Effect of perioperative inefficiency on neurosurgical theatre efficacy: A 15-year analysis.

INTRODUCTION: Effective utilisation of operating theatre time is an important issue in neurosurgery. There is a commonly held belief amongst surgeons that throughput of theatre is decreasing secondary to worsening perioperative delays. The aim of this paper is to explore some of the factors that lead to delays in the perioperative period by determining whether there has been a trend in the increasing length of case time over a fifteen-year period. MATERIALS AND METHODS: Case notes of all elective patients who consented for surgery between January 1998 and the end of 2012 were reviewed. Only patients who underwent elective surgery were included. Variables recorded included transit time from the ward to theatre, anaesthetic time, surgical time and time spent in recovery. These were compared over the 15-year period to look for apparent trends. RESULTS: The total number of patients who consented for elective surgery at our institution between January 1998 and December 2012 was 6760. The mean anaesthetic time considering all operations performed was 43 mins each over the 15-year period. Anaesthetic time was deemed to be trending upwards from 1998 where the mean time was 27 -60 mins in December 2012, thus reflecting an increase of 33 mins. The mean surgical times over the 15-year period were 131 mins. However in 1998, mean surgical time was 127 mins compared with 133 mins in 2012. DISCUSSION AND CONCLUSION: For the operations analysed, anaesthetic time seems to be increasing and has effectively doubled over a 15-year period. Surgical time and non-clinical time are shown to be virtually constant. This delays the overall theatre list and increases the cancellation rate. For compensating this, changes need to be made when allocating resources to both elective and emergency theatres. Staff recruitment needs to be assessed and internal audits need to be conducted within institutions to analyse ways to optimise the throughput of an operation theatre. If these principles are not adhered to, it will have a negative impact as our populations, and hence our case loads increase to instrumental levels. This will in turn have a negative impact on health workers and patients alike.

Redefining the cast index: the optimum technique to reduce redisplacement in pediatric distal forearm fractures.

BACKGROUND: The aim of this study was to identify the optimal cast index (CI) level that reduces the risk of fracture redisplacement. The CI is the ratio of sagittal to coronal width from the inside edges of the cast at the fracture site. Previous studies have used 0.7 as the standard. METHODS: Case records and radiographs of 1001 children who underwent a manipulation under anesthesia for a displaced fracture of the distal forearm were studied. Redisplacement was defined as > 15 degrees of angulation and/or > 80% of translational displacement on check radiographs at 2 weeks. Angulation (degrees) and translational displacement (%) were measured on the initial and check radiographs. The CI was measured on the check radiographs. The CI has previously been validated in an experimental study. RESULTS: The adequacy of reduction after manipulation was determined by translation and angulation of the radius and ulna in anteroposterior and lateral plain film radiographs. From the 1001 patients who qualified for the study, fracture redisplacement was seen in 107 (10.6%) cases at the 2-week follow-up. A total of 752 (75%) patients had CIs of ≤ 0.8, whereas 249 (25%) had casting indices of ≥ 0.81. In patients with CIs of ≤ 0.8, the displacement rate was only 5.58%. However, in patients with CIs of ≥ 0.81, the displacement rate was 26%. A high CI was the sole factor that was significantly higher in the redisplacement group. No statistically significant difference was seen for age, sex, or surgeon seniority. Statistical differences were not noted in initial angular deformity or initial displacement. DISCUSSION: The CI is a simple reliable radiographic measurement to predict the redisplacement of forearm fractures in children. A plaster with a CI of > 0.81 is prone to redisplacement. High CIs are associated with redisplacement of fractures and should be avoided when molding casts in distal forearm fractures. LEVELS OF EVIDENCE: Level III--retrospective comparative study.

Thoracic disc herniation: An unusual complication after prone positioning in spinal surgery.

Neurological complications of the prone position have been well documented. Post-operative paraplegia and neurological deterioration unrelated to the site of surgery after proning in spinal surgery is a rare but potentially devastating complication. We describe the case of a 47 year old female who underwent an L4/5 discectomy and posterior instrumented fusion. A few hours after surgery she developed bilateral lower limb weakness with a T11 sensory level. Post-operative MRI revealed an acute disc herniation at the T11/12 level with associated spinal cord compression. This was not present on the pre-operative imaging. A subsequent T11/12 discectomy and instrumented fusion was performed and the patient's motor and sensory function returned to normal.

Optimising neurosurgical outpatient care: a paradigm shift?

INTRODUCTION: The Wellington Regional Hospital (WRH) neurosurgical service has noted a substantial increase in patient volumes over the last decade, with referrals to the neurosurgical outpatient clinic appearing to have increased even more substantially. AIM: To quantify the increase in referrals to the WRH neurosurgical outpatient service and to determine whether this has translated into an increase in the number of neurosurgical procedures performed. METHODS: All referrals to the WRH neurosurgical department from the lower North and upper South Islands of New Zealand spanning 10 years were collected. Key outcome data were the number of interventions performed. In addition to GP referrals, all specialist referrals to the WRH neurosurgical outpatient service were also analysed as a comparison. RESULTS: In total, 19 201 patients were referred to the WRH neurosurgical service over the 10 years of the study. Within this timeframe, 7105 patients were referred by GPs and 12 096 were referred by specialist teams. Only 348 patients (4.9%) referred by GPs underwent some form of therapeutic intervention, compared to 3489 patients (28.8%) referred by specialist teams. DISCUSSION: Our data shows that specialist referrals result in a proportionally greater number of therapeutic interventions than GP referrals. This is in part due to the wider array of diagnostic tests available to specialists compared to GPs. The development of relevant guidelines for primary care referral to a neurosurgical service appears warranted and could facilitate initiation of appropriate investigations in primary care.

Staged Surgical Management in the Treatment of Primary Epidural Hydatidosis of the Spine: A Case Series and Review.

Hydatid disease is a parasitic infection linked to the Echinococcus granulosus tapeworm. Infected cysts can present anywhere in the human body, but the liver is the most frequently involved organ, followed by the lungs. The prognosis is generally poor and may be comparable to that of neoplastic disease. Primary spinal hydatidosis accounts for less than 1% of all cases and virtually all these cases have extradural involvement. We describe a case review consisting of two patients who presented over a three week period with primary spinal extradural hydatidosis in the Western Cape region of South Africa. Both patients presented with lower limb paraparesis and were treated aggressively with two-stage surgical procedures, resulting in a dramatic improvement in their neurological status.

Thoracic Vertebral Actinomycosis Secondary to a Pulmonary Origin.

Actinomycosis is a chronic infection caused by a gram-positive anaerobic bacteria from the species Actinomycesand causes a chronic colliquative inflammatory reaction known as actinomycotic granuloma, which is characterized macroscopically by suppuration, sinus tract formation, and purulent discharge containing yellowish sulfur granules. It can invade any part of the human body. This is a case report of a 40-year-old male patient known to the cardiothoracic team due to a sarcoma of the left lung. He presented with progressive thoracic myelopathy. Initially, the diagnosis was thought to be a spinal metastasis from the lung lesion. Further investigation revealed a thoracic actinomycosis with epidural granuloma tissue causing a spinal compression.

Infection rates in open fractures of the tibia: is the 6-hour rule fact or fiction?

Aims. Emergency debridement has long been the standard of care for open fractures of the tibia as infection is an important complication. The timing of operative debridement can be debated. We review open fractures of the tibia and compare infection rates in those that were operated on within and after 6-hours. Method. 103 consecutive open fractures of the tibia were reviewed. The data was analysed retrospectively with regard to severity of fracture and incidence of infection. Infection rates over a three-month period were compared between the two groups. Results. 12 (11.6%) patients developed an infection within the first 3 months of injury. 7 of which were taken to theatre within 6-hours, and 5 after 6-hours. No significant differences were found between these two groups. Conclusion. There is no significant difference in timing of surgery. Initial basic interventions may play more of a role in limiting the risk of infection.