Evaluation of locally manufactured patient-specific custom made implants for cranial defects using a silicone mould.

BACKGROUND: Cranial vault defects can pose a significant problem for neurosurgeons where autologous bone is no longer available for cranioplasty. Numerous materials exist to create implants which include polymethyl methacrylate (PMMA) and titanium. A technique using 3-dimensional CT scan reconstruction of a cranial defect and creating a silicon mould which can be autoclaved in theatre to create a PMMA implant was developed. OBJECTIVE: The aim of this study is to evaluate the efficacy, cosmetic result, safety and cost-effectiveness of this procedure and compare this to existing techniques. METHOD: An ambispective study was performed in patients requiring cranioplasty with a custom made implant. Patients were assessed for risk factors and cosmetic outcome, surgical technique was described and complications and cost compared to existing literature between 2010 and 2016. RESULTS: Thirty retrospective and 30 consecutive prospective patients were recruited into the study. Overall sepsis rate was 8.3%. All septic cases had superficial sepsis of which 2 grafts were removed due to cerebrospinal fluid leakage resulting in wound breakdown. A 100% accurate implant to defect ratio was achieved leading to a high satisfaction rate. Average cost was 5 times cheaper than the closest market related product. CONCLUSION: Patient specific moulds using PMMA to create custom implants are safe, have excellent cosmetic results and are a very cost-effective option to manage cranial defects. Accurate planning strategies for large craniotomies, where bone will potentially be discarded, add to surgical effectiveness and cost-saving to the patient.

CSF protein concentration associated with ventriculoperitoneal shunt obstruction in tuberculous meningitis.

INTRODUCTION: Hydrocephalus occurs in 85% of patients with tuberculous meningitis (TBM). Ventriculoperitoneal shunt (VPS) insertion is first-line treatment for relieving increased intercranial pressure. VPS obstruction secondary to increased protein levels in cerebrospinal fluid (CSF) is a known complication. OBJECTIVE: To ascertain if there is a difference in protein levels 1) between cranial and lumbar CSF, and to quantify levels associated with VPS obstruction, and 2) obtained from lumbar puncture vs. ventricular CSF. METHOD: A 30-year retrospective analysis was undertaken. CSF protein levels were statistically analysed to determine correlation between these levels and VPS obstruction. RESULTS: Of 214 children and 376 adults who underwent VPS insertion for TBM, respectively 27.5% and 25.5% sustained blocked VPS. The mean protein level in CSF collected from the non-obstructed group was 1.76 g/l, compared to 2.94 g/l in the obstructed group. The mean CSF protein level from intraoperative ventricular vs. lumbar puncture samples in the VPS obstruction group was respectively 2.471 g/l and 2.474 g/l. CONCLUSION: Patients with increased protein levels in CSF are at a high risk of VPS blockage. In these patients, temporary measures should be employed until CSF protein levels decrease.

Proteus mirabilis abscess involving the entire neural axis.

Intramedullary spinal cord abscesses are rare and potentially devastating lesions usually associated with other infective processes such as bacterial endocarditis, or pulmonary or urogenital infection. We describe a 2-year-old girl who presented with an infected dermal sinus leading to an intraspinal abscess. This abscess eventually spread and involved the entire neural axis leaving her quadriparetic. Drainage of the abscess resulted in recovery and the child regained normal function of her limbs. To our knowledge this is the first documented case of an intramedullary abscess involving the entire neural axis.

Comparative outcomes of ulnar nerve transposition versus neurolysis in patients with entrapment neuropathy at the cubital tunnel: a 20-year analysis.

BACKGROUND: Entrapment neuropathy of the ulnar nerve at the level of the elbow is the shared domain of multiple surgical specialties. A wide variety of operative methods for its surgical management have been reported. Our hospital utilizes neurolysis (NL) and subcutaneous transposition (AST). The aim of this paper was to compare the clinical outcomes in patients treated by ulnar nerve transposition versus neurolysis over a 20-year period. METHODS: We included patients who underwent either neurolysis or an ulnar nerve transposition. A retrospective analysis was performed which included 480 patients at our institution between January 1992 and December 2012. In total, physical and electronic records for 480 patients were reviewed. Three-hundred and one underwent ulnar nerve transposition and 179 underwent ulnar nerve neurolysis . RESULTS: In the AST group 201/301 patients suffered from parasthesiae pre-operatively and 156/301 had pain at and around the cubital tunnel. Paresis of the ulnar nerve innervated muscles was present in 99/301 patients. At the 3-month follow-up appointment, 187/201 patients with parasthesiae and 113/156 patients with local pain had resolution of their symptoms. In the NL group 151/179 patients had parasthesiae pre-operatively and 126/179 had pain at and around the cubital tunnel. Paresis of the ulnar nerve innervated muscles was present in 56/179 patients. At the 3-month follow-up appointment, 141/151 patients with parasthesiae and 117/126 patients with local pain had resolution of their symptoms. CONCLUSIONS: In cases of ulnar nerve compression at the cubital tunnel, both neurolysis and transposition are effective in improving clinical outcome. The only statistically significant advantage of neurolysis over transposition seems to be relief of localized elbow pain. We recommend neurolysis as the preferred procedure.

Familial colloid cyst.

Colloid cysts of the third ventricle are rare benign tumours that can present as symptomatic hydrocephalus or be an incidental finding on imaging. This report presents familial colloid cysts found in a mother and daughter. Prior examples of familial colloid cysts are also reviewed and suggestions regarding the mode of inheritance and screening strategy are proposed.

The evolution of neurosurgery: how has our practice changed?

INTRODUCTION: Neurosurgery is a rapdily evolving speciality and has often taken a lead in adopting new technologies. Advancing technology however is not the only force driving change in this discipline. Other factors include an escalation in patient expectations, an increasing (and ageing) population and the prevailing economic conditions. The aim of our study was to analyse the trends in neurosurgical practice over a 10-year period. MATERIALS AND METHODS: The details of every neurosurgical procedure performed at Wellington Regional Hospital from 2001 to 2011 were prospectively recorded in a relational database. This was then retrospectively interrogated to provide data for this study. RESULTS: Neurosurgical practice has clearly evolved over the last decade. Predictable changes include a trend towards coiling rather than clipping of cerebral aneurysms, an increasing number of tumour resections (particularly for malignant glioma) coupled with the increased use of image guidance and endoscopy. The number of operations on the cervical spine has also increased although overall the number of procedures for spinal degenerative conditions has declined, perhaps reflecting local practice. The rates of craniotomy for trauma and burr holes for chronic subdural haematoma have remained essentially unchanged. We have demonstrated a significant increase in annual case-load that is disproportionate to any change in population size. Collaboration between specialties is increasingly evident. CONCLUSION: The most important changes have occured in the fields of neuro-oncology, vascular neurosurgery and spinal surgery. Inter-specialty collaboration is establishing itself as a model of care. These data may guide resource allocation for a population increasing both in number and in age.

Spinal cord compression in a patient with blue rubber bleb nevus syndrome.

Blue rubber bleb nevus syndrome is a rare condition characterised by venous malformations that affect the gastrointestinal tract and skin. There may be involvement of other organs. We describe a 70-year-old male with multiple extradural venous malformations resulting in spinal cord compression.

Headache after substance abuse: a diagnostic dilemma.

An 18-year-old man inhaled a substance containing synthetic cannabinoids and 1 hour later developed a severe global headache. Imaging revealed a perimesencephalic subarachnoid haemorrhage. An angiogram suggested that a small superior cerebellar artery aneurysm was the culprit. This report discusses the, as yet undefined, relationship between "herbal highs" and intracranial haemorrhage.

Laminated multi-segment rib graft in anterior column reconstruction.

Rib harvested during thoracotomy can be effectively used for anterior column reconstruction. An innovative technique is described to convert multiple individual rib segments into a robust single anterior column reconstruction graft using cortical screws.

Irradiation of chewable tobacco mixes for improvement in microbiological quality.

Microbiological quality of chewable tobacco mixes traditionally known as "Gutkha" was studied. The microbiological analysis of 15 samples analyzed revealed high bacterial and fungal counts. The total viable counts were in the range of 1.8 x 10(4) to 7.2 x 10(4) CFU g(-1) and the yeast and mold count from 3.6 x 10(3) to 7.1 x 10(4) CFU g(-1). The proteolytic and lipolytic counts were 9 x 10(2) to 2.6 x 10(3) CFU g(-1) and 2.6 x 10(3) CFU g(-1), on an average, respectively. Lecithinase-positive Staphylococcus aureus was found in 2 of the 15 samples analyzed; the counts were up to 3.4 x 10(3) CFU g(-1). Coliform and Salmonella spp. were found to be absent. Aflatoxins B , B2, and G2 were found to be present in all the samples. These samples were exposed to gamma radiation (60Co) at 1-, 2-, 3-, 5-, 10-, and 25-kGy doses. The decrease in total viable count and fungal count was noticed with increase of radiation dose. The 3-kGy dose was observed to be the sterilization dose for Gutkha. At this dose no survival of organisms was noticed and no revival was observed during postirradiation storage at room temperature for 6 months.

Control of Yersinia enterocolitica in raw pork and pork products by gamma-irradiation.

gamma-Radiation response of Y. enterocolitica 5692 and 152 was studied at 0 degrees C and at -40 degrees C in phosphate buffer (pH 7.00) as well as in 10% raw meat/salami homogenate. The strains investigated did not differ in their response and were found to be sensitive to gamma-radiation but exhibited a tailing phenomenon in the survival curve. The D10 in homogenate was 0.25 kGy at 0 degrees C. This response was not affected at -40 degrees C. Storage studies of packs, inoculated artificially with heavy inoculum of Y. enterocolitica (10(6) cfu/g) showed that while samples of salami and cooked ham could be decontaminated at doses of 4 and 3 kGy respectively; cells could not be eliminated from raw pork meat even at the higher dose of 6 kGy. The role of different treatments given prior to irradiation for revival of Y. enterocolitica after irradiation storage was studied. The dose of 1 kGy at -40 degrees C was efficient in eradicating low numbers (< 10(3)) of naturally occurring of Y. enterocolitica from raw pork meat without any revival during storage at refrigeration temperature.

Evidence for plasmid-mediated toxin production inBacillus cereus BIS-59.

A strain ofBacillus cereus, isolated from shrimps pasteurized by radiation, harboured a 7.6MDa plasmid. When cells were cured with Acridine Orange, they still produced the haemolytic toxin but not the non-haemolytic one. The results therefore suggest that the plasmid encodes the gene(s) responsible for the non-haemolytic toxin.

Influence of cellular differentiation on ultraviolet induced DNA damage and its repair mechanisms in B. cereus.

Susceptibility to UV irradiation of B. cereus BIS-59 spores undergoing germination at various stages-dormant spores to vegetative cell stage and their ability to recover from radiation damage were studied. For a given dose of radiation, the number of spore photoproducts (SPP) formed in the DNA of dormant spores was about 5-times greater than that of thymine dimers (TT) formed in the DNA of vegetative cells. At intermediate stages of the germination cycle, there was a rapid decline in the UV radiation-induced SPP formed in DNA with a concomitant increase in the UV radiation-induced TT formed in DNA. Bacterial spores undergoing germination (up to 3 hr) in the low nutrient medium (0.3% yeast extract) displayed much higher resistance to UV radiation than those germinating in the rich nutrient medium, even though there was no discernible difference under the two incubation conditions in respect of the extent of germination and the time at which the outgrowth stage appeared (3 hr). This was due to the formation TT in the DNA of spores germinating in the low nutrient as compared to that of spores germinating in the rich-nutrient medium. In UV-irradiated dormant spores, SPP formed in the spore DNA did not disappear even after prolonged incubation in the non-germinating medium. However, when the UV-irradiated dormant spores were germinated in low or rich nutrient medium, a significant proportion of SPP in DNA was eliminated. The dormant spores incubated in either of the germinating media for 15 min and then UV-irradiated were capable of eliminating SPP (presumably by monomerization) even by incubation in a non-germinating medium and in the complete absence of protein synthesis (buffer holding recovery), thereby implying that spore-repair enzymes were activated in response to initial's germination. The acquisition of photo-reactivation ability appeared in spores subjected to germination only in the rich-nutrient medium at the outgrowth stage and required de novo synthesis of the required enzymes.

Involvement of calcium and dipicolinic acid in the resistance of Bacillus cereus BIS-59 spores to u.v. and gamma radiations.

The role of dipicolinic acid (DPA) in determining the resistance of Bacillus cereus spores to u.v. and gamma radiation was investigated. B. cereus BIS-59 spores containing varying amounts of DPA were prepared by appropriate compositional adjustments in the secondary media. Compared with spores containing 6 per cent DPA (dry weight) those containing 0.8 per cent DPA were far more sensitive to u.v. radiation. Similar u.v. radiation sensitivity was also found in respect of a DPA-less mutant of B. cereus T 6A 1. Pre-treatment of DPA deficient spores (of wild type or mutant B. cereus) with DPA or the presence of DPA during irradiation resulted in increased resistance of these spores to u.v. radiation. In the range 0.2 to 1 per cent DPA content of spores of B. cereus BIS-59, a striking inverse relationship could be discerned between the DPA content and the number of spore photo-products (5-thymidyl, 5,6-dihydrothymine) formed in DNA and spore viability. The resistance of B. cereus spores to gamma radiation did not seem to be influenced by their DPA content.

Mechanism of Ca2+ and dipicolinic acid requirement for L-alanine induced germination of Bacillus cereus BIS-59 spores.

Spores prepared from different sporulating media containing varying amounts of Ca and dipicolinic acid (DPA), exhibited differential responses to germination in L-alanine (0.25 M). Ca-spores with moderately high Ca and DPA contents could be triggered to germination by L-alanine, whereas P-spores with low contents of Ca and DPA could not be germinated by L-alanine unless Ca2+ or DPA was exogenously added. The initiation of L-alanine induced germination by P-spores in the presence of 45CaCl2 was associated with a marked uptake of 45Ca2+. Experiments involving stepwise extraction of 45Ca from prelabelled spores indicated that a part of the spore calcium may be involved in L-alanine induced germination. Both Ca2+ and DPA seemed to have a stimulatory effect on the incorporation of 14C-L-alanine.