensate urinary retention) secondary to an IDEM tumour. Initial nTMS assessment showed bilateral upper limb representation with no positive responses for both lower limbs. He underwent successful surgical resection for his IDEM (meningioma WHO grade 1). At 1-year follow-up, the patient's gait was improved and his bladder function normalised. nTMS documented positive responses for both upper and lower limbs and a decrease in the area (right side: 1.01 vs 0.39cm2; left side: 1.92 vs 0.81cm2) and volume (right side: 344.2 vs 42.4uVcm2; left side: 467.1 vs 119uVcm2) of cortical activation for both upper limbs, suggesting a functional reorganisation of the motor areas after tumour resection. nTMS motor mapping and derived metrics can characterise preoperative motor deficit and cortical plasticity during follow-up after IDEM resection.

A single centre's experience of managing spheno-orbital meningiomas: lessons for recurrent tumour surgery.

BACKGROUND: Spheno-orbital meningiomas are complex tumours involving the sphenoid wing and orbit. Various surgical strategies are available but treatment remains challenging and patients often require more than one surgical procedure. This study evaluated whether smaller surgical approaches and newer reconstructive methods impacted the surgical and clinical outcomes of patients undergoing repeat surgery. METHODS: We retrospectively analysed the medical records of consecutive patients who underwent surgery for a spheno-orbital meningioma at a single tertiary centre between 2005 and 2016. We recorded procedural details and analysed complications, postoperative visual status and patient-reported cosmetic outcome. RESULTS: Thirty-four procedures were performed in 31 patients (M:F 12:22, median age 49 years) including 19 (56%) primary operations and 15 (44%) repeat procedures. Seven patients (20.5%) had a pterional craniotomy, 19 (56%) had a standard orbitozygomatic craniotomy and 8 (23.5%) underwent a modified mini-orbitozygomatic craniotomy. Calvarial reconstruction was required in 19 cases with a variety of techniques used including titanium mesh (63%), PEEK (26%) and split calvarial bone graft (5%). Total tumour resection (Simpson grade I-II) was significantly higher in patients undergoing primary surgery compared with those having repeat surgery (41% and 0%, respectively; p = 0.0036). Complications occurred in 14 cases (41%). Proptosis improved in all patients and visual acuity improved or remained stable in 93% of patients. Cosmetic outcome measures were obtained for 18 patients (1 = very poor; 5 = excellent): 1-2, 0%; 3, 33%; 4, 28%; 5, 39%. Tumour recurrence requiring further surgery occurred in four patients (12%). There was no significant difference in clinical outcomes between patients undergoing primary or repeat surgery. CONCLUSION: Spheno-orbital meningiomas are highly complex tumours. Surgical approaches should be tailored to the patient but good clinical and cosmetic outcomes may be achieved with a smaller craniotomy and custom-made implants, irrespective of whether the operation is the patient's first procedure.

Has the survival of patients with glioblastoma changed over the years?

BACKGROUND: Over the last decade, the approach to the management of brain tumours and the understanding of glioblastoma tumour biology has advanced and a number of therapeutic interventions have evolved, some of which have shown statistically significant effects on overall survival (OS) and progression-free survival in glioblastoma. The aim of this study is to compare survival in glioblastoma patients over a 10-year period (1999-2000 and 2009-2010). METHODS: A retrospective cohort study was performed. Identification of all histologically confirmed glioblastoma in a single centre in years 1999, 2000, 2009 and 2010, and production of survival analysis comparing 1999-2000 and 2009-2010 were achieved. RESULTS: A total of 317 patients were included in the analysis (133 in year 1999-2000, and 184 in year 2009-2010). Cox regression analysis showed that the survival was significantly longer in patients in years 2009-2010 than those in 1999-2000 at P<0.001 with HR=0.56, confidence interval (CI) (0.45-0.71). The 1- and 3-year survival rates were 20.7% and 4.4%, respectively, for patients in 1999-2000, improving to 40.0% and 10.3%, respectively, for patients in 2009-2010. The comparisons between the two groups in survival at 1, 2 and 3 years are all statistically significant at P<0.001, respectively. The median OS was 0.36 and 0.74 in 1999-2000 and 2009-2010 groups, respectively. CONCLUSIONS: Over this period, OS from glioblastoma has increased significantly in our unit. We believe this is due to the institution of evidence-based surgical and oncological strategies practised in a multidisciplinary setting.

Neurobehavioural changes in patients following brain tumour: patients and relatives perspective.

PURPOSE: Patients and relatives experiences of behavioural and personality changes following brain tumour were assessed to determine whether these changes are more prominent in the experience of patients with frontal tumours and their relatives as a first step to evaluate the need to develop appropriate support and management of such changes, which have a substantial impact on social functioning, and ultimately to improve quality of life. METHODS: Patients and relatives rated the patients' current levels of apathy, disinhibition and executive dysfunction on the Frontal Systems Behaviour Scale. Patients also completed the Hospital Anxiety and Depression Scale. The data from 28 patients with frontal tumours and 24 of their relatives, and 27 patients with nonfrontal tumours and 25 of their relatives, were analysed. RESULTS: Patients with frontal tumours rated themselves significantly higher than patients with nonfrontal tumours on all frontal systems-related behaviours. The number of patients reporting clinical levels of difficulty was significantly greater in patients with frontal tumours for disinhibition. The ratings of relatives of patients with frontal tumours were significantly higher than those of relatives of patients with nonfrontal tumours for apathy. Clinically significant levels of apathy and executive dysfunction were however reported by at least 40 % of patients and relatives regardless of tumour location. Clinical levels of anxiety were reported by significantly more patients with frontal tumours than those with nonfrontal tumours. CONCLUSION: Support and management of behavioural and personality change for patients with brain tumours and their relatives, regardless of tumour location, would be most appropriate.

Neurenteric cyst in an adult: a diagnosis in a quinquagenarian.

Neurenteric cysts are congenital lesions of the spine usually diagnosed in children. There are few reports of diagnosis in adults. The abnormality is thought to arise during embryonic life and can be associated with other congenital deformities. We describe a case where the diagnosis occurred in a 54-year-old woman, whose symptoms improved following surgical excision of the cyst. We postulate that the cyst contributed to symptoms of cord tethering rather than cord compression and that the lateness of presentation was due to age-related spinal degeneration.

Primary reconstruction of pelvic floor defects following sacrectomy using Permacol graft.

AIMS: The large pelvic floor defect following sacrectomy for sacral masses leaves the challenging problem of primary closure and herniation. We present the outcome of primary repair using Permacol, a biomaterial made of acellular porcine cross-linked dermal collagen and with similar tensile strength to polypropylene mesh. It is non-allergenic and possibly less likely than synthetic mesh to cause inflammation leading to small bowel adherence; fistula formation and graft extrusion. Following implantation, Permacol is colonized by host cells and resists degradation by host enzymes. METHODS: Three patients had sacrectomy with primary repair of pelvic floor defects between March 2004 and August 2005. Two had excision of sacral chordomas and one excision of a sacrococcygeal teratoma. Repair of the defect was carried out using the Permacol graft, suturing to the sacrum, anococcygeal raphe and ischial spines. Two suction drains were placed superficial to the mesh. RESULTS: All patients had gross en-bloc tumour resections and over a median follow-up period of 1year (range 8-25months), there were no complications related to primary repair. CONCLUSION: Primary closure of a large defect following sacrectomy using a Permacol graft, in our early experience seems to be convenient and safe without the development of herniation.

Audit of neurosurgery senior house officer training in the United Kingdom and Eire: a postal survey.

An audit was performed to describe the current training conditions of senior house officers in neurosurgery in the UK and Eire. A postal questionnaire was sent to all neurosurgery senior house officers in a 6-month training period between February and August 2003. The questionnaire covered most aspects of working pattern, training and job satisfaction by the end of the 6-month post. The results from the audit showed that there are deficiencies in certain areas of the current system being employed for senior house officer training. Improvements to this training system in line with the establishment of a generic neurosciences training programme will benefit future surgical trainees.

Pilocytic astrocytoma of the adult--clinical features, radiological features and management.

Pilocytic astrocytoma is a histological subtype of astrocytoma classically located in the cerebellum of children and young adults. Cases occurring over the age of 30 years are rare and have not been classified in terms of their clinical features and management. Suitable cases were identified using diagnostic coding and by reviewing a neuropathology database. Casenotes and neuroradiology were reviewed retrospectively. Ten cases were identified over a 6 year period with an incidence of 0.49 cases per million population per year. Tumours were equally distributed between the supra- and infra-tentorial spaces. The most common symptom was headache occurring in 90%. No patient suffered seizures. Total macroscopic treatment remains the treatment of choice. Pilocytic astrocytoma of the adult is a rare tumour with a favourable prognosis.

Cauda equina syndrome: outcome and implications for management.

A retrospective review of all patients who had surgery for cauda equina syndrome (CES) due to a herniated lumbar disc between January 1996 and November 1999 was undertaken. All underwent laminectomy and discectomy, and had been admitted as emergencies with cauda equina syndrome. Ten women and 10 men with a mean age of 45 years (range 33-67) had their diagnosis verified with MRI in 19 cases and CT in one case. Only half the patients had been catheterized at the time of admission to the neurosurgical unit. Nine patients had emergency decompressive surgery within 5 h of presentation to our unit. The others had surgery on the next available list, but within 24 h of admission. No difference was found between urgently operated patients and those operated on the next available list when urological outcome and quality of life assessments were made using a validated questionnaire at a mean time of 16 months after surgery (range10-48). Twenty per cent of a control group who had undergone laminectomy and discectomy for large disc herniations, but without CES had new urological symptoms when questioned postoperatively, but similar quality of life status. Emergency decompressive surgery did no significantly improve outcome in CBS compared with a delayed approach.

Posterior lumbar interbody fusion for revision disc surgery: review of 50 cases in which carbon fiber cages were implanted.

OBJECT: The authors undertook a study to assess the value of posterior lumbar interbody fusion (PLIF) in which carbon fiber cages (CFCs) were placed in patients undergoing revision disc surgery for symptoms suggesting neural compression with low-back pain. METHODS: The authors followed their first 50 patients for a maximum of 5 years and a minimum of 6 months after implantation of the CFCs. Patients in whom magnetic resonance (MR) imaging demonstrated "simple" recurrent herniation did not undergo PLIF. Surgery was performed in patients with symptoms of neural root compression, tension signs, and back pain with focal disc degeneration and nerve root distortion depicted on MR imaging compatible with clinical signs and symptoms. In 40 patients (80%) pedicle screws were not used. Clinical outcome was assessed using the Prolo Functional Economic Outcome Rating scale. Fusion outcome was assessed using an established classification. Symptoms in 46 patients (92%) improved after surgery, and given their outcomes, 45 (90%) would have undergone the same surgery again. Two thirds of patients experienced good or excellent outcomes (Prolo score > or = 8) at early and late follow up. There was no difference in clinical outcome between those in whom pedicle screws were and were not implanted (p = 0.83, Mann-Whitney U-test). The fusion rate at 2 years postsurgery was 95%. There were minimal complications, and no patients fared worse after surgery. No patient has undergone additional surgical treratment of the fused intervertebral space. CONCLUSIONS: In this difficult group of patients the aim remains to improve symptoms but not cure the disease. A high fusion rate is possible when using the CFCs. Clinical success depends on selecting patients in whom radiological and clinical criteria accord. Pedicle screws are not necessary if facet joints are preserved, and high fusion rates and clinical success are possible without them.

Local anaesthesia for laminectomy surgery.

Neurosurgical patients presenting for laminectomy surgery may have premorbid pathology that either contraindicates general anaesthesia or at least represents a significant risk to the patient. We present a sample case from a series of ten patients in whom laminectomy surgery was performed under local anaesthesia. The mean duration of surgery was 98 minutes and the average dose of lignocaine used was 1.91 mg/kg and, therefore, within safe limits. One patient was converted to a general anaesthetic. We believe that local anaesthesia can offer a safe and satisfactory alternative, in patients who may otherwise be denied surgery. The additional advantage of awake neuro-monitoring, may also reduce the risk of inadvertant spinal cord injury.

Spinal meningiomas: a 20-year review.

The long-term outcome of 78 patients with spinal meningiomas operated on over 20 years at a single neurosurgical unit was analysed. Age, sex and tumour location were similar to those reported by others. Overall, 95% of our patents were independently mobile postoperatively, despite 25% of the group being unable to walk before operation, including four paraplegic patients. Only two tumours were entirely extradural, and a further two were both intra- and extradural. In all cases, tumour exposure was by posterior laminectomy, without recourse to more complex approaches. Complete tumour resection was achieved in 77 (98%) of cases. The dural attachment was excised in 20 cases and diathermy was applied in 58. There was one recurrence, 14 years after the original surgery. Complex and technically challenging surgical approaches are unnecessary to obtain complete removal even for anteriorly placed tumours. Excision of the dural base would seem unnecessary to attain a low recurrence rate.

Preliminary experience of carbon fibre cage prostheses for treatment of cervical spine disorders.

The objective of this study was to assess the technical feasibility, and the clinical and radiological results of interbody fusion with a carbon fibre cage following anterior cervical discectomy. Nineteen consecutive patients, eight male and 11 female, with an age range from 28 to 75 years (mean 45) underwent anterior cervical discectomy and interbody fusion with a carbon fibre cage at one or two levels. Subjective assessment of symptomatic improvement and radiological assessment of cervical spine alignment and stability was made. All complications were recorded. The procedure was technically feasible. There was no increased morbidity and the length of procedure was no longer when compared with the similar operation but using tricorticate bone graft. All patients initially lost their radicular symptoms and the patients with myelopathy had subjective improvements of their symptoms. Fourteen of the 17 patients with neck pain showed some improvement. Bony fusion was achieved in all cases.

Modification of the standard pterional approach for aneurysms of the anterior circle of Willis.

A modification of the standard pterional approach for aneurysms of the anterior circulation is described. Our technique utilizes a smaller curvilinear skin incision, splitting the temporalis and a limited craniectomy. Reduced tissue dissection results in a smoother postoperative course and improves cosmesis without compromising neurological recovery. Minimal brain retraction is required as the technique allows the surgeon to make full use of the basal opening without temporalis muscle obscuring the view.

Head injuries in the accident and emergency department: are we using resources effectively?

This paper reports a retrospective criterion based audit which reviewed head injury management in two accident and emergency (A&E) departments. Management was compared with regionally agreed criteria for ordering a skull radiograph (SXR) and a computerized tomogram (CT scan) and for admission, and the quality of medical documentation was assessed. A total of 158 patients were reviewed and 132 patients (84%) satisfied the three key areas of recommended head injury management. Failures to satisfy recommended guidelines were present in 19 patients (12%) for SXR, four (2%) for admission and three (2%) for CT scanning. Three skull fractures (two in young babies) would have been missed if the criteria had been adhered to strictly. There was one adverse outcome when a patient who should have been admitted returned to A&E 8 days after initial attendance with a subdural haemorrhage and died shortly afterwards. Apart from 'loss of consciousness', the quality both in content and legibility of the medical documentation was poor. The result of 84% correctly managed patients may be over-optimistic according to the criteria used. Although criteria have a valuable role to play, there are problems with prescriptive standard setting. A recommendation was made to develop a head injury pro forma to address the poor quality medical documentation and it was also recommended that the SXR, CT scan and admission criteria for babies and young children be reviewed.