Can a culture of team psychological safety and MDT proforma improve team performance and patient outcomes in spinal MDTs?

PURPOSE: Spinal multidisciplinary teams (MDTs) are now standard of care for complex patient management in tertiary spinal units. This study investigates whether a scheduling proforma, and cultural change to the team that promotes psychological safety, can improve spinal MDT effectiveness for team members and patients. METHODS: Retrospective cohort study including 165 spinal MDT patients before and after intervention. The intervention was use of a scheduling proforma and team learning to promote a culture of psychological safety. Data on accident and emergency (A&E) attendances, unplanned emergency admissions and post-operative 30-day readmissions were collected. At the team level, data were collected from 16 MDT participants using the MDT Observational Assessment Rating Scale (MDT-OARS), which measures MDT effectiveness. RESULTS: Pre-intervention MDT-OARS was 28. Analysis of 80 patients demonstrated there were six A&E attendances, three unplanned emergency admissions and four post-operative 30-day re-admissions. Post-intervention MDT-OARS was 38 (p < 0.05). Analysis of 85 patients demonstrated there were three A&E attendances, one unplanned emergency admission and one post-operative re-admission. CONCLUSIONS: Team culture that promotes psychological safety, along with use of a scheduling proforma, can improve MDT effectiveness for participants in spinal MDTs.

Conservative Management of Type II Odontoid Fractures in Older People: A Retrospective Observational Comparison of Osseous Union Versus Nonunion.

BACKGROUND: Type II odontoid fractures are a common cervical fracture in older people. Lower osseous-union rates are reported in those treated conservatively compared to surgically; however, the clinical relevance of a nonunion is unknown. OBJECTIVE: To compare pain, disability, and quality of life in older people following conservative management of type II odontoid fractures demonstrating osseous-union and nonunion. METHODS: Electronic records were searched from 2008 to 2018 for adults ≥65 yr with type II odontoid fracture, managed in a semi-rigid collar. Clinical and demographic data were retrieved from electronic patient notes. Surviving patients were invited to complete questionnaires to assess pain, disability, and quality of life. Ethical approval was granted. RESULTS: A total of 125 patients were identified: 36 (29%) demonstrated osseous-union, 89 (71%) had nonunion, of which 33 (40%) had radiological instability. Mean age at fracture was 84 yr (osseous-union 83 yr; nonunion 84 yr). A total of 53 had deceased (41 nonunion). Median length of survival was 77 mo for osseous-union vs 50 mo for nonunion; P = .02. No patient developed myelopathy during the follow-up period. Questionnaire response rate was 39 (58%). There were no statistically significant differences between the groups in terms of pain, disability, or quality of life (P > .05). Both groups reported mild disability and pain but low quality of life. CONCLUSION: Management with a semi-rigid collar in older people with type II odontoid fracture is associated with low levels of pain and disability without statistically significant differences between those demonstrating osseous-union or stable or unstable nonunions. Conservative management appears to be a safe treatment for older people with type II fractures.

An Awake Throughout Approach for Awake Craniotomy: A Perspective from a Resource-Limited Country.

BACKGROUND: An awake throughout (AT) approach for awake craniotomy is mostly under utilized. The purpose of this study was to review the efficacy of the technique at our tertiary care center. The primary objective was to identify the incidence of perioperative complications. The secondary objective was to review the patients' satisfaction, satisfaction of surgical team, length of stay (LOS) in special care unit (SCU), and overall LOS in the hospital. METHODS: The study was a retrospective review of patients data. All patients were treated with the AT technique. This included preoperative assessment, psychologic preparation, and institution of scalp block. The incidence of perioperative complications, including satisfaction of surgical team was noted. The patients' satisfaction and the LOS in SCU and in the hospital was also recorded. RESULTS: In total, the data from 55 patients were reviewed. Their mean age was 41 years, and 63% were reported to have seizures at presentation. The AT approach was successful in 100% of cases. The incidence of intraoperative seizures was 7.4%, of vomiting was 5.4%, and of conversion to general anesthesia was 0%. The surgical team was able to perform gross total resection in 53% of patients and rated a satisfaction score of 8 out of 10. Postoperative seizures occurred in 5.4% of patients and vomiting in 3.6%. The mean LOS in SCU was 1.2 days, and the overall hospital LOS was 4 days. The patients remained fully satisfied, as evidenced by a mean satisfaction score of 8.6. CONCLUSION: An AT approach might be very useful in resource-limited setups because of the low incidence of complications, the use of resources, and significant surgeon and patient satisfaction.

Pre-operative Voriconazole in patients undergoing surgery for Central Nervous System fungal infections: Special Report.

Fungal infections of the central nervous system (CNS) are uncommon. Despite several advancements in diagnosis and treatment of these infections, the mortality rates remain high. The current retrospective study was planned to define the demographic and clinical features of patients with CNS fungal infections. Conducted at Aga Khan University Hospital, Karachi, and comprising CNS fungal infections operated between January 2000 and December 2015. The study analysed whether a short course of pre-operative anti-fungal therapy may improve outcomes in these patients. There were 47 cases confirmed on histopathology and/or microbiology. Outcome measures used were Glasgow coma score (GCS), Glasgow outcome score (GOS) and Karnofsky performance score (KPS). The overall 30-day mortality was 20(42.5%). Fungal infections of the CNS can occur in both immune-compromised and immune-competent patients. Early diagnosis, radical surgery, pre-operative anti-fungal therapy for at least 2 weeks, pre- and postoperative Voriconazole therapy results in more favourable outcomes.

Prognostic Implications of Histological Clear Cells in High-Grade Intracranial Ependymal Tumors: A Retrospective Analysis from a Tertiary Care Hospital in Pakistan.

BACKGROUND: Clear cell variant in ependymal tumors is rare. We aimed to compare the features and outcome of the World Health Organization (WHO) Grade 3 ependymal tumors with clear cells to the WHO Grade 3 classic anaplastic ependymoma (AE). MATERIALS AND METHODS: A retrospective cohort study conducted at the Department of Neurosurgery, Aga Khan University, Pakistan, from 2003 to 2013. The medical records and radiology of patients with proven histopathology were reviewed. The analysis was done on SPSS 20. RESULTS: Nine cases of clear cell variant and 23 cases of classic AE were found, both of which combined equated to 4% of the total tumor burden in 11 years. The median age of clear cell ependymoma (CCE) and AE were 49 and 37 years, respectively. Presenting symptoms included headache in 66% of CCE and 63% in AE, raised intracranial pressure accounting for 33% of CCE and 54% of AE, dizziness in 22% CCE and 39% AE, while seizures presented equally in both. Supratentorial location was observed in 77% CCE and 48% AE. Both showed hypointense signals on T1-weighted images of magnetic resonance imaging (MRI) while T2-weighted images showed hyperintensity in all cases of CCE but only 80% of AE. MRI characteristics such as the presence of cystic component were found in 89% of CCE and 68% of AE, necrosis in 33% CCE, and 22% AE, hemorrhagic in 22% CCE and 9% AE, and equivalent contrast enhancement. Gross total resection was achieved in 5 (55%) patients of CCE, compared to 6 (26%) patients in AE. Subtotal resection was done in 4 (44%) patients of CCE and 15 (65%) patients of AE. Radiotherapy was given to 5 (55%) patients of CCE and 12 (52%) patients of AE. Recurrence was observed in 77% cases of CCE and 70% of AE, with metastasis in 29% of AE and in only one patient of CCE. Repeat surgery was done in 3 (33%) cases of CCE and 8 (35%) cases of AE. Median progression-free survival and overall survival were 9 and 13 months, respectively, in CCE while 14 and 18 months, respectively, for AE. CONCLUSION: Clear cells in the WHO Grade 3 ependymal tumors are found mainly in a comparatively older adult population with a predilection for supratentorial location and are more aggressive in behavior with poorer outcome than AE.

Delayed spinal cord infarction following anterior cervical surgical decompression.

Anterior cervical discectomy and fusion (ACDF) for cord compression is a safe and effective procedure with good outcomes. However, worsening of myelopathy is the most feared adverse event of the surgery. We report the case of a 36-year-old male patient who presented with an acute non-traumatic C5-6 cervical disc herniation causing incomplete quadriparesis. He underwent an uncomplicated ACDF at C5-6, and after an initial period of improvement, he developed a delayed onset of an anterior cord syndrome on day 3, without any discerning cause. We have reviewed similar cases reported in the literature and believe that our patient's postsurgical course is consistent with a delayed ischaemic/reperfusion injury to the cord following surgical decompression and restoration of blood flow through the anterior spinal artery and we make suggestions for management of such clinical events.

Quality of Life in Individuals Surgically Treated for Congenital Hydrocephalus During Infancy: A Single-Institution Experience.

BACKGROUND: Congenital hydrocephalus (CH) is a frequently encountered birth anomaly that can hinder long-term neurologic maturity and social well-being of affected children. This study was undertaken to assess quality of life (QOL) 10-15 years after surgical treatment for primary CH during infancy at a tertiary care hospital in a developing country. METHODS: This retrospective cohort study included individuals who presented to Aga Khan University Hospital, Karachi, Pakistan, between 1995 and 2005 at <1 year old and underwent surgery for primary CH. The Hydrocephalus Outcome Questionnaire was used to assess outcomes with respect to QOL. RESULTS: Of 118 patients, 90 patients participated in the study. Mean age at first admission was 6.2 months. Mean length of follow-up was 5.4 years. Of these, 28 patients had died after surgery. Shunt infection (P = 0.012) and delayed milestones (P = 0.003) were found to be statistically significant factors affecting mortality in the patients who died. The mean overall health score was 0.67 ± 0.30. Age <6 months at the time of first surgery was a poor predictor of overall health on the Hydrocephalus Outcome Questionnaire (P = 0.039). CONCLUSIONS: In our analysis, we assessed the QOL associated with CH. We hope that these results will provide insight for future prospective work with the ultimate goal of improving long-term QOL in children with CH.

Spontaneous Intraventricular Hemorrhage: A Rare Presentation of a Skull Base Mesenchymal Chondrosarcoma.

BACKGROUND: Chondrosarcomas are very rare malignant, slow-growing tumors that develop in or near the petroclival region of the brain. We report a very rare case in which the tumor originated from left petrous bone and induced intraventricular hemorrhage leading to an acute comatose presentation. CASE DESCRIPTION: A 28-year-old man initially presented to the outpatient department with a 1-month history of headache, vomiting, vertigo, and left facial numbness. A lesion at the cerebellopontine angle with extension into the middle cranial fossa was demonstrated on computed tomography and magnetic resonance imaging. The following night his condition worsened, and he presented to the emergency department with intraventricular hemorrhage with hydrocephalus. An external ventricular drain was placed in the emergency department to relieve hydrocephalus, and definitive surgical resection of the tumor was subsequently. Postoperatively, his Glasgow Coma Scale score improved, and he was transferred to the surgical intensive care unit where he remained for 3 days. He was subsequently stepped down to a special care unit and then to a ward room. The patient is currently awake and has grade II facial palsy (House-Brackmann), demonstrates spontaneous purposeful eye opening, inconsistently obeys single-step orders, demonstrates no meaningful phonation or vocalization, and has at least grade 4 power in all 4 extremities. He is currently fed through a nasogastric tube and is in rehabilitation. CONCLUSIONS: Our experience of petroclival junction chondrosarcoma causing intraventricular hemorrhage may be the first to be documented. Preferred treatment of this highly malignant lesion is radical removal with postoperative radiotherapy.

Ependymal tumors with oligodendroglioma like clear cells: Experience from a tertiary care hospital in Pakistan.

BACKGROUND: Ependymal tumors with oligodendroglioma like clear cells have never been reported from Pakistan. We aimed to see the features and outcomes of this rare entity. METHODS: It was retrospective cohort conducted at the Department of Neurosurgery, Aga Khan University from 2003 to 2013. The medical records and radiology of patients with proven histopathology were reviewed. Analysis was done on SPSS 20. RESULTS: Eleven cases of ependymal tumors with clear cells were found, which equated to 1.5% of the total tumor burden in 11 years. The median age was 49 years. Most common presenting symptom was headache 54.5%. Out of 11 patients, 9 patients had a supratentorial tumor. Magnetic resonance imaging showed hypointense signals on T1 and hyperintense signals on T2-weighted images in all cases. Contrast enhancement was found in 9 patients (77.8%), necrosis and hemorrhage was found in 4 (36%) and 3 (27%) patients, respectively. Immunohistochemistry showed glial fibrillary acidic protein and epithelial membrane antigen positivity in all cases. Ki-67 showed high proliferative index in 6 patients. According to the World Health Organization grading of ependymal tumors, 2 patients had Grade II tumors, and 9 patients had Grade III tumors with clear cells. Gross total resection was achieved in 6 (54.5%) and subtotal resection in 5 patients (45.4%). Recurrence was observed in 9 patients. Six patients died of the disease. Median progression-free survival and overall survival was 8 months and 10 months, respectively. CONCLUSION: Ependymal tumors with clear cells presented more commonly in Grade III lesions and were more aggressive in behavior with poorer outcome compared to similar studies.

Respiratory dyskinesia--an under-recognized side-effect of neuroleptic medications.

Respiratory dyskinesia is an under-recognized side effect of neuroleptic administration. There are only few studies that have addressed the prevalence of respiratory dyskinesia in patients with tardive dyskinesia. Our case report highlights the need to regularly examine patients on antipsychotics for any evidence of dyskinetic movements including respiratory musculature. Since RD is underrecognized and misdiagnosed, early detection can improve long term prognosis as treatment options are few and usually of only limited effect. A 62-year-old Asian male, retired civil engineer, had more than 20 years history of depressive illness, developed antidepressant induced hypomania, and was given risperidone upto 1 mg per day. He developed extrapyrmidal side effects as tremors, rigidity and later dyskinetic movements of lips with shortness of breathing, dyspnoea, grunting or gasping. He was referred to the pulmonologist who got the neccessary medical work up done, which was normal. A diagnosis of respiratory dyskinesia was made. Respiratory dyskinesia is an under-recognised and distressing condition that clinicians need to be aware of when treating patients with anti-psychotic medications. And also there is a need to regularly examine patients on antipsychotics for any evidence of dyskinetic movements including respiratory musculature for early diagnosis and better outcome. This case report also is worth reading for professionals of other specialties also because of the presentation of this patient, it can be easily misdiagnosed and result in poor outcome.