Lumbar microdiscectomy and post-operative activity restrictions: a protocol for a single blinded randomised controlled trial.

BACKGROUND: Lumbar microdiscectomy is the most commonly performed spinal surgery procedure, with over 300,000 cases performed annually in the United States alone. Traditionally, patients were advised to restrict post-operative activity as this was believed to reduce the risk of disc reherniation and progressive instability. However, this practice would often delay patients return to work. In contemporary practice many surgeons do not restrict patient post-operative activity due to the perception this practice is unnecessary. We describe a randomised controlled trial to assess the impact of activity restrictions on clinical outcome following lumbar discectomy. METHODS/DESIGN: The lumbar microdiscectomy and post-operative activity restriction trial is a multi-centre, randomised, controlled single blinded trial. Two hundred ten patients due to undergo single level lumbar microdiscectomy without a history of previous spine surgery, infection or fracture are randomised to be advised either restricted or unrestricted activity for a period of 30 days following lumbar microdiscectomy. Actual adherence with trial allocation will be monitored bioelectronically via a wearable device. Outcome assessment at follow up will occur at 1, 3, 6 and 12 months. The primary outcome will be a composite endpoint comprising changes in Visual Analogue Scale (Leg and Back), Oswestry Disability Index and the absence of intervertebral disc reherniation or secondary intervention. DISCUSSION: This randomised controlled trial will directly compare post-operative protocols of activity restrictions and no restrictions following lumbar discectomy with adherence monitored bioelectronically. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12616001360404 (retrospectively registered 30/09/2016).

Characteristics and outcomes of patients with drug overdose requiring admission to Intensive Care Unit.

OBJECTIVE: Approximately 20% of patients admitted to hospital with drug overdose will require intensive care unit (ICU) admission. An understanding of the characteristics of these patients may assist with their management and identify those patients at risk of multiple hospital presentations due to drug overdose. Our aim was to examine the characteristics of patients admitted to ICU following drug overdoses and identify the predictors of multiple hospital presentations due to drug overdose. METHODS: Patients admitted to a metropolitan ICU over a three-year period following drug overdoses were identified using ICU patient databases, and their medical records. RESULTS: There were 254 admissions due to drug overdoses. The majority of overdoses were intentional (82.7%) and included multiple agents (68.1%). Two-thirds of patients had psychiatric diagnosis, and 54% had documented history of substance use disorders. In-hospital mortality was 2.8%. Over half of patients admitted had documented history of prior hospital presentation due to overdoses. Personality disorder and schizophrenia were independent predictors of multiple hospital presentations due to overdoses. CONCLUSION: Personality disorders or schizophrenia were independent predictors of patients with multiple overdose presentations. Preventative strategies focusing on these patients may reduce the incidence of their hospital presentations and ICU admissions.

Patient Wellbeing and Quality of Life After Nasoseptal Flap Closure for Endoscopic Skull Base Reconstruction.

BACKGROUND: The endoscopic endonasal approach to the skull base avoids some of the surgical morbidity associated with a transcranial approach, however it often results in large skull-base defects requiring secure closure. The nasoseptal flap has become the preferred method for closure of such defects but may be associated with its own morbidity. METHODS: A consecutive cohort of patients with skull base pathology with prospectively collected quality of life data using ASBQ and SNOT was analysed. They were grouped into those who received a nasoseptal flap and those who did not. Pre-operative total ASBQ and SNOT scores, and their individual components, were compared to data collected at days 1, 3, and 7; six-weeks; and 3, 6, and 12-months postoperatively. RESULTS: Of 158 patients available for analysis, nasoseptal flaps were performed in 52 (33%). Average follow-up (±standard deviation) was 8.1 ± 3.9 months for ASBQ data and 8.2 ± 3.8 months for SNOT data. In the first post-operative week, nasal symptoms and otalgia were worse in the flap group. At six-weeks and beyond, there was no difference between groups in overall ASBQ or SNOT scores, or in the rate of clinically-significant improvement in SNOT or ASBQ scores or their components. CONCLUSION: In the largest cohort of patients to date, the use of a nasoseptal flap is associated with nasal symptoms and otalgia in the acute post-operative period, but is not associated with any long-term detriment to quality of life after endoscopic skull base surgery.

Dynamic Posture-Related Preoperative Pain as a Single Clinical Criterion in Patient Selection for Extreme Lateral Interbody Fusion Without Direct Decompression.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: Evidence on predicting the success of indirect decompression via extreme lateral interbody fusion (XLIF) is scarce. The authors investigated if patients who could achieve a pain-free position preoperatively would derive clinical benefit from XLIF without direct decompression. METHODS: Data from 50 consecutive patients who underwent XLIF with and without direct decompression by a single surgeon from January 2014 to August 2017 was collected. Primary outcome is the rate of failure of patients who underwent XLIF without direct decompression, characterized by persistence of pain postoperatively that required reoperations within 6 months postoperatively. Secondary outcomes are clinical outcomes and patient-reported quality of life outcome data, including visual analogue scale for leg (VASL) and back (VASB) pain, Oswetry Disability Index (ODI), and Physical Component Score (PCS) and Mental Component Score (MCS) of SF-12, for up to 2 years postoperatively. RESULTS: One patient with preoperative dynamic posture-related pain who underwent XLIF without direct decompression subsequently had a reoperation due to persisting pain. Statistically significant improvement was achieved across all patient reported outcomes (P < .05): improvement of 68% for VASL, 61% for VASB, 50% for ODI, 33% for PCS, and 11% for MCS of SF-12 at last follow-up. Six patients had thigh symptoms that resolved. CONCLUSION: The simple clinical criterion based on postural pain status preoperatively may help clinicians in patient selection for indirect decompression of XLIF without the need for direct decompression. Further studies with larger cohorts are warranted to establish the validity of the algorithm.

Perioperative care for lumbar microdiscectomy: a survey of Australasian neurosurgeons.

BACKGROUND: Lumbar microdiscectomy is the most commonly performed spine surgery procedure. Over time it has evolved to a minimally invasive procedure. Traditionally patients were advised to restrict activity following lumbar spine surgery. However, post-operative instructions are heterogeneous. The purpose of this report is to assess, by survey, the perioperative care practices of Australasian neurosurgeons in the minimally invasive era. METHODS: A survey was conducted by email invitation sent to all full members of the Neurosurgical Society of Australasia (NSA). This consisted of 11 multi-choice questions relating to operative indications, technique, and post-operative instructions for lumbar microdiscectomy answered by an electronically distributed anonymized online survey. RESULTS: The survey was sent to all Australasian Neurosurgeons. In total, 68 complete responses were received (28.9%). Most surgeons reported they would consider a period of either 4 to 8 weeks (42.7%) or 8 to 12 weeks (32.4%) as the minimum duration of radicular pain adequate to offer surgery. Unilateral muscle dissection with unilateral discectomy was practiced by 76.5%. Operative microscopy was the most commonly employed method of magnification (76.5%). The majority (55.9%) always refer patients to undergo inpatient physiotherapy. Sitting restrictions were advised by 38.3%. Lifting restrictions were advised by 83.8%. CONCLUSIONS: Australasian neurosurgical lumbar microdiscectomy perioperative care practices are generally consistent with international practices and demonstrate a similar degree of heterogeneity. Recommendation of post-operative activity restrictions by Australasian neurosurgeons is still common. This suggests a role for the investigation of the necessity of such restrictions in the era of minimally invasive spine surgery.

Interobserver Reliability of Spinal Adverse Events Severity System - Neuro (SAVES-N): A Prospective Adverse Event Reporting System for Neurosurgical Cases.

BACKGROUND: The reporting of adverse events (AEs) in neurosurgery uses inconsistent definitions and subjective grading systems. A standardized system for recording and describing AEs would allow valid comparisons to be drawn between different institutions, using different technologies, at different times. The Spinal Adverse Events Severity System - Neuro (SAVES-N) system is a modification of the well-validated SAVES-V2 system that encompasses complications from both cranial and spinal surgery. The objective of this study was to assess the interobserver reliability of SAVES-N in spinal and cranial neurosurgery. METHODS: Ten vignettes, including cranial and spinal neurosurgical cases, were assessed by groups of consultant neurosurgeons (n = 5) and neurosurgical registrars (n = 5) using the SAVES-N system. Interobserver reliability for the presence of AEs, the type of AE, and the SAVES severity grade of the AE were calculated using Gwet's AC2 and Fleiss' kappa and were interpreted using the thresholds described by Landis and Koch. RESULTS: Neurosurgeons had almost-perfect agreement (Gwet AC2 = 0.93), whereas registrars had substantial agreement (Gwet's AC2 = 0.74) in determining the presence or absence of AEs. Both neurosurgeons (Fleiss' kappa = 0.78) and registrars (Fleiss' kappa = 0.70) demonstrated substantial agreement within their groups as to the type of AE. Similarly, neurosurgeons (Gwet's AC2 = 0.94) and registrars (Gwet's AC2 = 0.81) both graded the severity of the AE with almost perfect agreement. CONCLUSIONS: The results of this study demonstrate that the scope of the well-validated SAVES-V2 system may be broadened to cranial neurosurgical cases by SAVES-N with substantial to almost-perfect interobserver reliability.

Pre-operative embolization of hypervascular spinal metastasis using percutaneous direct intra-tumoural injection with Onyx under local anesthesia.

Intra-operative blood loss remains a major cause of perioperative morbidity for patients with hypervascular spinal metastasis undergoing surgery. Pre-operative embolization is used to reduce intraoperative blood loss and operative time. This is commonly performed under general anesthesia via a trans-arterial approach, which carries a risk of spinal stroke. We propose an alternative technique for embolization of hypervascular metastases using the Onyx embolic agent via a percutaneous direct intra-tumoural injection under local anesthesia and sedation to reduce embolization risks and procedure time, as well as operative blood loss and operative time. A 74-year-old man presented with thoracic myelopathy with back and radicular pain on background of metastatic renal cell carcinoma. Magnetic resonance imaging (MRI) revealed a 3cm mass centered on the right lamina of T10 with extension into the spinal canal. The patient underwent a percutaneous imaging-guided direct intra-tumoural contrast parenchymogram, and Onyx embolization via a single needle. Initial needle placement and tumour assessment was completed in 30min; embolization time was 15min. Complete devascularization was achieved with no complications. Surgical resection was performed with lower than expected operative blood loss (150ml) and operative time (90min). His pre-operative symptoms improved, and he was discharged home the following day. At 6-month follow-up there was no recurrence of his symptoms. Further evaluation of direct percutaneous intra-tumoural Onyx embolization for hypervascular spinal tumours is warranted.

Ovine Lumbar Intervertebral Disc Degeneration Model Utilizing a Lateral Retroperitoneal Drill Bit Injury.

Intervertebral disc degeneration is a significant contributor to the development of back pain and the leading cause of disability worldwide. Numerous animal models of intervertebral disc degeneration have been developed. The ideal animal model should closely mimic the human intervertebral disc with regard to morphology, biomechanical properties and the absence of notochordal cells. The sheep lumbar intervertebral disc model fulfils these criteria. We present an ovine model of intervertebral disc degeneration utilizing a drill bit injury through a lateral retroperitoneal approach. The lateral approach significantly reduces the incision and potential morbidity associated with the traditional anterior approach to the ovine spine. Utilization of a drill-bit method of injury affords the ability to produce a consistent and reproducible injury, of precise dimensions, that initiates a consistent degree of intervertebral disc degeneration. The focal nature of the annular and nucleus pulposus defect more closely mimics the clinical condition of focal intervertebral disc herniation. Sheep recover rapidly following this procedure and are typically mobile and eating within the hour. Intervertebral disc degeneration ensues and sheep undergo necropsy and subsequent analysis at periods from eight weeks. We believe that the drill bit injury model of intervertebral disc degeneration offers advantages over more conventional annular injury models.

Migraine: Does aura require investigation?

OBJECTIVES: Migraine is a debilitating condition that affects approximately 15% of the general population. It represents a huge proportion of presentations to the emergency department and a significant number of neurology admissions. Patients are often investigated with imaging. This is particularly the case with migraine with aura (MA). The yield of imaging is however low. There is limited information on Australian hospital presentations and utility of imaging. We aimed to analyse the demographics of migraine presentations to our hospital and the yield of imaging in our centre to help guide future approaches to these patients. PATIENTS AND METHODS: We retrospectively looked at medical records of patients presenting to the western health from January 2012 to June 2013. Patients were classified as either having migraine with aura or without. Baseline demographics, cardiovascular risk factors and imaging studies (CT brain, MRI brain and carotid Doppler studies) in each group were evaluated. Patients found to have white matter hyperintensities on MRI were further evaluated. RESULTS: We found patients with aura were more likely to have hypercholesterolemia (12% vs 7%, p=0.05). Patients with aura were more likely to be evaluated with imaging (CT brain (70% vs 41% p<0.0001) and MRI brain (44% vs 17% p<0.0001)). The patients investigated with imaging had no clinically significant findings. 21% of patients with aura were investigated with carotid Doppler studies. Only 1 patient had an abnormal result. Patients with white matter hyperintensities were older (51 vs 39 years; p<0.0001) and were more likely to have Hypertension (29% vs 14% p=0.019), Hypercholesterolemia (29% vs 11% p=0.003) and T2DM (16% vs 4% p=0.011). CONCLUSION: We found patients with MA and without aura to be largely similar. We also found imaging in either group to be of almost no clinical value.

Co-occurrence of Pituitary Adenoma with Suprasellar and Olfactory Groove Meningiomas.

INTRODUCTION: The co-existence of pituitary adenoma and meningioma is extremely rare. It is even rarer in patients with no previous known risk factors for either tumour. Here, we present a case of synchronous non-functioning pituitary adenoma with suprasellar and olfactory groove meningiomas in a patient without previous irradiation. METHODS: The tumours were diagnosed on MRI in the 65-year-old patient who presented with patchy visual deficits. The decision was made to undergo surgery for resection of the suprasellar meningioma and the pituitary adenoma, leaving the small olfactory groove meningioma intact. Extended endoscopic transsphenoidal surgery was performed. RESULTS: Macroscopic clearance was achieved for pituitary macroadenoma and suprasellar meningioma. Postoperatively, visual field tsting and pituitary axis hormonal levels were normal. The pituitary macroadenoma was confirmed to be a non-functioning pituitary adenoma. The meningioma was diagnosed to be of WHO grade 1. CONCLUSION: The rationale for choosing such management option, including its risks and benefits in this challenging patient is discussed.