Awake craniotomy for high-grade gliomas - a prospective cohort study in a UK tertiary-centre.

BACKGROUND: Studies from the UK reporting on awake craniotomy (AC) include a heterogenous group of patients which limit the evaluation of the true impact of AC in high-grade glioma (HGG) patients. This study aims to report solely the experience and outcomes of AC for HGG surgery from our centre. METHODS: A prospective review of all patients who underwent AC for HGG from 2013 to 2019 were performed. Data on patient characteristics including but not limited to demographics, pre- and post-operative Karnofsky performance status (KPS), tumour location and volume, type of surgery, extent of resection (EOR), tumour histopathology, intra- and post-operative complications, morbidity, mortality, disease recurrence, progression-free survival (PFS) and overall survival (OS) from the time of surgery were collected. RESULTS: Fifteen patients (6 males; 9 females; 17 surgeries) underwent AC for HGG (median age = 55 years). Two patients underwent repeat surgeries due to disease recurrence. Median pre- and post-operative KPS score was 90 (range:80-100) and 90 (range:60-100), respectively. The EOR ranges from 60 to 100 % with a minimum of 80 % achieved in 81.3 % cases. Post-operative complications include focal seizures (17.6 %), transient aphasia/dysphasia (17.6 %), permanent motor deficit (11.8 %), transient motor deficit (5.9 %) and transient sensory disturbance (5.9 %). There were no surgery-related mortality or post-operative infection. The median PFS and OS were 13 (95%CI 5-78) and 30 (95%CI 21-78) months, respectively. CONCLUSION: This is the first study in the UK to solely report outcomes of AC for HGG surgery. Our data demonstrates that AC for HGG in eloquent region is safe, feasible and provides comparable outcomes to those reported in the literature.

A national survey on the management of foot drop secondary to lumbar degenerative disease in the United Kingdom.

PURPOSE: There is considerable variation in the management of foot drop secondary to lumbar degenerative disease (LDD) that occurs between centres and surgeons (spinal surgeons and neurosurgeons). The lack of standardised practice reflects the paucity in evidence base for management of this condition. In this survey, we aimed to assess current practice in the UK and identify the areas of variation. METHODS: A case-based survey was distributed to members of the Society of British Neurological Surgeons and British Association of Spine Surgeons through an online questionnaire. The survey consisted of 10 questions designed to determine the management of foot drop secondary to LDD. RESULTS: A total of 163 responses were collected among UK neurosurgeons and spinal surgeons with good geographical representation. 92% were Consultants. 86% of the respondents would offer surgery. The indication for offering surgery varied but 54% of respondents would offer surgery to patients who present with a painful foot drop. There was a huge variation in offering surgery dependent on the grade of weakness. The strongest prognostic indicator predicted was duration of weakness (92%). The timing of intervention was wide-ranging in the responses received. Almost all responded that they would be willing to participate in a prospective study in the future to determine best practice. CONCLUSIONS: This survey highlights the significant variability in management of foot drop secondary to LDD amongst consultant surgeons within the UK. It is also suggestive of a weak evidence base and indicates an urgent need for a high quality national prospective study.

Risk of iatrogenic injury to the infrapatellar branch of the saphenous nerve during hamstring tendon harvesting: A meta-analysis.

INTRODUCTION: Our goal was to conduct a comprehensive analysis of studies reporting data on the rate of injury to the infrapatellar branch of the saphenous nerve following hamstring tendon graft harvesting with respect to the type of incision over the pes anserinus. METHODS: A broad search through all major electronic databases was conducted to identify articles eligible for inclusion. All available data were extracted and pooled into the analysis. RESULTS: Eleven studies (n = 1,050 patients) were included in the meta-analysis. The study revealed that a vertical incision during hamstring tendon harvesting over the pes anserinus was associated with the highest rate of injury with a pooled rate of 51.4% (95% confidence interval [CI], 34.6-67.2%). This was followed by oblique and horizontal incisions with pooled rates of 26.0% (95% CI,1.3-61.3%) and 22.4% (95% CI, 5.4-45.5%), respectively. CONCLUSIONS: We highly recommend the use of the shortest possible oblique incision during hamstring tendon harvesting over the pes anserinus. Muscle Nerve 56: 930-937, 2017.

Development of the anatomical quality assessment (AQUA) tool for the quality assessment of anatomical studies included in meta-analyses and systematic reviews.

Critical appraisal of anatomical studies is essential before the evidence from them undergoes meta-epidemiological synthesis. However, no instrument for appraising anatomical studies with inherent applicability to different study designs is available. We aim to develop a generic yet comprehensive tool for assessing the quality of anatomical studies using a formal consensus method. The study steering committee formulated an initial conceptual design and generated items for a preliminary tool on the basis of a literature review and expert opinion. A Delphi procedure was then adopted to assess the validity of the preliminary tool. Feedback from the Delphi panelists was used to improve it. The Delphi procedure involved 12 experts in anatomical research. It comprised two rounds, after which unanimous consensus was reached about the items to be included. The preliminary tool consisted of 20 items, which were phrased as signaling questions and organized into five domains: 1. Aim and subject characteristics, 2. Study design, 3. Characterization of methods, 4. Descriptive anatomy, and 5. Results reporting. Each domain was set to end with a risk of bias question. Following round 1, some of the items underwent major revision, although agreement was reached regarding inclusion of all the domains and signaling questions in the preliminary tool. The tool was revised only for minor language inaccuracies after round 2. The AQUA Tool was designed to assess the quality and reliability of anatomical studies. It is currently undergoing a validation process. Clin. Anat. 30:6-13, 2017. © 2016 Wiley Periodicals, Inc.

The Variable Emergence of the Infrapatellar Branch of the Saphenous Nerve.

The infrapatellar branch of the saphenous nerve (IPBSN) is a cutaneous nerve of the lower limb, which arises distal to the adductor canal. High variability in the emergence, course, branching, termination, and morphometrics of the IPBSN poses an increased risk of injury to the nerve during surgical interventions on the anteromedial aspect of the knee. The aim of this study was to describe the anatomical characteristics of the IPBSN. This study utilized cadaveric (n = 100) and ultrasonography (n = 30) assessments, and meta-analysis. In the cadaveric study, the presence of IPBSN and its emergence mode in relation to the sartorius muscle (SaM) was determined (type A-anterior; type B-posterior; type C-penetrating the SaM). Ultrasonography examinations were conducted on healthy volunteers to determine the presence and mode of the emergence of the nerve. Finally, from electronic databases searching, all studies reporting the IPBSN emergence data were pooled into a meta-analysis. The mean distance between the medial border of the patellar ligament (MBPL) and the IPBSN at the level of the patellar apex (PA) was also analyzed in the cadaveric, ultrasonography, and meta-analysis portions of the study. Six studies (n = 336 limbs), including the present cadaveric study, were pooled into the meta-analysis of emergence. The most prevalent IPBSN emergence mode was type C (42.9%) followed by type B (41.9%) and type A (15.4%). In the ultrasonography assessment, type A was found to be the most common (82.8%). The mean distance between the MBPL and the IPBSN at the level of the PA was 4.89 ± 0.22 cm, and 5.57 ± 0.91 cm, for the cadaveric and meta-analysis studies combined, and the ultrasonography assessment, respectively. This multimodality study shows that the most common type of IPBSN emergence is type C. The horizontal distance between the MBPL and the IPBSN at the level of the PA is usually between 4.5 and 5.6 cm. Understanding the anatomy of IPBSN emergence is crucial for orthopedic surgeons to minimize the risks of iatrogenic nerve injury during surgical procedures in the region.

Anatomical Variations in the Sinoatrial Nodal Artery: A Meta-Analysis and Clinical Considerations.

BACKGROUND AND OBJECTIVE: The sinoatrial nodal artery (SANa) is a highly variable vessel which supplies blood to the sinoatrial node (SAN). Due to its variability and susceptibility to iatrogenic injury, our study aimed to assess the anatomy of the SANa and determine the prevalence of its anatomical variations. STUDY DESIGN: An extensive search of major electronic databases was performed to identify all articles reporting anatomical data on the SANa. No lower date limit or language restrictions were applied. Anatomical data regarding the artery were extracted and pooled into a meta-analysis. RESULTS: Sixty-six studies (n = 21455 hearts) were included in the meta-analysis. The SANa usually arose as a single vessel with a pooled prevalence of 95.5% (95%CI:93.6-96.9). Duplication and triplication of the artery were also observed with pooled prevalence of 4.3% (95%CI:2.8-6.0) and 0.3% (95%CI:0-0.7), respectively. The most common origin of the SANa was from the right coronary artery (RCA), found in 68.0% (95%CI:55.6-68.9) of cases, followed by origin from the left circumflex artery, and origin from the left coronary artery with pooled prevalence of 22.1% (95%CI:15.0-26.2) and 2.7 (95%CI:0.7-5.2), respectively. A retrocaval course of the SANa was the most common course of the artery with a pooled prevalence of 47.1% (95%CI:36.0-55.5). The pooled prevalence of an S-shaped SANa was 7.6% (95%CI:2.9-14.1). CONCLUSIONS: The SANa is most commonly reported as a single vessel, originating from the RCA, and taking a retrocaval course to reach the SAN. Knowledge of high risk anatomical variants of the SANa, such as an S-shaped artery, must be taken into account by surgeons to prevent iatrogenic injuries. Specifically, interventional or cardiosurgical procedures, such as the Cox maze procedure for atrial fibrillation, open heart surgeries through the right atrium or intraoperative cross-clamping or dissection procedures during mitral valve surgery using the septal approach can all potentiate the risk for injury in the setting of high-risk morphological variants of the SANa.

Costs of Real-Life Endovascular Treatment of Critical Limb Ischemia: Report from Poland-A European Union Country with a Low-Budget Health Care System.

BACKGROUND: To analyze the costs of inhospital, percutaneous treatment of patients with critical limb ischemia (CLI) carried out in Poland, a European Union country with a low-budget national health system. METHODS: A retrospective analysis of prospectively collected data on all patients admitted to a tertiary care hospital for endovascular treatment of CLI over 1 year. SETTING: A single, large volume, tertiary angiology center located in Southern Poland. PARTICIPANTS: CLI patients due to aortoiliac, femoropopliteal, or infrapopliteal arterial stenoses or occlusions with indications for first-line endovascular therapy or similar patients who refused open surgical procedure despite having primary indications for vascular surgery. INTERVENTIONS: Direct stenting using bare-metal stents was the primary mode of treatment for lesions located within the aortoiliac and femoropopliteal arterial segments. Plain old balloon angioplasty (POBA) was the second most commonly used technique. For below-the-knee arteries, POBA was the mainstay of treatment, which was occasionally supported by drug-eluting stent angioplasty. Directional atherectomy, scoring balloon angioplasty, or local fibrinolysis was used infrequently. Drug-eluting balloon percutaneous transluminal angioplasty was not used. MAIN OUTCOME MEASURES: The main outcome measures were the mean reimbursement of costs provided by the Polish National Health Fund (NHF) for inhospital treatment of patients for whom endovascular procedures were performed as initial treatment for CLI and the inhospital costs of endovascular treatment calculated by the caregiver in the 2 years since the first procedure. The average total number of days spent in hospital, amputation-free survival (AFS), overall survival (OS), and limb salvage rate (LSR) according to a life-table method were also calculated for the 2 years. RESULTS: In the first year, there were 496 endovascular and 15 surgical hospitalizations for revascularization procedures to treat 340 limbs in 327 patients, with a further 53 revascularization procedures in the second year. There were an additional 90 hospitalizations over the first year and 38 over the second year for CLI-associated cardiovascular comorbidities. The mean reimbursement for hospitalizations of patients included into observation, provided by the NHF, was $4901.94 per patient for the first year and $833.57 per patient alive to the second year. The mean cost of hospitalization for percutaneous revascularization treatment was $3804.25 per patient for the first year and $3340.30 per patient requiring revascularization within the second year. All costs were calculated in constant 2011 USD. The average total number of days spent in hospital was 8.4 days for the first year and 1.97 days per patient alive to the second year. At 1 and 2 years, the AFS was 76.8% and 66.6%, the OS was 86.5% and 77.3%, and the LSR was 89.4% and 86%, respectively. CONCLUSIONS: Endovascular therapy using the currently available techniques can be performed in almost all patients suffering from CLI at relatively low costs, and satisfactory results can be obtained. Physicians play a pivotal role in ensuring quality of treatment and the reduction of treatment cost in these patients.

Procalcitonin as a Serum Biomarker for Differentiation of Bacterial Meningitis From Viral Meningitis in Children: Evidence From a Meta-Analysis.

Several studies have explored the use of serum procalcitonin (PCT) in differentiating between bacterial and viral etiologies in children with suspected meningitis. We pooled these studies into a meta-analysis to determine the PCT diagnostic accuracy. All major databases were searched through March 2015. No date or language restrictions were applied. Eight studies (n = 616 pediatric patients) were included. Serum PCT assay was found to be very accurate for differentiating the etiology of pediatric meningitis with pooled sensitivity and specificity of 0.96 (95% CI = 0.92-0.98) and 0.89 (95% CI = 0.86-0.92), respectively. The pooled positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio (DOR), and area under the curve (AUC) for PCT were 7.5 (95% CI = 5.6-10.1), 0.08(95% CI = 0.04-0.14), 142.3 (95% CI = 59.5-340.4), and 0.97 (SE = 0.01), respectively. In 6 studies, PCT was found to be superior than CRP, whose DOR was only 16.7 (95%CI = 8.8-31.7). Our meta-analysis demonstrates that serum PCT assay is a highly accurate and powerful test for rapidly differentiating between bacterial and viral meningitis in children.

The prevalence and anatomical characteristics of the accessory head of the flexor pollicis longus muscle: a meta-analysis.

Background and Objectives. The accessory head of the flexor pollicis longus muscle (AHFPL), also known as the Gantzer's muscle, was first described in 1813. The prevalence rates of an AHFPL significantly vary between studies, and no consensus has been reached on the numerous variations reported in its origin, innervation, and relationships to the Anterior Interosseous Nerve (AIN) and the Median Nerve (MN). The aim of our study was to determine the true prevalence of AHFPL and to study its associated anatomical characteristics. Methods. A search of the major electronic databases PubMed, EMBASE, Scopus, ScienceDirect, and Web of Science was performed to identify all articles reporting data on the prevalence of AHPFL in the population. No date or language restriction was set. Additionally, an extensive search of the references of all relevant articles was performed. Data on the prevalence of the AHFPL in upper limbs and its anatomical characteristics and relationships including origin, insertion, innervation, and position was extracted and pooled into a meta-analysis using MetaXL version 2.0. Results. A total of 24 cadaveric studies (n = 2,358 upper limb) were included in the meta-analysis. The pooled prevalence of an AHFPL was 44.2% (95% CI [0.347-0.540]). An AHFPL was found more commonly in men than in women (41.1% vs. 24.1%), and was slightly more prevalent on the right side than on the left side (52.8% vs. 45.2%). The most common origin of the AHFPL was from the medial epicondyle of the humerus with a pooled prevalence of 43.6% (95% CI [0.166-0.521]). In most cases, the AHFPL inserted into the flexor pollicis longus muscle (94.6%, 95% CI [0.731-1.0]) and was innervated by the AIN (97.3%, 95% CI [0.924-0.993]). Conclusion. The AHFPL should be considered as more a part of normal anatomy than an anatomical variant. The variability in its anatomical characteristics, and its potential to cause compression of the AIN and MN, must be taken into account by physicians to avoid iatrogenic injury during decompression procedures and to aid in the diagnosis and treatment of Anterior Interosseous Nerve Syndrome.

Anatomical variations of the formation and course of the sural nerve: A systematic review and meta-analysis.

INTRODUCTION: The sural nerve (SN) is a sensory nerve in the lower extremity which branches to supply the skin on the distal posterolateral third of the lower limb. Typically, the medial sural cutaneous nerve (MSCN) and the peroneal communicating nerve (PCN) unite to form the SN. Other variations in the formation, course, and morphometry of the SN have also been described in the literature. OBJECTIVE: To study anatomical variations in the formation and course of the SN and establish a new classification system for formation patterns of the SN. METHODS: A systematic search of all major databases identified articles that studied the prevalence of variations in the formation of the SN. No date or language restrictions were set. Anatomical data was extracted according to our new classification system where the SN is formed by: union of the MSCN and the PCN (Type 1); union of the MSCN and the Lateral Sural Cutaneous Nerve (LSCN) (Type 2); continuation of the MSCN with absent PCN (Type 3); the PCN alone (Type 4); the LSCN (Type 5); or the Sciatic Nerve (SCN) directly (Type 6). Pooled prevalence rates were calculated using MetaXL 2.0. RESULTS: A total of 39 studies (n=3974 limbs) were included in the meta-analysis. The most common patterns were Type 1, Type 3, and Type 2 with a pooled prevalence of 51.5% (95% CI: 0.293-0.591), 31.2% (95% CI: 0.143-0.410), and 13.8% (95% CI: 0.035-0.234), respectively. The rest of the patterns were rare, with pooled prevalence of Types 4, 5, and 6 calculated to be 1.8% (95% CI: 0-0.063), 1.1% (95% CI: 0-0.050), and 0.7% (95% CI: 0-0.041), respectively. In 83.7% (95% CI: 0.765-0.899) of limbs, the site of union was in the lower half of the lower extremity. The pooled mean length of the SN from the formation to the lateral malleolus was 14.78 (±5.76) cm, while the mean diameter of the SN was 0.28 (±0.03) cm. CONCLUSIONS: Anatomical variations in the formation and course of the SN are common in the population. Clinicians, especially surgeons, should be aware of these variations to avoid iatrogenic injury to the nerve during operative procedures.

The Prevalence of Anatomical Variations of the Median Nerve in the Carpal Tunnel: A Systematic Review and Meta-Analysis.

BACKGROUND AND OBJECTIVE: The course and branches of the median nerve (MN) in the wrist vary widely among the population. Due to significant differences in the reported prevalence of such variations, extensive knowledge on the anatomy of the MN is essential to avoid iatrogenic nerve injury. Our aim was to determine the prevalence rates of anatomical variations of the MN in the carpal tunnel and the most common course patterns and variations in its thenar motor branch (TMB). STUDY DESIGN: A systematic search of all major databases was performed to identify articles that studied the prevalence of MN variations in the carpal tunnel and the TMB. No date or language restrictions were set. Extracted data was classified according to Lanz's classification system: variations in the course of the single TMB--extraligamentous, subligamentous, and transligamentous (type 1); accessory branches of the MN at the distal carpal tunnel (type 2); high division of the MN (type 3); and the MN and its accessory branches proximal to the carpal tunnel (type 4). Pooled prevalence rates were calculated using MetaXL 2.0. RESULTS: Thirty-one studies (n = 3918 hands) were included in the meta-analysis. The pooled prevalence rates of the extraligamentous, subligamentous, and transligamentous courses were 75.2% (95%CI:55.4%-84.7%), 13.5% (95%CI:3.6%-25.7%), and 11.3% (95%CI:2.4%-23.0%), respectively. The prevalence of Lanz group 2, 3, and 4 were 4.6% (95%CI:1.6%-9.1%), 2.6% (95%CI:0.1%-2.8%), and 2.3% (95%CI:0.3%-5.6%), respectively. Ulnar side of branching of the TMB was found in 2.1% (95%CI:0.9%-3.6%) of hands. The prevalence of hypertrophic thenar muscles over the transverse carpal ligament was 18.2% (95%CI:6.8%-33.0%). A transligamentous course of the TMB was more commonly found in hands with hypertrophic thenar muscles (23.4%, 95%CI:5.0%-43.4%) compared to those without hypertrophic musculature (1.7%, 95%CI:0%-100%). In four studies (n = 423 hands), identical bilateral course of the TMB was found in 72.3% (95%CI:58.4%-84.4%) of patients. CONCLUSIONS: Anatomical variations in the course of the TMB and the MN in the carpal tunnel are common in the population. Thus, we recommend an ulnar side approach to carpal tunnel release, with a careful layer by layer dissection, to avoid iatrogenic damage to the TMB.

The role of serum procalcitonin in the diagnosis of bacterial meningitis in adults: a systematic review and meta-analysis.

OBJECTIVE: Clinically, it is often difficult to differentiate between bacterial and viral aetiologies in adults with suspected meningitis. Several studies have demonstrated the potential use of serum procalcitonin (PCT) in making this differentiation. The aim was to pool these studies into a meta-analysis to determine the diagnostic accuracy of PCT. METHODS: Major electronic databases were searched for articles studying the use of serum PCT in the differentiation of bacterial and viral meningitis in adult patients. No date or language restrictions were applied. Data analysis was performed using Meta-DiSc 1.4 and MIX 2.0. RESULTS: Nine studies (n=725 patients) were included in the meta-analysis. Serum PCT was found to be a highly accurate test for diagnosing meningitis. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio (DOR) for PCT were 0.90 (95% confidence interval (CI) 0.84-0.94), 0.98 (95% CI 0.97-0.99), 27.3 (95% CI 8.2-91.1), 0.13 (95% CI 0.07-0.26), and 287.0 (95% CI 58.5-1409.0), respectively. PCT was found to be far superior to C-reactive protein, which had a pooled DOR of only 22.1 (95% CI 12.7-38.3). CONCLUSIONS: Serum PCT is a highly accurate diagnostic test that can be used by physicians for rapid differentiation between bacterial and viral causes of meningitis in adults.

Association of migraine headaches with anatomical variations of the Circle of Willis: Evidence from a meta-analysis.

BACKGROUND: Several studies have attempted to investigate whether variations in the Circle of Willis (COW) are more common in migraine patients and whether the subsequent changes in perfusion may contribute to the pathomechanism of migraine. However, studies are not in agreement as to whether or not there is an increased prevalence of COW variations in migraineurs. OBJECTIVE: To determine if migraine headaches are associated with variations in morphology of the COW. METHODS: A systemic search of the major electronic databases was performed for articles studying the association of variations in the COW and migraine. Data on the prevalence of variations in patients with migraine were extracted and pooled into the meta-analysis. RESULTS: A total of four articles (n=807 patients) were deemed eligible for the meta-analysis. Migraine, regardless of subtype, was found to be associated with variations in the COW (OR=2.27, 95%CI 1.53-3.38, p<0.0001). An incomplete posterior circle (OR=2.60, 95%CI 1.79-3.76, p<0.00001) was found to be more strongly associated with migraine than an incomplete anterior circle (OR=2.01, 95%CI 1.15-3.53, p=0.01). In sub-group analysis, migraine with aura was found to be associated with both an incomplete posterior (OR=3.55, 95%CI 2.25-5.59, p<0.00001) and an incomplete anterior circle (OR=2.35, 95%CI 1.20-4.62, p=0.01). Migraine without aura was found only to be associated with an incomplete posterior circle (OR=2.10, 95%CI 1.39-3.17, p=0.0004). CONCLUSIONS: Migraine is associated with anatomical variations in both the anterior and posterior portions of the COW. However, larger prospective trials are needed to determine the true prevalence of variations and their pathological significance.