Thoracic Intradural Extramedullary Ependymoma with Anaplastic Transformation: Case Report and Discussion.

BACKGROUND: Intradural extramedullary spinal ependymomas arising from outside the region of the conus medullaris are rare clinical entities, and anaplastic transformation of these lesions is even more exceptional. CASE DESCRIPTION: We report on a case of an intradural extramedullary T5-T6 ependymoma that underwent gross total resection. Histologic analysis of the initial tumor revealed a World Health Organization grade 2 ependymoma. Two years after initial surgical resection, there was radiologic recurrence and a re-do resection was performed with subsequent spinal stabilization. Histologic analysis of the recurrent tumor revealed a World Health Organization grade 3 ependymoma. After surgery the patient received radiotherapy, and he remains disease free at 2 years following his second surgery. In addition, we employed carbon fiber screws and rods for stabilization in his second operation to reduce artefact on follow-up imaging. CONCLUSIONS: We advocate that primary spinal ependymomas should be within the differential of intradural extramedullary lesions arising outside the region of the conus medullaris.

Endovascular treatment of wide-necked intracranial aneurysms using the novel Contour Neurovascular System: a single-center safety and feasibility study.

BACKGROUND AND PURPOSE: Wide-necked bifurcation aneurysms pose a significant challenge to the treating clinician. The Contour Neurovascular System embolization device is a novel tool for the treatment of such intracranial aneurysms. We report on our experience with this device. METHODS: Prospective clinical and radiological data were collected for all patients treated with the Contour device at our center. All our patients were treated on an elective basis. RESULTS: We have treated 11 patients successfully with the Contour device to date. All patients were women with a mean (SD) age of 65.0 (6.4) years. In total, four basilar tip, two internal carotid artery, three middle cerebral artery, one anterior communicating artery, and one superior cerebellar artery aneurysms were treated. At 1-year follow-up, complete occlusion (Raymond Class 1) was seen in 55.56% (5/9) of cases, with 44.44% (4/9) having small neck remnants (Raymond Class 2). One patient declined 1-year catheter angiography and another had no further follow-up due to an unrelated medical condition. For six patients, 2-year radiological follow-up is available and shows stability. At 6 weeks, nine of the 11 patients had a modifed Rankin Scale score of 0, with two patients scoring 1 for headaches. Two patients had thromboembolic events, but there were no complications leading to permanent neurological disability or death. We additionally had three patients where the Contour device was attempted but was unable to be successfully used. CONCLUSION: Initial results are promising although larger case numbers and longer follow-up are necessary to draw further conclusions on the utility and risk profile of this new device.

Minimally Invasive Versus Open Surgery for Lumbar Synovial Cysts.

OBJECTIVE: Lumbar synovial cysts are relatively infrequent. Historically, these benign lesions have been treated with open excision, sometimes associated with fusion. The aim of this study is to compare minimally invasive surgery (MIS) with open surgery (OS) for the treatment of lumbar synovial cysts. METHODS: This was a retrospective review of patients who underwent minimally invasive or open excision of lumbar synovial cysts. Clinical outcomes, recurrence rate, and surgical complications were compared in the 2 groups. RESULTS: A total of 37 cases were identified, of which 24 were MIS and 13 were OS. MIS was significantly more effective in improving leg pain and radicular symptoms. There was no statistical difference between the 2 groups with regard to improvements of back pain and neurogenic claudication. Postoperative length of hospital stay and postoperative pain were significantly reduced in the MIS group (15 hours vs. 24 hours and 0.9/10 vs. 4.7/10 respectively, P < 0.5). There were no statistical differences in duration of surgery, intra- or postoperative complications, no recurrence of cyst in either of the 2 groups, and no patients required fusion at a later stage. CONCLUSIONS: In this study, MIS for the treatment of lumbar synovial cysts appears to be more effective than OS in relieving radicular symptoms. Furthermore, MIS is better tolerated by patients and is potentially cost saving for the Health Service, due to the reduction in hospital stay and the reduced requirement for painkillers.

Improving handover of patient care using a new weekend proforma with a focus on ceiling of care.

Patient handover is paramount for effective patient care and is often poorly documented or incomplete. North Bristol NHS Trust weekend handover proformas identify medical patients requiring weekend review. Many patients seen during on-call shifts are not handed over. Our aim was to develop Friday ward round proforma sheets for medical patients, to encourage clear documentation of management plans in order to improve handover of important information, particularly ceiling of care decisions. Questionnaires were completed by F1 doctors regarding current handover systems. Baseline data collected by on-call F1s included time of understanding a patient's ceiling of care decision, and difficulty of comprehension of medical notes. Repeat data were collected with novel proformas in situ. Multiple cycles were performed to refine the sheets and target problems arising in their use. Ninety-three percent of F1s wanted improved patient handover, with ceiling of care (87%) and management plans (73%) being the most difficult areas to understand. Time taken to ascertain ceiling of care decisions improved with the introduction of Friday handover proformas; mean time 153 seconds before and 5 seconds after. Clarity and documentation of management plans improved, with 50% improvement in ease of understanding medical notes. Results demonstrate that introducing Friday ward round proformas for medical patients improves communication between weekday and on-call teams, highlights current escalation of care plans, and leads to faster decision-making. Future plans include the introduction of a short educational session to the new F1 doctors and continued progress with introduction into hospital stationary.