Real-time symptom reporting during elective intracranial pressure monitoring using an interactive handset.

BACKGROUND: Determining whether symptoms are related to abnormal intracranial pressure (ICP) may prove challenging in some cases. We evaluated the utility of an in-house designed interactive handset which allows the real-time recording of symptoms during ICP monitoring. METHODS: Adult patients undergoing elective continuous ICP monitoring using the device to investigate symptoms between November 2013 and June 2015 were included in this retrospective observational cohort study. The device allowed the following symptoms to be recorded: mild, moderate and severe headache, visual disturbance and nausea. The corresponding ICP and ICP trend were also recorded. RESULTS: Twenty seven patients underwent 29 episodes of ICP monitoring, reporting 383 symptoms (mild 18%, moderate 39%, severe 20% headaches, visual disturbance 15% and nausea 8%) over a median period of 48 hours (IQR 12). The median number of symptoms reported during each episode was 11 (IQR 11). The mean ICP associated with a symptom episode was 7mmHg (Range -10 to 45). Mild, moderate and severe headache complaints were associated with mean ICPs of 5 (-9 to 26), 6 (-10 to 35) and 14 (-10 to 45) mmHg respectively. The majority of complaints (68%) were reported during instances of normal ICP. Following monitoring, non-operative management was employed on 21 occasions (72%) including valve pressure adjustment on two occasions whilst surgical intervention was required on eight occasions (28%; two surgeries for under-drainage and six for over-drainage). CONCLUSIONS: The device allows the clinician to accurately match a patient's symptoms with ICP to facilitate management decisions. In most instances, symptoms did not closely correlate with an abnormal ICP. By automating and standardising the collection of symptom data, this device may serve as an efficient adjunct when investigating patients with complex hydrocephalus.

Counting the cost of negligence in neurosurgery: Lessons to be learned from 10 years of claims in the NHS.

INTRODUCTION: Despite substantial progress in modernising neurosurgery, the specialty still tops the list of medico-legal claims. Understanding the factors associated with negligence claims is vital if we are to identify areas of underperformance and subsequently improve patient safety. Here we provide data on trends in neurosurgical negligence claims over a 10-year period in England. METHODS: We used data provided by the National Health Service Litigation Authority to analyse negligence claims related to neurosurgery from the financial years 2002/2003 to 2011/2012. Using the abstracts provided, we extracted information pertaining to the underlying pathology, injury severity, nature of misadventure and claim value. RESULTS: Over the 10-year period, the annual number of claims increased significantly. In total, there were 794 negligence claims (range 50-117/year); of the 613 closed cases, 405 (66.1%) were successful. The total cost related to claims during the 10 years was £65.7 million, with a mean claim per successful case of £0.16 million (total damages, defence and claimant costs of £45.1, £6.36 and £14.3 million, respectively). Claims related to emergency cases were more costly compared to those of elective cases (£209,327 vs. £112,627; P=0.002). Spinal cases represented the most frequently litigated procedures (350; 44.1% of total), inadequate surgical performance the most common misadventure (231; 29.1%) and fatality the commonest injury implicated in claims (102; 12.8%). Negligence claims related to wrong-site surgery and cauda equina syndrome were frequently successful (26/26; 100% and 14/16; 87.5% of closed cases, respectively). CONCLUSION: In England, the number of neurosurgical negligence claims is increasing, the financial cost substantial, and the burden significant. Lessons to be learned from the study are of paramount importance to reduce future cases of negligence and improve patient care.

Routine but risky: a multi-centre analysis of the outcomes of cranioplasty in the Northeast of England.

BACKGROUND: Cranioplasty is undertaken as a routine secondary operation following craniectomy. At a time when decompressive craniectomy is being evaluated by several large trials, we aimed to evaluate the morbidity associated with cranioplasty and investigate its potential effect on outcome. METHODS: The outcomes of 166 patients undergoing cranioplasty at two centres in the United Kingdom between June 2006 and September 2011 were retrospectively analysed. Outcome measures included mortality, morbidity and functional outcome determined by the modified Rankin score (mRS) at last follow-up. A logistic regression analysis was performed to model and predict determinants related to neurological outcome following cranioplasty. RESULTS: Sixty-seven out of 166 patients (40.4 %) experienced at least one complication during a median follow-up time of 15 months (inter-quartile range 5-38 months). Thirty six patients (21.7 %) developed infection requiring antibiotics, with 27 (16.3 %) requiring removal of the cranioplasty. Nine of 25 patients (36 %) with bi-frontal defects developed an infection whereas 21 of the 153 patients (16.4 %) with a defect other than bi-frontal developed an infection (Chi square p = 0.009). Further surgery in the two groups was required in 16.4 % and 11.7, % respectively. Pseudomeningocoele (9 %), seizures (8.4 %) and poor cosmesis (7.2 %) were also commonly observed. Logistic regression analysis identified initial operation (p < 0.03), mRS at the time of cranioplasty (p < 0.0001) and complications (p < 0.04) as being predictive of neurological outcome at last follow-up. Age at the time of cranioplasty and the timing of cranioplasty were not predictive of last mRS score at follow-up. CONCLUSIONS: Cranioplasty harbours significant morbidity, a risk that appears to be higher with a bifrontal defect. The complications experienced influence subsequent functional outcome. The timing of cranioplasty, early or late, after the initial operation does not impact on the ultimate outcome. These findings should be considered when making decisions relating to craniectomy and cranioplasty.