UK neurosurgical workforce planning. What changes have occurred in the consultant body 2014-2018?

Introduction: The British Neurosurgery Trainee Association aimed to investigate the amount of trainees qualifying through the British national training scheme and the rate at which potential consultant posts became available from 2014 to 2018.Methodology: A survey was sent to representatives from each neurosurgical unit and deanery across the United Kingdom to ask about the changes in consultant numbers and those who had attained CCT (Completion of Certificate of Training) over 5 years.Results: At the end of 2018, there were 416.5 full-time equivalent consultants in neurosurgical posts, 388.5 in substantive posts; a median of 11 per unit. The rate of vacating substantive posts was 3.04% per year, with 60% doing so due to retirement. There were 119 substantive appointments, 74 of which were expansion posts (an expansion rate of 4.31% per year). 66% of the appointments went to those with a British CCT. 107 trainees achieved CCT over the 5 years. Five separate scenarios are presented to show the potential variation in the future. If current trends continue there will be 666 consultants by 2031 and 102 too few UK-trained trainees to fill consultant posts. If expansion slows to 467 consultants by 2031, there will potentially be 211 post-CCT trainees more than available consultant posts.Conclusion: There is a wide range of outcomes for workforce planning, greatly impacted upon by retirement rates and consultant body expansion; therefore, a workforce planning committee has been created to monitor and respond to the ongoing situation, with representation from the SBNS, BNTA and SAC.

Successful treatment of bilateral symmetrical skeletal haemangiomata: a case report.

We describe a case of giant bilateral skull vault haemangiomas in a patient with diffuse skeletal haemangiomatosis. The clinical details, histological and radiographic findings and surgical management are reviewed. This is the first described case of radical surgical management of bilateral giant haemangiomas with relief of intractable headache.

Proposal for a prospective multi-centre audit of chronic subdural haematoma management in the United Kingdom and Ireland.

BACKGROUND. Chronic subdural haematoma (CSDH) is a common condition that increases in incidence with rising age. Evacuation of a CSDH is one of the commonest neurosurgical procedures; however the optimal peri-operative management, surgical technique, post-operative care and the role of adjuvant therapies remain controversial. AIM. We propose a prospective multi-centre audit in order to establish current practices, outcomes and national benchmarks for future studies. METHODS. Neurosurgical units (NSU) in the United Kingdom and Ireland will be invited to enrol patients to this audit. All adult patients aged 16 years and over with a primary or recurrent CSDH will be eligible for inclusion. OUTCOME MEASURES AND ANALYSIS. The proposed outcome measures are (1) clinical recurrence requiring re-operation within 60 days; (2) modified Rankin scale (mRS) score at discharge from NSU; (3) morbidity and mortality in the NSU; (4) destination at discharge from NSU and (5) length of stay in the NSU. Audit standards have been derived from published systematic reviews and a recent randomised trial. The proposed standards are clinical recurrence rate < 20%; unfavourable mRS (4-6) at discharge from NSU < 30%; mortality rate in NSU < 5%; morbidity rate in NSU < 10%. Data will be submitted directly into a secure online database and analysed by the study's management group. CONCLUSIONS. The audit will determine the contemporary management and outcomes of patients with CSDH in the United Kingdom and Ireland. It will inform national guidelines, clinical practice and future studies in order to improve the outcome of patients with CSDH.

Has the impact of the working time regulations changed neurosurgical trainees' attitudes towards the European working time directive 5 years on?

We report the results from a survey of the British Neurosurgical Trainees' Association which aimed to assess current rota patterns and their compliance with the government's working time regulations. The survey questioned whether trainees felt that shift working, imposed as a result of the European working time directive, is continuing to impact on patient care and training opportunities in neurosurgery. The responses to this survey indicate that neurosurgical trainees remain concerned with the impact that the current working time regulations have on all facets of their work: training, work- life balance, and the provision of patient care. The survey comments show that the majority would support a change in legislation to allow greater flexibility in the working time regulations.

Retroclival subdural haematoma secondary to pituitary apoplexy.

Retroclival haematomas are rare entity and they are mostly caused by trauma. There has been only one case published to have a retroclival haematoma following pituitary apoplexy. We present a patient diagnosed with pituitary apoplexy who was found to have acute subdural retroclival haematoma on the MRI.

A report from the inaugural meeting of the British Neurosurgical Trainee Research Collaborative held in the Royal College of Surgeons of England, 19 October 2012.

Clinical research, which is essential for improving patient outcomes, is increasingly carried out in the context of networks established between multiple institutions. Research is also considered an important component of training curricula. The recent successful completion of a randomised trial (ROSSINI), which was led by general surgical trainees of the West Midlands Research Collaborative, has established the feasibility of trainee collaborative research networks. A research network for neurosurgical trainees in the UK and Ireland was, therefore, established following the meeting of the British Neurosurgical Trainee Association (BNTA) in Aberdeen on 19 April 2012. This BNTA initiative quickly gained the full support from the Society of British Neurological Surgeons and the UK Neurosurgical Research Network. The inaugural meeting of the British Neurosurgical Trainee Research Collaborative took place at the Royal College of Surgeons of England, London, on 19 October 2012. The purpose of this report is both to record progress to date and to promote this concept.

Pneumorrhachis with pneumocranium: an unusual complication of intra-abdominal sepsis.

We present this unusual case of a 60-year-old gentleman who presented with meningism and reduced conscious level. Imaging demonstrated a perforated sigmoid colon with retroperitoneal air associated with pneumorrhachis and pneumocranium. He required a Hartmann's procedure and broad spectrum intra-thecal antibiotics which led to resolution of the pneumorrhachis and pneumocranium.

Internal Carotid Artery Test Balloon Occlusion Using Single Photon Emission Computed Tomography Scan in the Management of Complex Cerebral Aneurysms and Skull Base Tumors: A 20-Year Review.

BACKGROUND: Test balloon occlusion (TBO) is important in the management of complex cerebrovascular and skull base lesions when permanent occlusion (PO) of a parent artery may be indicated. Several adjuncts may be used to increase the sensitivity of TBO to predict whether PO will be tolerated. This is an observational study to evaluate the utility of internal carotid artery (ICA) TBO using single photon emission computed tomography (SPECT) scan in the management of complex vascular pathology and skull base tumors. METHODS: All TBO procedures performed over a 20-year period were analyzed. Clinical assessment and angiographic collateral flow were combined with semi-quantitative cerebral blood flow analysis using 99mTc hexamethylpropylene-amine oxime SPECT scan during ICA TBO. Evaluation of collateral circulation after TBO, and the complications of TBO and the safety of PO after successful TBO were evaluated. RESULTS: Eighty-three patients underwent TBO without complication. Of 45 patients with satisfactory TBO, 28 proceeded to PO. Three patients developed transient ischemic symptoms thought to be embolic in origin. Thirty-eight patients had unsatisfactory TBO, of whom 15 required PO accompanied by a bypass procedure. Forty patients in the series did not undergo permanent vessel occlusion. CONCLUSIONS: SPECT scan-enhanced TBO is an important component of the management of complex vascular pathology and skull base tumors, permitting safe PO of the parent vessel and definitive treatment of the main pathology.

Giant Juvenile Ectopic Schwannoma of the Temporal Bone.

BACKGROUND: Ectopic intracranial schwannomas (those that do not arise from a named cranial nerve) are rare. They account for <2% of surgically resected central nervous system schwannomas. CASE DESCRIPTION: We report the case of a 14-year-old boy presenting with a left conductive hearing loss and temporal bone deformity. No facial or cranial nerve deficits were present. Cross-sectional imaging demonstrated a large expansile extra-axial temporal bone mass, extending into and distorting the middle cranial fossa. At surgical resection the tumor was functionally and anatomically distinct from the facial nerve or any other identifiable neural structure within the middle ear or temporal bone. Histology confirmed a World Health Organization grade 1 schwannoma. CONCLUSIONS: This is the first reported case of a giant juvenile ectopic schwannoma within the temporal bone.

Clipping aneurysms improves outcomes for patients undergoing coiling.

OBJECTIVEMost intracranial aneurysms are now treated by endovascular rather than by microsurgical procedures. There is evidence to demonstrate superior outcomes for patients with aneurysmal subarachnoid hemorrhage (aSAH) treated by endovascular techniques. However, some cases continue to require microsurgery. The authors have examined the relationship between the number of aneurysms treated by microsurgery and outcome for patients undergoing treatment for aSAH at neurosurgical centers in England.METHODSThe Neurosurgical National Audit Programme (NNAP) database was used to identify aSAH cases and to provide associated 30-day mortality rates for each of the 24 neurosurgical centers in England. Data were compared for association by regression analysis using the Pearson product-moment correlation coefficient and any associations were tested for statistical significance using the one-way ANOVA test. The NNAP data were validated utilizing a second, independent registry: the British Neurovascular Group's (BNVG) National Subarachnoid Haemorrhage Database.RESULTSIncreasing numbers of microsurgical cases in a center are associated with lower 30-day mortality rates for all patients treated for aSAH, irrespective of treatment modality (Pearson r = 0.42, p = 0.04), and for patients treated for aSAH by endovascular procedures (Pearson r = 0.42, p = 0.04). The correlations are stronger if all (elective and acute) microsurgical cases are compared with outcome. The BNVG data validated the NNAP data set for patients with aSAH.CONCLUSIONSThere is a statistically significant association between local microsurgical activity and center outcomes for patients with aSAH, even for patients treated endovascularly. The authors postulate that the number of microsurgical cases performed may be a surrogate indicator of closer neurosurgical involvement in the overall management of neurovascular patients and of optimal case selection.

Anterior transvertebral transposition of the spinal cord for the relief of paraplegia associated with congenital cervicothoracic kyphoscoliosis. Technical note.

The authors describe a technique for the relief of spinal cord compression associated with congenital kyphoscoliosis. A 13-year-old girl with congenital cervicothoracic kyphoscoliosis had undergone in situ fusion; spastic paraparesis and bladder disturbance developed postoperatively. Spinal cord detethering and posterolateral decompression temporarily arrested the neurological deterioration; however, the patient's condition then progressed to paraplegia with a partial sensory level at L-1. Imaging demonstrated persisting cord compression at the apex of the kyphotic curve. Transvertebral transposition of the spinal cord was performed using sagittal vertebrotomies, preserving the lateral aspects of the vertebral bodies, pedicles, and fusion mass. By 2 years postoperatively she had recovered normal sensation and good bladder function and was walking unaided. Transposition of the spinal cord may be used to relieve spinal cord compression associated with complex spinal deformities.

Is long-term follow-up of adequately coil-occluded ruptured cerebral aneurysms always necessary? A single-center study of recurrences after endovascular treatment.

PURPOSE: Aneurysm recurrence following coil occlusion is well recognized. However, there is controversy as to how long these patients should be followed up after coiling to detect reopening. We aimed to identify the rate of late reopening and the risk factors for reopening in a large single-center cohort of ruptured aneurysms that appeared adequately occluded at 6 months. We also aimed to assess whether rates of recurrence have altered over time with improving coil and angiographic technology. METHODS: Patients treated between 1996 and 2010 were assessed and those with both 6-month initial and subsequent long-term follow-up with either digital subtraction angiography or magnetic resonance angiography were included. Aneurysms were stratified by features such as size, neck width, anatomical location and time of treatment: 1996-2005 (cohort 1) and 2006-2010 (cohort 2). ORs for risk of recurrence were calculated for aneurysm features and rates of recurrence in each cohort were compared using a χ(2) test. RESULTS: 437 patients with 458 adequately occluded aneurysms at 6 months had mean long-term follow-up of 31 months; 57 (12.4%) were large (≥ 10 mm) and 104 (22.7%) were wide-necked (>4 mm). Nine aneurysms (2%) showed significant late anatomical deterioration whereby retreatment was considered or undertaken. The risk was greater for large aneurysms (≥ 10 mm) (OR 15.61, 95% CI 3.79 to 64.33, p=0.0001) or wide-necked aneurysms (>4 mm) (OR 12.70, 95% CI 2.60 to 62.13, p=0.0017). The frequency of significant late anatomical deterioration and retreatment was also less common in those treated in cohort 2 (p<0.05). No completely occluded aneurysm at 6 months demonstrated significant late recurrence. CONCLUSIONS: Most aneurysms adequately occluded at 6 months did not show evidence of late recurrence. Large and wide-neck aneurysms are, however, at greater risk of later recurrence.

The new Frenchay artificial cervical joint: results from a two-year pilot study.

STUDY DESIGN: A clinical prospective observational cohort study of 15 patients undergoing cervical intervertebral disc replacement. OBJECTIVE: To assess the safety, clinical stability, and capacity of a newly designed cervical intervertebral disc replacement for preserving motion in the cervical spine of patients with degenerative disc disease. SUMMARY OF BACKGROUND DATA: Anterior cervical discectomy and interbody fusion results in loss of motion segments and there is evidence of accelerated degenerative changes occurring at adjacent levels. Intervertebral disc replacement may be a valid alternative to fusion. There is a need for cervical disc replacement to be evaluated in prospective studies before it can be adopted as an acceptable surgical technique. METHODS: The study enrolled 15 patients with cervical radiculopathy or myelopathy and radiologically confirmed cervical disc herniation or posterior vertebral body osteophytes. Eligibility for the study required that patients have either a previous adjacent-level surgical or congenital spinal fusion or radiologic evidence of adjacent-level degenerative disc disease. After decompressive surgery via an anterior approach, all 15 patients received the artificial joint. Follow-up visits were at set intervals and included clinical examination, radiologic assessment, and evaluation by patient-completed questionnaires. RESULTS: In all cases, the artificial joint maintained motion at the operative levels while reestablishing intervertebral height. The procedure was considered safe for experienced spine surgeons to perform, and the device was stable, with no dislocation of components or backing out of screws. Two screws broke, but without any consequence. Improvements in assessment scores were noted. CONCLUSIONS: Cervical intervertebral motion can be maintained with the new device, which is clinically stable. Meticulous attention must be paid to the surgical technique to maximize the chances of a good result. The pilot study was successful, although it has yet to be determined what conditions will benefit most from this technology.