The Effect of COVID-19 National Lockdown on the Time from Presentation to Surgery of Patients with Suspected Cauda Equina Syndrome: Two UK Tertiary Centers' Study.

OBJECTIVE: To investigate if COVID-19 UK lockdown measures resulted in a delay in the presentation and treatment of patients with cauda equina syndrome (CES). METHODS: This is a multicenter retrospective study of patients with surgically treated CES across 3 time periods: April-May 2020 (first lockdown), August-September 2020 (no-lockdown group), and January-February 2021 (second lockdown). Data regarding duration of symptoms, time from referral to admission, time from admission to surgery, and postoperative outcomes were collected. RESULTS: A total of 56 patients (male: 26, female: 30, mean age: 44.3 years) were included in the study (n = 14, n = 18, and n = 24 in the 3 time periods, respectively). There was no significant difference in duration of symptoms across the time periods (12.6 days vs. 8.2 days vs. 3.8 days) (P = 0.16). Nearly all the patients were admitted within 48 hours of referral (n = 55, 98.2%). The majority of patients were operated on within 48 hours: first lockdown (n = 12, 85.7%), no-lockdown (n = 16, 88.9%), and second lockdown (n = 21, 87.5%). The length of hospital stay was significantly shorter in the second lockdown (3.3 days) versus the other 2 time periods (4.4 days and 6.4 days) (P = 0.02). Thirteen complications were present, with dural tear being the most common (n = 6, 10.7%). Majority reported symptom improvement (n = 53, 94.6%), with a similar number discharged home (n = 54, 96.4%). CONCLUSION: Despite the pandemic, patients with CES were promptly admitted and operated on with good outcomes. Shorter duration of hospital stay could be attributed to adaptation of spinal services.

Neurosurgery activity levels in the United Kingdom and republic of Ireland during the first wave of the covid-19 pandemic - a retrospective cross-sectional cohort study.

The impact of Covid-19 on surgical patients worldwide has been substantial. In the United Kingdom (UK) and the Republic of Ireland (RoI), the first wave of the pandemic occurred in March 2020. The aims of this study were to: (1) evaluate the volume of neurosurgical operative activity levels, Covid-19 infection rate and mortality rate in April 2020 with a retrospective cross-sectional cohort study conducted across 16 UK and RoI neurosurgical centres, and (2) compare patient outcomes in a single institution in April-June 2020 with a comparative cohort in 2019. Across the UK and RoI, 818 patients were included. There were 594 emergency and 224 elective operations. The incidence rate of Covid-19 infection was 2.6% (21/818). The overall mortality rate in patients with a Covid-19 infection was 28.6% (6/21). In the single centre cohort analysis, an overall reduction in neurosurgical operative activity by 65% was observed between 2020 (n = 304) and 2019 (n = 868). The current and future impact on UK neurosurgical operative activity has implications for service delivery and neurosurgical training.

Cavernous sinus meningioma presenting as third nerve palsy in pregnancy.

A 33-year-old female patient presented with diplopia and left eye ptosis 26 weeks into her first pregnancy. No investigation was conducted at the time and her symptoms subsided 4 weeks post partum. This same phenomenon occurred during second pregnancy at 20 weeks of gestation, with patient becoming symptom-free again 6 weeks after giving birth. MRI revealed a lesion in the left cavernous sinus in keeping with a meningioma. Due to the surgically challenging location, the lesion was treated with gamma knife radiosurgery. To date, the patient remains asymptomatic with no progression on follow-up imaging 9 years on.

Recurrent hiccups may signal brainstem pathology and should be investigated.

While occasional hiccups are normal, their persistent recurrence is distressing and may have an underlying aetiology. Patients with recurrent hiccups may undergo a long journey and see many physicians before the diagnosis is finally made. The purpose of this report is to increase awareness of central nervous system lesions as a possible cause for recurrent hiccups and provide an illustrative case of an otherwise fit man presenting with ongoing hiccups caused by a medullary haemangioblastoma.

Trigemino-Cervical Neuropathic Pain Relieved by Serially Repeated Peripheral Nerve Field Stimulation Without Tolerance: Case Report.

BACKGROUND: With its relative simplicity and safety, peripheral nerve field stimulation (PNFS; PENS) is contributing to the re-emergence of peripheral nerve stimulation as an effective therapy for neuropathic pain (NPP). CASE PRESENTATION: A 70-year-old woman had developed severe, medically refractory NPP unilaterally in the scalp and face 20 years earlier, following a maxillofacial surgical procedure. PNFS gave substantial relief of the pain and allodynia and was repeated successfully on a further 25 occasions over the subsequent five years. Tolerance did not develop. CONCLUSION: Serially repeated PNFS can provide sustained relief of NPP over long periods, without tolerance, where a permanent implant may be inappropriate, unavailable, or declined.

The isolated fourth ventricle.

Isolated enlargement of the fourth ventricle, or 'encysted' fourth ventricle is a rare late complication following shunt insertion of the lateral ventricles for hydrocephalus. Caudal and rostral obstruction of the fourth ventricle and its subsequent dilation results in compression of adjacent cerebellum and brain stem structures; treatment with further shunt insertion directly to the fourth ventricle is invariably successful. There is potential for diagnostic delay, when clinical symptoms and signs of cerebellar and brain stem compromise are unrecognised or attributed to other factors, and attention on the CT is focused on the lateral ventricular system and the already existing ventriculoperitoneal shunt, which will appear unchanged from previous scans. We report two cases with isolated fourth ventricular obstruction and review the literature to highlight the importance of recognising this condition.

Excision of vestibular schwannomas--is there a learning curve and how best to demonstrate it?

OBJECTIVE: To demonstrate the existence of a learning curve in a consultant neurosurgeon's performance in excising vestibular schwannomas by plotting the cumulative sum (CUSUM) chart. Also, to evaluate the influence of new technology in the form of the facial nerve monitor (FNM) and the KTP-532 Laser on surgical performance. METHOD: Analysis was carried out on a prospectively collected data series of 102 consecutive cases of vestibular schwannomas excisions between 1986 and 2000 by a single neurosurgeon using the retrosigmoid approach. The CUSUM score chart of the surgical outcomes across the series was plotted for all and large tumour sizes separately. The changes in CUSUM scores were assessed using statistical change-point analysis. Using the multivariate logistic regression analysis, we inspected the association between use of FNM and laser on outcome. RESULTS: After the first 27 cases and coinciding with the introduction of the FNM there was a clear change in the direction of the slope of the CUSUM chart, showing a clear improving trend in performance (p = 0.09). The same phenomenon was also seen when plotting the CUSUM chart for large tumours only, although this was not statistically significant. The use of FNM reduces the risk of bad House Brakmann-score by approximately 90% for all tumours (risk of bad outcome with FNM = 3.2% and without FNM = 26.7%, odds ratio = 0.10 and 95% confidence interval (0.02-0.61), p = 0.013) after adjusting for age at operation, but no significant association was seen with the use of laser. CONCLUSION: There appears to be a learning curve in the performance of a neurosurgeon. Compared to previous reports of sequential block analysis, the CUSUM method is less arbitrary and more transparent. The CUSUM is most useful as an audit tool that can help spare patients from undesirable learning curves, and help to demonstrate good standards in appraisal and revalidation.

Retracing "Ondine's curse".

"Ondine's curse" is a term used to denote a rare neurological condition causing failure of automatic respiration. The patients are no longer capable of breathing spontaneously-they must consciously and voluntarily force themselves to do so. Ondine (also known as "Undine"), a mythological figure of European tradition, was a water nymph or sprite who could become human only when she fell in love with a mortal man. However, if the mortal was unfaithful to her, he was destined to forfeit his life. In the 16th century, Paracelsus coined the term "Undine" to describe the spirit that inhabited the element of water. Baron de la Motte-Fouque wrote the story of Undine in the late 18th century. It has since become a popular subject for theater productions. Jean Giraudoux, the French playwright, introduced the concept of the loss of automaticity of all functions as the "curse of Ondine." The legend was popularized in the form of the fairy tale "The Little Mermaid" by Hans Christian Andersen and as an animated motion picture by Walt Disney Productions. In this study, we look at the origins of this eponymous term, the personalities intertwined with its popularity, and its misrepresentations in the medical literature.

Surgical outcome in rheumatoid Ranawat Class IIIb myelopathy.

OBJECTIVE: Rheumatoid arthritis frequently affects the craniovertebral junction (CVJ) and may lead to severe neck pain, quadriparesis, and respiratory dysfunction. Surgery in rheumatoid nonambulatory (Ranawat Class IIIb) patients carries a significant risk. This study presents the surgical outcome of Class IIIb patients with CVJ rheumatoid myelopathy and reviews the literature. METHODS: One hundred twelve consecutive patients with rheumatoid cervical myelopathy underwent surgical decompression and stabilization. Thirty-two of the patients (mean age, 66.81 +/- 10.25 yr) with CVJ rheumatoid arthritis were in Class IIIb, and all had atlantoaxial subluxation. A halo brace was applied before surgery and continued during surgery. Eleven patients with reducible atlantoaxial subluxation underwent direct posterior fusion. Twenty-one patients with fixed atlantoaxial subluxation underwent transoral decompression and then posterior fusion while they were under anesthesia. RESULTS: At a mean follow-up of 39 months, four patients improved to Class II and 14 improved to Class IIIa, whereas six remained in Class IIIb. Neck pain was relieved in all patients. There was one perioperative death after transoral surgery (posterior fusion not done), and seven other patients died subsequently of causes unrelated to surgery. The morbidity of surgery included construct failure, cerebrospinal fluid leak, superficial wound or graft donor site infection, transient dysphagia, and lung infection. CONCLUSION: A large subset of patients with CVJ rheumatoid myelopathy may reach Class IIIb. These patients have unique management considerations. Surgery (despite high morbidity) often remains the best therapeutic option available to them. Improvement of even one grade in their Ranawat score from Class IIIb to Class IIIa brought about by surgery confers on them a significant benefit in terms of their quality of life and survival.