Strategic design for pediatric neurosurgery missions across the Western Hemisphere.

BACKGROUND: With growing interest in global health, surgeons have created outreach missions to improve health care disparities in less developed countries. These efforts are mainly episodic with visiting surgeons performing the operations and minimal investment in local surgeon education. To create real and durable advancement in surgical services in disciplines that require urgent patient care, such as pediatric neurosurgery, improving the surgical armamentarium of the local surgeons must be the priority. METHODS: We propose a strategic design for extending surgical education missions throughout the Western Hemisphere in order to transfer modern surgical skills to local neurosurgeons. A selection criteria and structure for targeted missions is a derivative of logistical and pedagogical lessons ascertained from previous missions by our teams in Peru and Ukraine. RESULTS: Outreach programs should be applied to hospitals in capital cities to serve as a central referral center for maximal impact with fiscal efficiency. The host country should fulfill several criteria, including demonstration of geopolitical stability in combination with lack of modern neurosurgical care and equipment. The mission strategy is outlined as three to four 1-week visits with an initial site evaluation to establish a relationship with the hospital administration and host surgeons. Each visit should be characterized by collaboration between visiting and host surgeons on increasingly complex cases, with progressive transfer of skills over time. CONCLUSION: A strategic approach for surgical outreach missions should be built on collaboration and camaraderie between visiting and local neurosurgeons, with the mutual objective of cost-effective targeted renovation of their surgical equipment and skill repertoire.

Ethical considerations in targeted paediatric neurosurgery missions.

Within the context of global health development approaches, surgical missions to provide care for underserved populations remain the least studied interventions with regard to their methodology. Because of the unique logistical needs of delivering operative care, surgical missions are often described solely in terms of cases performed, with a paucity of discourse on medical ethics. Within surgery, subspecialties that serve patients on a non-elective basis should, it could be argued, create mission strategies that involve a didactic approach and the propagation of sustainable surgical care. The ethical considerations have yet to be described for paediatric neurosurgical outreach missions. We present here the perspectives of neurosurgeons who have participated in surgical outreach missions in Central America, South America, Eastern Europe and sub-Saharan Africa from the vantage point of both the visiting mission team and the host team that accommodates the mission efforts.

Biological horizons for targeting brain malignancy.

Though currently available clinical treatments and therapies have clearly extended the survival of patients with brain tumors, many of these advances are short lived, particularly with respect to high grade gliomas such as glioblastoma multiforme. The missing link to an efficacious treatment of high grade gliomas is a more complete understanding of the basic molecular and cellular origin of brain tumors. However, new discoveries of stem cell and developmental neurobiology have now borne the cancer stem cell hypothesis, drawing off of intriguing similarities between benign and malignant cells within the central nervous system. Investigation of cancer stem cell hypothesis and brain tumor propagation is the current frontier of stem cell and cancer biology. Neurosurgery is also watching closely this promising new area of focus. "Molecular neurosurgery", glioma treatments involving biologics using neural stem cells to target the cancer at the level of individual migratory cell, is a rapidly evolving field. This coming progression of applied cancer stem cell research, coupled with current modalities, promises more comprehensive brain cancer interventions.

Prolonged Jackson-Pratt drainage in the management of lumbar cerebrospinal fluid leaks.

BACKGROUND: Cerebrospinal fluid (CSF) leak is a complication of spinal surgery. Intraoperative or postoperative identification of a CSF leak often results in wound healing complications, lumbar drain placement, and/or reoperation. These complications usually extend a patient's hospital stay, can be painful, and have their own associated risks. The authors describe a technique that may improve on traditional interventions by managing postoperative CSF leaks after lumbar instrumentation without an additional procedure or extended hospitalization. METHODS: A retrospective review of lumbar instrumentation cases performed by 5 attending surgeons from the Division of Neurosurgery, University of California at San Diego, was performed. In all, 184 charts were reviewed, spanning a 3-year period. There were 16 cases in which a dural tear and repair were carried out and subsequently treated with subfascial Jackson-Pratt (JP) drainage. Of those 16 cases, 8 patients were managed with prolonged JP drainage using the intraoperatively placed subfascial drain. Patients were discharged home on oral antibiotics according to the customary criteria with the JP drain in place and were instructed regarding proper drain maintenance. Jackson-Pratt drains were removed in clinic in a delayed fashion, approximately 10 to 17 days postoperatively. Patients were subsequently reevaluated at regular intervals for any persistent CSF leak. RESULTS: In the 8 cases reviewed, all patients were discharged in a time frame comparable to that of patients undergoing similar instrumentation in which no CSF leak was identified, or in whom a CSF leak was identified and repaired intraoperatively. No patients suffered complications arising from prolonged drain presence. No patients suffered from persistent CSF leak after drains were removed. CONCLUSION: Our study suggests that routine intraoperative subfascial JP drain placement aids in the early diagnosis of postoperative lumbar CSF leak. Primary closure of dural tear remains the standard of care. Furthermore, in select cases, prolonged JP drainage in the setting of postoperative CSF leak may be a useful technique for the treatment of these leaks.

Minimally disruptive decompression and transforaminal lumbar interbody fusion.

BACKGROUND: Posterior spinal procedures through tubular exposures have been described. However, tubes restrain visibility and require co-axial instrument manipulation, increasing difficulty and potentially compromising surgical results. An independent-blade retractor system overcomes the obstacles of working through a tube and has been used to perform minimally-disruptive decompression and instrumented tranforaminal lumbar interbody fusion (TLIF). PURPOSE: To evaluate the advantages to patient recovery and surgical efficacy of this technique. METHODS/RESULTS: Retrospective review of technique employing a minimally-disruptive approach to decompression and transforaminal lumber interbody fusion (TLIF). CONCLUSIONS: Minimally-disruptive decompression and instrumented TLIF can be performed in a safe and effective manner using an independent-blade retractor system. Relative to traditional-open techniques, surgical goals can be accomplished, but with the benefits of minimally-disruptive surgery.

Surgical correction of metopic synostosis.

BACKGROUND: Premature closure of the metopic suture results in deformation of the anterior portion of the calvarium, which can vary from mild to severe. In mild forms, there is only prominent ridging of the metopic suture; more severe forms result in a marked narrowing of the frontal and temporal regions that in turn affects the supraorbital rims and produces hypotelorism. METHODS: The authors retrospectively reviewed 39 consecutive cases of metopic synostosis treated over a 12-year period. RESULTS: The average age at referral was 5 months, with surgery performed at an average age of 7.5 months. Fifteen infants had other congenital anomalies, with eight having synostosis of other sutures. Follow-up ranged from 7 months to 6 years, with an average of 29 months. In three mild cases, burring of the metopic ridge was performed with excellent aesthetic results in all cases. The other 36 patients had significant deformity of the supraorbital ridges and temporal regions, with obvious hypotelorism for over 50% of the time. In these cases, the patients underwent craniofacial reconstruction to normalize their appearance. In addition, the lateral aspect of the sphenoid ridges, including the orbital roof and lateral orbital wall to the infraorbital fissure, was removed to free the cranial base. The average blood loss was under 400 ml and the average hospital stay was 3.6 days. Results were considered good to excellent in all except three cases, which had recurrence of a prominent metopic ridge; two required a second operation after 6 months for burring of this ridge, whereas the third was treated conservatively with an orthotic headband. CONCLUSION: Mild forms of metopic synostosis can be successfully treated with burring of the metopic ridge alone. Severe forms require craniofacial reconstruction and may be associated with other congenital abnormalities, additional synostosis, and developmental delay. In all cases, the operative procedure must be tailored to the nature and severity of the deformity.

The science of shrinking human heads: tribal warfare and revenge among the South American Jivaro-Shuar.

THE PRACTICE OF "head-shrinking" has been the proper domain not of Africa but rather of the denizens of South America. Specifically, in the post-Columbian period, it has been most famously the practice of a tribe of indigenous people commonly called the Jivaro or Jivaro-Shuar. The evidence suggests that the Jivaro-Shuar are merely the last group to retain a custom widespread in northwestern South America. In both ceramic and textile art of the pre-Columbian residents of Peru, the motif of trophy heads smaller than normal life-size heads commonly recurs; the motif is seen even in surviving carvings in stone and shell. Moreover, although not true shrunken heads, trophy heads found in late pre-Columbian and even post-Columbian graves of the region demonstrate techniques of display very similar to those used by the Jivaro-Shuar, at least some of which are best understood in the context of head-shrinking. Regardless, the Jivaro-Shuar and their practices provide an illustrative counterexample to popular myth regarding the culture and science of the shrinking of human heads.

Effect of vagus nerve stimulator magnet on programmable shunt settings.

OBJECTIVE: Vagus nerve stimulators and programmable shunt valves are used in the operative care of epilepsy and hydrocephalus, respectively. Both devices use magnetic fields to activate and program their various settings and functions. The authors conducted several ex vivo trials to better elucidate any interplay between the two systems. METHODS: A pulse generator controller (Cyberonics Corp., Houston, TX) was brought to within 4 cm of Strata programmable shunt valves (Medtronic Neurosurgery, Goleta, CA). Each of five valves was preset to either a low- or high-pressure setting and then challenged with the vagus nerve stimulator generator. Each valve was challenged 20 times, for a total of 100 trials. RESULTS: In 100 trials, 78 inadvertent pressure setting adjustments were recorded. In 46 attempts, the valve pressure was increased, and in 34 attempts, the pressure was decreased. CONCLUSION: This study provides some support to the anecdotal reports of inadvertent adjustments of programmable shunt valves by the external magnetic field created by vagus nerve stimulator pulse generator controllers. Further trials and a double-blind study are necessary to illustrate more clearly the possible relationship of these magnetically controlled neurosurgical devices.

Reengineering intravenous drug and fluid administration processes in the operating room: step one: task analysis of existing processes.

BACKGROUND: A reengineering approach to intravenous drug and fluid administration processes could improve anesthesia care. In this initial study, current intravenous administration tasks were examined to identify opportunities for improved design. METHODS: After institutional review board approval was obtained, an observer sat in the operating room and categorized, in real time, anesthesia providers' activities during 35 cases ( approximately 90 h) into 66 task categories focused on drug/fluid tasks. Both initial room set-up at the beginning of a typical workday and cardiac and noncardiac general anesthesia cases were studied. User errors and inefficiencies were noted. The time required to prepare de novo a syringe containing a mock emergency drug was measured using a standard protocol. RESULTS: Drug/fluid tasks consumed almost 50 and 75%, respectively, of the set-up time for noncardiac and cardiac cases. In 8 cardiac anesthetics, drug/fluid tasks comprised 27 +/- 6% (mean +/- SD) of all prebypass clinical activities. During 20 noncardiac cases, drug/fluid tasks comprised 20 +/- 8% of induction and 15 +/- 7% of maintenance. Drug preparation far outweighed drug administration tasks. Inefficient or error prone tasks were observed during drug/fluid preparation (e.g., supply acquisition, waste disposal, syringe labeling), administration (infusion device failure, leaking stopcock), and organization (workspace organization and navigation, untangling of intravenous lines). Anesthesia providers (n = 21) required 35 +/- 5 s to prepare a mock emergency drug. CONCLUSIONS: Intravenous drug and fluid administration tasks account for a significant proportion of anesthesia care, especially in complex cases. Current processes are inefficient and may predispose to medical error. There appears to be substantial opportunity to improve quality and cost of care through the reengineering of anesthesia intravenous drug and fluid administration processes. General design requirements are proposed.