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1.
Br J Neurosurg ; : 1-5, 2024 Aug 15.
Article in English | MEDLINE | ID: mdl-39145752

ABSTRACT

OBJECTIVES: To evaluate a technique of multi-layered CSF repair following endonasal anterior skull base surgery using medpor graft. DESIGN: Retrospective review of consecutive case series from a single centre. SUBJECTS: 68 cases of repair of CSF leaks utilising medpor identified from a larger prospectively maintained database of endonasal endoscopic procedures at our centre. METHODS: Retrospective review of a database of consecutive anterior skull base cases from 2016-2022, and further data collection from electronic hospital records. RESULTS: During follow up there were 7 cases of post-op CSF leak (10.3%). There were no radiological complications, and no cases of medpor removal or extrusion. Rates of infection were low, there were 3 (4.4%) cases of confirmed bacterial meningitis within our cohort. The mean length of stay was 4.7 days (median 3 days), with 16 cases discharged on the first post-operative day. CONCLUSIONS: Our experience of using medpor in anterior skull base reconstruction demonstrates that medpor is a readily available, easily handled, and reliable graft option with relatively low rates of infection and post-op CSF leak. Its use reduces the use of autologous graft materials and the associated donor site morbidity. Our long term follow up data further demonstrates the safety and efficacy of this technique.

2.
Br J Neurosurg ; : 1-9, 2024 Jul 12.
Article in English | MEDLINE | ID: mdl-39001642

ABSTRACT

BACKGROUND: Cervical foraminal stenosis on MRI may be assessed using the Kim, modified Kim or Siller methods. This study aimed to investigate which morphological features of cervical foraminal stenosis in patients with cervical radiculopathy correlated best with pre-operative and post-operative surgical outcome following Anterior Cervical Discectomy (ACD) or a Posterior Cervical Foraminotomy (PCF). METHODS: Pre-operative MRIs of adults with cervical radiculopathy were assessed by six raters. The following measurements were made; uncompressed nerve root diameter, maximal compressed nerve root diameter, anterior & posterior compression, length of the neuroforaminal canal where the diameter was less than the uncompressed nerve root diameter and the distance of maximum compression from the apex of the ligamentum flavum. The Kim, modified Kim and Siller grades were calculated. Neck Disability Index (NDI) was measured pre-operatively and six weeks post-operatively. The radiological measurements and grades were compared to the pre-operative and change in NDI. RESULTS: Mean NDI was higher in female (58.2) than male patients (45.6) p = 0.05. No other baseline, operative or radiological factors where significantly associated with the pre-operative NDI. The mean [±SD] post-operative NDI was 14.3 [±22.5]. This represents a change of 37.8 (p < 0.001). The pre-operative NDI correlated strongly with the post-operative NDI but no other patient, operation or radiological factors correlated significantly. Neither pre-operative NDI or change in NDI was statistically different in those treated with ACD and those treated with PCF. CONCLUSION: There was no association between pre-operative NDI and any of the radiological measurements or radiological grades. Furthermore, whilst surgery significantly improved NDI, for those patients with anterior compression, there was no difference in outcome between those treated with an ACD and those treated with a PCF. Current axial MRIs do not adequately assess the cervical nerve root foramina or predict surgical approach, 3D isotropic acquisition and DTI should be explored.

3.
Acta Neurochir (Wien) ; 162(6): 1281-1286, 2020 06.
Article in English | MEDLINE | ID: mdl-32144485

ABSTRACT

BACKGROUND: Enhanced recovery after surgery (ERAS) is a constant motivation. There is growing evidence that an endoscopic (rather than microscopic) transsphenoidal approach to pituitary tumours can play a role, facilitating faster recovery and a commensurate reduction in length of stay (LOS). Reducing LOS is beneficial to both patients and healthcare systems. We sought to assess the safety, patient feedback, and resource implications of adopting an enhanced recovery and accelerated discharge policy for elective pituitary surgery. METHODS: We retrospectively assessed two consecutive cohorts of patients undergoing elective surgery for pituitary adenoma in a single UK centre between July 2016 and November 2019. The pre-ERAS cohort included 52 sequential patients operated prior to protocol change. The ERAS cohort included 55 sequential patients operated after a protocol change. Patient demographic data, tumour characteristics, intra- and post-operative CSF leak, the rate and cause of readmission (within 30 days), and the mean and median LOS were recorded. Patient feedback was collected from a subset of patients (n = 23) in the ERAS group. RESULTS: The two cohorts were well-matched with respect to their demographic, pathological, and operative characteristics. The rates of readmission within 30 days of discharge were similar between the two groups (8% pre-ERAS cohort, 9% ERAS cohort, p = 0.75). In the pre-ERAS cohort, the mean LOS was 4.5 days and median LOS was 3 days. This compares with significant reduction in LOS for the ERAS group: mean of 1.7 days and median of 1 day (p < 0.05). Thirty-nine of 55 patients in the ERAS group were discharged on post-operative day 1. Patient feedback was very positive in the ERAS group (mean patient satisfaction score of 9.7/10 using a Likert scale). CONCLUSIONS: An enhanced recovery protocol after elective endoscopic pituitary surgery is safe, reduces length of stay, and is associated with high patient satisfaction.


Subject(s)
Elective Surgical Procedures/adverse effects , Endoscopy/adverse effects , Neurosurgical Procedures/adverse effects , Patient Reported Outcome Measures , Pituitary Neoplasms/surgery , Postoperative Complications/epidemiology , Adult , Aged , Costs and Cost Analysis , Elective Surgical Procedures/economics , Endoscopy/economics , Female , Humans , Length of Stay , Male , Middle Aged , Neurosurgical Procedures/economics , Patient Discharge , Postoperative Complications/economics
4.
Br J Neurosurg ; 32(5): 536-540, 2018 Oct.
Article in English | MEDLINE | ID: mdl-29764206

ABSTRACT

OBJECTIVE: To compare multidisciplinary team (MDT) decision making at our centre with the suggested management from the recently published Unruptured Intracranial Aneurysm Treatment Score (UIATS), with particular focus on disagreements between the two bodies of expert opinion. DESIGN: A retrospective audit of local practice. SUBJECTS: Adult patients with incidental cerebral saccular aneurysms referred to The National Hospital for Neurology and Neurosurgery Neurovascular MDT. METHODS: Review of MDT records from 2010-2015 and collection of UIATS criteria. MDT decisions for each aneurysm were designated as conservative or treatment group, then assessed for correlation with the UIATS. RESULTS: Data was collected on 398 aneurysms from 296 patients. 57% of aneurysms were managed conservatively and 43% were treated with endovascular or open repair. Total follow up was 8409 aneurysm months (mean: 21 months per aneurysm). The overall proportion of agreement (p0) was 66.6% (95% CI: 61.9-71.2). Cohen's Kappa (k) was 0.325 suggesting only a "fair" level of agreement between the two raters. Absolute agreement rates increased from 60% in 2010 to 74% in 2015. Aneurysm size was an important factor for disagreement, 77% of aneurysms treated following MDT, but not in agreement with the UIATS, were >7 mm, compared with only 70.5% in those treated following MDT and in agreement with UIATS. CONCLUSION: There was disagreement between the two expert opinions analysed in this study. A key factor was aneurysm size, with decision making at our centre seemingly more guided by older landmark papers such as work by the International Study of Unruptured Intracranial Aneurysms (ISUIA) group. However, agreement was at its highest at the end of the study period, suggesting increasing convergence between the two bodies of expert opinion. The reasons for disagreement and particularly clinicians' reliance on aneurysm size in decision making is something that needs consideration when planning and auditing aneurysm services.


Subject(s)
Clinical Decision-Making , Incidental Findings , Intracranial Aneurysm/therapy , Patient Care Team , Adult , Aged , Aneurysm, Ruptured/epidemiology , Aneurysm, Ruptured/therapy , Conservative Treatment , Endovascular Procedures , Female , Humans , Intracranial Aneurysm/diagnostic imaging , Intracranial Aneurysm/surgery , Male , Middle Aged , Neurosurgical Procedures , Observer Variation , Retrospective Studies , Treatment Outcome
5.
World Neurosurg ; 126: e1315-e1320, 2019 Jun.
Article in English | MEDLINE | ID: mdl-30898748

ABSTRACT

BACKGROUND: Intracranial arachnoid cysts are a common incidental finding. Most of these remain asymptomatic with surgical intervention being reserved for those cysts causing symptoms from mass effect or hydrocephalus. It is not properly understood why cysts enlarge nor is it possible to predict in which cysts this will occur. The aim of this study is to review the natural history of incidental arachnoid cysts. METHODS: A retrospective case review was conducted of all patients diagnosed with an arachnoid cyst between 2007 and 2016. Case notes and radiology reports were reviewed for demographics, symptoms, and changes in cyst sizes. RESULTS: Four hundred and eighty-five patients were diagnosed with an arachnoid cyst during this time period; of these, 425 (87.6%) were asymptomatic. Patients with symptomatic cysts were significantly younger and more likely to have associated hydrocephalus. The most common indications for imaging which resulted in the diagnosis of the cyst were headaches (n = 106), stroke (n = 51), and seizures (n = 41). The cyst size remained stable or reduced in 147 patients (99.3%) with follow-up imaging (n = 148), and the enlarging cyst remained asymptomatic. CONCLUSIONS: Asymptomatic arachnoid cysts have a low rate of cyst enlargement on follow-up imaging, which supports not routinely imaging these patients. However, serial imaging and surgery may still be indicated in asymptomatic patients at risk of obstructive hydrocephalus which, in this series, was only seen in the pediatric population. A better understanding of the natural history of intracranial arachnoid cysts allows for more efficient follow-up planning.


Subject(s)
Arachnoid Cysts/pathology , Adolescent , Adult , Aged , Aged, 80 and over , Child , Child, Preschool , Female , Humans , Infant , Infant, Newborn , Male , Middle Aged , Retrospective Studies , Young Adult
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