Foramen Magnum Decompression for Chiari Malformation Type 1: Is There a Superior Surgical Technique?

BACKGROUND: Foramen magnum decompression is a common operation used to treat Chiari malformation. There are different surgical techniques; however, some are anecdotally more effective than others. Our aim was to determine whether there is a superior technique in relation to revision rates, presence of persistent postoperative headache and nausea, and syrinx reduction. METHODS: This was a retrospective analysis of foramen magnum decompressions performed between 2012 and 2017 for Chiari 1 in a single institution. Three types of operations were performed: 1) bony decompression alone; 2) bony decompression with durotomy and dura left open; 3) bony decompression with opening of dura and duraplasty. We compared postoperative symptoms and revision rates between these 3 operations. RESULTS: In 168 patients, 185 foramen magnum decompressions were performed. Among the 168 primary operations, in 66 the dura was not opened, in 86 the dura was opened without a duraplasty, and in 16 a duraplasty was performed. Of 185 operations, 17 were revision surgery. For primary procedures, the revision rates were 12 (18%) where the dura was not opened, 4 (5%) where the dura was left open, and 1 (6%) when duraplasty was performed. Severe postoperative headache and nausea occurred in 2 (3%) patients where the dura was not opened, 4 (25%) patients after primary duraplasty, and 64 (74%) patients after primary durotomy. CONCLUSIONS: In this study, rate of revision surgery was highest in patients who had bony decompression without dural opening. Rate of postoperative headache and nausea was highest in the durotomy group. Overall duraplasty had the best results.

Foramen magnum decompression for Chiari malformation type I - UK surgical practice.

Background: Symptomatic Chiari 1 malformation (CM1) is a common condition in Neurosurgery. Surgery involves hindbrain decompression and restoration of CSF flow through different surgical approaches. No Class 1 evidence exists to suggest the superiority of any of the surgical techniques.Aims: To investigate current surgical practice for symptomatic CM1 patients in the United Kingdom (UK) and determine the willingness to participate in a randomised controlled trial (RCT) comparing different surgical techniques.Methods: An electronic survey was sent to consultant members of the Society of British Neurological Surgeons and the British Chiari-Syringomyelia Group. The questions covered pre-operative and intra-operative management, presence of equipoise/uncertainty in optimal technique and willingness to participate in an RCT.Results: 98 responses were received. 67% operate on adults. 30% on adult and paediatric patients. There is variation in routine pre-operative use of: ICP monitoring (18%), flexion/extension x-rays (16%), venography (20%) and ophthalmology assessment (26%). 18% of neurosurgeons would not offer foramen magnum decompression when the presenting symptom is only refractory cough/sneeze headache. 15% routinely perform bony decompression alone in adults vs 8% in children. In 68% of adult cases, durotomy is performed routinely (46% of them leave the dura open, 54% perform a type of duroplasty) and 16% routinely resect the cerebellar tonsils. Only 17% leave the dura open in children. The most common indicators for durotomy are syringomyelia and intra-operative ultrasound findings. 61% believe there is equipoise/uncertainty in the optimal strategy for decompression and would be willing to participate in an RCT. Comments also mention the heterogeneity of CM1 and that treatment should be tailored to each patient.Conclusion: There is wide variation in pre- and intra-operative management of CM1 patients in the UK and the majority of neurosurgeons would be willing to participate in an RCT comparing bony decompression alone vs dural opening with/without duroplasty.

Women in neurosurgery in the United Kingdom: past, present and future.

Whilst a growing number of women in the United Kingdom (UK) are making a success of a career in medicine as a whole, a considerable gender imbalance persists in neurosurgery. The extent of this disparity and the factors that perpetuate it are difficult to assess. Furthermore, over the 70 years since the first female neurosurgeon in the UK commenced her postgraduate training, it is difficult to gauge the progress that has been made. In this article we present a snapshot of women who have played, and who are playing, a key role in UK neurosurgery, highlighting their diverse career paths. We also present the current training distribution and subspecialties of women in UK neurosurgery. We use these data to reflect upon the possible barriers to completion of neurosurgical training, obtaining a substantive consultant position, and reaching positions of academic and clinical leadership. We discuss potential interventions that may overcome these. Highlighting the role women play in UK neurosurgery's past, present and future should inspire more female neurosurgeons to become leaders in the coming years.

Post-Traumatic Bifrontoparietal Extradural Hematoma with Superior Sagittal Sinus Detachment: A Case Report and Review of the Literature.

OBJECTIVE: To present, to our knowledge, the first case of a single bilateral extradural hematoma due to superior sagittal sinus detachment that was treated conservatively with an excellent outcome. METHODS: Bilateral extradural hematomas are a rare condition, accounting for only 2%-5% of all extradural hematomas. They can be either 2 distinct hematomas on either side or 1 single bilateral hematoma mostly due to sagittal sinus injury, with the latter being the most rare owing to the firm attachment of the sinus to its subperiosteal loggia. These hematomas usually require immediate surgical evacuation, as patients present with decreased level of consciousness, and have good postoperative outcomes. We present a bilateral extradural hematoma due to superior sagittal sinus injury, which was treated conservatively. RESULTS: The patient had an excellent recovery, with no residual neurological deficits and a Glasgow outcome scale of 5 on discharge. CONCLUSION: Bilateral extradural hematomas due to superior sagittal sinus injury almost always require surgical intervention. We present a patient who was treated conservatively with an excellent outcome and we also perform a review of the current literature.

Novel antimicrobial agents against multi-drug-resistant gram-negative bacteria: an overview.

No novel antimicrobial agents against multi-drug-resistant Gram-negative bacteria have been available to daily clinical practice during the last 5 years. On the other hand, resistance rates and mechanisms of those pathogens are increasing worldwide. Pan-resistant (against which none of the currently available antibiotics is effective) strains of Klebsiella pneumoniae, Acinetobacter baumannii and Pseudomonas aeruginosa have been described. Encouraging is the fact that several novel compounds (some of them with mechanisms of action different to those of the antibiotics commercially available) are through the development stages. We summarize the main such compounds that show potential for offering solution to the treatment of Gram-negative multi-resistant bacteria along with the discussion of some patents associated with the topic.

Novel antimicrobial agents against multi-drug-resistant gram-positive bacteria: an overview.

Antimicrobial resistance threatens to compromise the treatment of bacterial infectious diseases. Strains resistant to most (if not all) antibiotics available have emerged. Gram-positive such representatives include strains of Methicillinresistant Staphylococcus aureus (MRSA), Vancomycin-resistant Enterococci (VRE) and highly-resistant to penicillin Streptococcus pneumoniae. Although the phenomenon of antimicrobial drug resistance is expanding, limited number of new antibiotics has been successfully developed in the last few decades. Several novel antimicrobial agents, however, are currently in diverse phases of development and undergoing clinical trials. This review will summarize the main candidates for novel antibacterial agents active against Gram-positive multi-resistant pathogens along with the discussion of some patents relevant to the topic.