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.

An assessment of patient-reported long-term outcomes following surgery for cauda equina syndrome.

BACKGROUND: Data regarding long-term outcomes following surgery for cauda equina syndrome (CES) is scarce. In addition, these studies rely on patient descriptions of the presence or absence of symptoms, with no gradation of severity. This study aimed to assess long-term bladder, bowel, sexual and physical function using validated questionnaires in a CES cohort. METHODS: A pre-existing ethically approved database was used to identify patients who had undergone surgery for CES between August 2013 and November 2014. Patients were contacted over a 1-month period between August and September 2017 and completed validated questionnaires via telephone, assessing bladder (Urinary Symptom Profile), bowel (Neurogenic Bowel Dysfunction Score), sexual dysfunction (Arizona Sexual Experiences Scale) and physical function (Physical Component Summary of SF-12 Questionnaire), with scores compared between those presenting with incomplete CES (CES-I) and CES with retention (CES-R). Patients were also asked which of their symptoms currently they would most value treatment for and what healthcare services they had accessed post-operatively. RESULTS: Forty-six of 77 patients (response rate 72%, inclusion rate 60%) with a mean age of 45 years (21-83) and mean time since admission of 43 months (range 36-60) took part in the follow-up study. The prevalence of bladder dysfunction was 76%, bowel dysfunction 13%, sexual dysfunction 39% and physical dysfunction 48%. Patients presenting with CES-R had significantly worse long-term outcomes in bladder (stream domain), bowel and sexual function in compared to those with CES-I. Pain was chosen as the symptom patients would most value treatment for by 57%, but only 7% reported post-operative pain management referral. CONCLUSIONS: With a mean follow-up time of 43 months, these findings confirm the high prevalence of long-term bladder, sexual and physical dysfunction in CES patients and that a diagnosis of CES-R confers poorer outcomes. This study provides useful, objective data to guide the expectations of patients and clinicians.

Do surgeon credentials affect the rate of incidental durotomy during spine surgery.

PURPOSE: Incidental durotomy is a potential complication of spinal surgery which can cause a number of intra-operative and post-operative complications. The purpose of this study was to determine if the primary operator's credentials impacted on the incidence of durotomy intra-operatively. METHODS: Prospectively collected data of operator credentials in relation to the incidence of durotomy were acquired from the International Eurospine Tango database. The significance of variability and risk factors between operators was measured using the Chi-squared test. RESULTS: Data from a total of 3,764 patients were captured from the Tango registry. Of these 162 (4.3%) had a durotomy. Of the total number of patients, the primary operator was neurosurgical in 1,369 (36.4%) cases; orthopaedic in 180 (4.8%) cases; other (pre-certification) in 236 (6.3%) cases; specialised spine surgeon in 1,741 (46.3%) cases; 6 cases had missing operator data. cerebrospinal fluid (CSF) leak occurred in 57 (4.16%) of neurosurgeon-operated cases; 5 (2.78%) orthopaedic-operated cases; 19 (4.06%) of other surgeon-operated cases; and 81 (4.65%) in specialised spine surgeon-operated cases. Using Chi-squared test, the significance of the variation in incidence of CSF leak between primary operator groups was not statistically significant (P = 0.1405). CONCLUSION: From the data captured and analysed, the rate of durotomy ranged from 2.78 to 4.65% between operator groups with a mean rate of 4.3%. The primary operator credentials do not appear to significantly impact the rate of durotomy in spine surgery.

The ventriculocholecystic shunt: two case reports and a review of the literature.

We describe the re-siting of ventriculoperitoneal shunts to the gallbladder in two children. The first child had a rare case of hydrocephalus associated with plasminogen deficiency. She had had multiple VP shunt revisions due to non-absorption of CSF from the peritoneum. The second had craniopharyngioma-related hydrocephalus with once again a non-absorbing peritoneum. We report no surgical complications in the revisions for both the cases, and there has been a subsequent follow-up of 46 and 28 months, respectively, without incident. A review of the relevant literature describing the use and the performance of ventriculocholecystic shunts in comparison with other ventricular shunts is considered.

Papillary glioneuronal tumour: a review of the literature with two illustrative cases.

We report two cases of papillary glioneuronal tumour (PGNT). One was located in the supratentorial parenchyma and the other was intraventricular. Both patients underwent gross total resection of their tumour and have returned to normal lifestyle. Papillary glioneuronal tumor is a recently described rare cerebral neoplasm. Recently classified by the World Health Organization in 2007 as a Grade I neuronal-glial tumour, these tumours are infrequent lesions that can be challenging to the practising pathologist. Patients commonly present with headaches or seizures, but may be asymptomatic with the mass discovered incidentally. The characteristic radiological, histological and immunohistochemical features are discussed. Surgical excision has been curative in most of the cases with only a handful of cases of recurrence reported. The increasing number of reports in the literature shows how PGNT forms a good example of a newly diagnosed tumour category in evolution. New classifications and re-classifications of broad categories of brain tumours will hopefully lead to a narrower diagnostic, prognostic and therapeutic profile. The even rarer presence of atypia calls for longer follow-up to help elucidate further its biological behaviour.

From encephalitis lethargica to cerebral cytoarchitectonics: the polymath talent of Constantin von Economo (1876-1931), pioneer neuroanatomist, neurophysiologist and military aviator.

Born in Romania of Greek parents and raised in Trieste, Constantin von Economo was educated and influenced by Vienna's medical and scientific tradition. Better known for his description of encephalitis lethargica, a disease bearing his name, he made several contributions to as varied themes as the cytoarchitecture of the cerebral cortex, sleep regulation, evolutionary brain development and, outside medicine, in aviation. While still a student he showed an aptitude for meticulous accuracy and a skill in combining animal experiments with microanatomical techniques. Nurtured in the formidable environment of Viennese histology he produced a monumental account of the cytoarchitecture of the human cerebral cortex. This, in an attempt to correlate structure and function, was unique in its quality of accuracy and paved the way for subsequent achievements two decades later. Despite an untimely death at 55 years, he remains one of the most talented pioneers of modern neuroscience.

Progressive tension pneumocephalus as a delayed postoperative complication in the absence of any obvious CSF leak.

Tension pneumocephalus is a rare neurosurgical emergency usually causing rapid deterioration. Slowly-progressive postoperative tension pneumocephalus is very rare. We present a case that came to our attention 5 weeks after a craniotomy with gradual development of symptoms, and in the absence of any obvious CSF leak. A dural defect causing a one-way valve system was found at explorative craniotomy.

Paraganglioma of the Lumbar Spine: A case report and literature review.

INTRODUCTION: Lumbar paragangliomas are rare, vascular, neuroendocrine tumors. They are notoriously difficult to diagnose radiologically and can prove challenging to manage intraoperatively, if capable of catecholamine secretion. CASE REPORT: We report the case of a 45-year-old man, who presented with a lumbar spinal paraganglioma. The patient described a 2-year history of worsening lower back pain and sciatica. Neurological examination was normal. MRI revealed a lesion at L3, with prominent vessels, compressing the cauda equina. Gross total resection (GTR) of the tumor was performed. The patient recovered well, with relief of pain and no neurological deficit. DISCUSSION: A literature search of lumbar paraganglioma cases, from January 1970 to April 2018 was carried out. Results of this review highlighted the importance of inclusion of paraganglioma as a differential diagnosis in lumbar spinal tumor and also the requirement for preoperative investigations to determine any potential secretory activity. CONCLUSIONS: Lumbar paraganglioma behavior is most commonly benign and rates of recurrence are low after GTR. However, long-term postoperative follow-up is crucial, due to findings of late metastatic recurrence.

D-day on board a tank landing ship: meat, cheese and blood transfusion.

Tank Landing Ships were used as evacuation station hospitals during D-Day of World War Two. This historical vignette describes how difficulties were overcome in blood transfusion and trauma surgery aboard these ships. Their place in the evacuation chain is discussed in relation to previous experiences in military medicine.

Total disc replacement versus anterior cervical discectomy and fusion: a systematic review with meta-analysis of data from a total of 3160 patients across 14 randomized controlled trials with both short- and medium- to long-term outcomes.

Aims: The aim of this study was to determine how the short- and medium- to long-term outcome measures after total disc replacement (TDR) compare with those of anterior cervical discectomy and fusion (ACDF), using a systematic review and meta-analysis. Patients and Methods: Databases including Medline, Embase, and Scopus were searched. Inclusion criteria involved prospective randomized control trials (RCTs) reporting the surgical treatment of patients with symptomatic degenerative cervical disc disease. Two independent investigators extracted the data. The strength of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. The primary outcome measures were overall and neurological success, and these were included in the meta-analysis. Standardized patient-reported outcomes, including the incidence of further surgery and adjacent segment disease, were summarized and discussed. Results: A total of 22 papers published from 14 RCTs were included, representing 3160 patients with follow-up of up to ten years. Meta-analysis indicated that TDR is superior to ACDF at two years and between four and seven years. In the short-term, patients who underwent TDR had better patient-reported outcomes than those who underwent ACDF, but at two years this was typically not significant. Results between four and seven years showed significant differences in Neck Disability Index (NDI), 36-Item Short-Form Health Survey (SF-36) physical component scores, dysphagia, and satisfaction, all favouring TDR. Most trials found significantly less adjacent segment disease after TDR at both two years (short-term) and between four and seven years (medium- to long-term). Conclusion: TDR is as effective as ACDF and superior for some outcomes. Disc replacement reduces the risk of adjacent segment disease. Continued uncertainty remains about degeneration of the prosthesis. Long-term surveillance of patients who undergo TDR may allow its routine use. Cite this article: Bone Joint J 2018;100-B:991-1001.

A brief look at the history of the Deaconess Hospital, Edinburgh, 1894-1990.

The Deaconess Hospital, Edinburgh, opened in 1894 and was the first establishment of its kind in the UK, maintained and wholly funded as it was by the Reformed Church. Through its 96-year lifetime it changed and evolved to time and circumstance. It was a school: for the training of nurses and deaconesses who took their practical skills all over the world. It was a sanctum: for the sick-poor before the NHS. It was a subsidiary: for the bigger hospitals of Edinburgh after amalgamation into the NHS. It was a specialised centre: as the Urology Department in Edinburgh and the Scottish Lithotripter centre. And now it is currently student accommodation. There is no single source to account for its history. Through the use of original material made available by the Lothian Health Services Archives - including Church of Scotland publications, patient records, a doctor's casebook and annual reports - we review its conception, purpose, development and running; its fate on joining the NHS, its identity in the latter years and finally its closure.

Low cost, high risk: accidental nutmeg intoxication.

Nutmeg poisoning is rare but probably underreported and should be considered in recreational substance users with acute psychotic symptoms as well as central nervous system neuromodulatory signs that may mimic in part an anticholinergic hyperstimulation.

Peripheral ulcerative keratitis after clear corneal cataract extraction(1).

A previously healthy 80-year-old man had uneventful clear corneal cataract extraction. An extensive peripheral corneal infiltrate with overlying epithelial defect at the incision site was noted at the regular follow-up visit 1 week after surgery. Corneal cultures showed no evidence of infectious keratitis. A systemic evaluation uncovered early-stage, active rheumatoid arthritis. This case illustrates that peripheral ulcerative keratitis may occur with a small clear corneal incision and may be the presenting sign of a previously undiagnosed rheumatoid disease.

Subdural haematoma associated with an arachnoid cyst after repetitive minor heading injury in ball games.

We report the case of a chronic subdural haematoma caused by repetitive heading of a football which led to the diagnosis of a middle fossa arachnoid cyst. The association between arachnoid cysts and subdural haematoma is discussed as are safety implications in sporting injuries.

Arterial baroreflex control during mild-to-moderate nitrous oxide narcosis.

We hypothesized that light-to-moderate inert gas narcosis might play a role in bradycardia in divers by altering sensitivity or response dynamics of arterial baroreflexes. Carotid-cardiac and carotid-mean arterial pressure (MAP) baroreflex response curves were generated by applying multiple levels of neck pressure and suction. Seven healthy volunteers were studied during air breathing (control) and during inhalation of 39% nitrous oxide (N2O). Baseline (pre-stimulus) heart rate (HR) and MAP were not altered by N2O. Range, threshold level, saturation level, and delay of responses did not differ between conditions. For hypertensive stimuli, sensitivity of responses did not differ between air control and N2O inhalation, but for hypotensive stimuli, maximal response gain for HR tended to be reduced with N2O inhalation (P = 0.054). Our results speak against inert gas narcosis as a primary mechanism for hyperbaric bradycardia, but it remains possible that an attenuation of tachycardic responses to hypotensive stimuli plays a role.

[Hemangiopericytoma of the axillary artery (author's transl)]. / Hémangiopéricytome de l'artère axillaire.

A case of hemangiopericytoma is reported, and a possible correlation studied between treatment and the frequency of local recurrences after macroscopically satisfactory excision.

Horizontal gaze palsy and scoliosis: a case report and review of the literature.

BACKGROUND: The syndrome of horizontal gaze palsy with progressive scoliosis (HGPPS) is a rare human disease and while its association with scoliosis was first reported in 1974, thirty years later the responsible genetic mutations are being elucidated. This progress was due to the reporting of single interesting cases. CASE DESCRIPTION: We present the case of a 27 year-old male patient who was admitted for elective scoliosis correction surgery and who represented after an uncomplicated discharge with headache and vomiting; because of a gaze palsy he underwent brain imaging that confirmed a brainstem abnormality, consistent with the syndrome of horizontal gaze palsy with progressive scoliosis (HGPPS), a rare autosomal recessive human disease. CONCLUSION: This rare syndrome is a good example of how single case reports can lead to advances in laboratory research and genetic characterisation of diseases, together with implications for neurodevelopment. Vigilance in the neurological examination in an otherwise 'non-neurological' scoliosis will help identify potential such cases, whilst further genetic/molecular analysis may shed further light into neuro-embryological development and patterning.