The ethics of prophylactic antibiotics for neurosurgical procedures.

The prophylactic use of antibiotics has become a routine procedure in many areas of medicine. In neurosurgery, however, there is considerable debate over their use in the prevention of postoperative infection. We pose several ethical questions about antibiotic prophylaxis in a neurosurgical setting. These questions are discussed under the following categories: responsible usage of antibiotics; the ethical dilemmas of controlled, antibiotic clinical trials, and some problems inherent in not using prophylactic antibiotics.

Lumboperitoneal shunts.

BACKGROUND: To assess lumboperitoneal shunting as a simple method of relieving communicating hydrocephalus, treating pseudotumor cerebri, and resolving cerebrospinal fluid fistulae. METHOD: Three neurosurgeons at different hospitals report their combined experience over a 20-year period. RESULTS: Ease of insertion of the device and low rate of complications were reported in a combined series of 107 patients. CONCLUSIONS: Lumboperitoneal shunting is a technically simple and highly effective surgical technique for diversion of cerebrospinal fluid.

Arthroscopic microdiscectomy: an alternative to open disc surgery.

OBJECTIVE: To assess minimally invasive spinal surgery under endoscopic magnification and illumination (arthroscopic microdiscectomy) as a reliable alternative to open microsurgery for most herniated lumbar discs. METHOD: A total of 600 cases are evaluated retrospectively in terms of patient selection and technique. One series of 300 operations was performed by a key academician in the development of arthroscopic microdiscectomy. A second series of 300 patients was treated by a neurosurgeon in private suburban practice. RESULTS: In terms of patients self-evaluation, satisfactory outcome rates of 85-92% were realized. The patients considered brief intravenous anesthesia and same-day scheduling preferable to general anesthesia and hospitalization needed for open laminotomy and discectomy. Fewer than 2% of the cases required a second surgery. CONCLUSION: The authors are of the opinion that advantages include: (1) one-hour operative time, (2) negligible blood loss, (3) avoidance of significant scarring in the spinal canal, and (4) anterolateral fenestration of the annulus for continuing relief of intradiscal pressure and nerve root decompression.

Anterior cervical discectomy without fusion or instrumentation: 25 years' experience.

OBJECTIVE: To assess a minimalist approach to anterior cervical discectomy without instrumentation or bone grafting. METHOD: A total of 530 operations performed during a 25-year period were evaluated in terms of technique and patient outcome. RESULTS: Advantages included minimal blood loss, little tissue swelling, less narcotic requirement, fewer days in the hospital, and earlier return to customary activity. During the 2-year follow-up period, a repeat surgical procedure was required in only 2% of the group. CONCLUSIONS: Eliminating spinal fusion from anterior cervical discectomy shortened the operation, reduced the number of surgical instruments needed, and eliminated complications associated with obtaining a graft from the iliac crest or maintaining the bone in situ.

CT-guided needle procedures for brain lesions: 20 years' experience.

OBJECTIVE: To assess free-hand needle procedures with CT guidance for biopsy and drainage of brain lesions. METHOD: A series of 184 operations was carried out on 120 patients over a 20-year period. Sixty (60) cases of suspected neoplasm were biopsied; 40 cases of intracerebral hemorrhage and 20 cases of intracranial suppuration underwent drainage. RESULTS: The morbidity and mortality of the methods described were quite low due to steroid therapy, prophylactic antibiotics, and careful preparation of the access site. There was one complication of postoperative hemorrhage in a patient with metastatic melanoma. CONCLUSIONS: The simple and accurate techniques presented continue to have widespread application in the practice of neurosurgery and compare quite favorably with techniques using more elaborate equipment, stereotactic frames, and intraoperative monitoring.

Continuing experience with subgaleal shunting.

OBJECTIVE: To evaluate subgaleal shunting--the diversion of cerebrospinal fluid into the subgaleal space for temporary absorption by the membranes of the scalp. METHOD: Eighty-one (81) patients were treated over a 20-year period. There were 22 cases of hypertensive hydrocephalus, 52 cases of acute head trauma, and 7 cases of chronic subdural hematoma. The simple surgical technique is described. RESULTS: Of the eight-one patients, 33 improved, 27 did not change, and 21 expired within 72 hours. Intracranial pressure was monitored directly in 22 cases and demonstrated that subgaleal shunting provided effective short-term treatment. CONCLUSIONS: This simple, closed method for drainage of cerebrospinal fluid avoids the complications of open ventriculostomy or open drainage of the subdural space.

Subgaleal shunting: a 20-year experience.

OBJECT: The authors undertook a retrospective study to evaluate the effectiveness of diverting intracranial fluid into the subgaleal space for temporary absorption by the membranes of the scalp. METHODS: Eighty-one patients were treated over a 20-year period. There were 22 cases of hypertensive hydrocephalus, 52 cases of acute head trauma, and seven cases of chronic subdural hematoma. The simple surgical technique is described. Subgaleal shunting provided effective short-term treatment of hydrocephalus and increased intracranial pressure, which was monitored directly in 22 cases of cerebral contusion and edema. CONCLUSIONS: The closed method for drainage of cerebrospinal fluid avoids the complications of open ventriculostomy or open drainage of the subdural space.

Low incidence of delayed intracerebral hemorrhage secondary to ventriculoperitoneal shunt insertion.

OBJECT: Bleeding into the brain parenchyma or ventricles is an infrequently reported complication in adults who undergo insertion of a ventriculoperitoneal (VP) shunt. The purpose of this study was to establish the incidence of delayed intracerebral hemorrhage secondary to ventricular cannulation during shunting procedures. METHODS: Over a 24-year period, in a series of 125 adult patients with hydrocephalus, postoperative computerized tomography scans were obtained in every case within 48 hours of shunt surgery performed by the same neurosurgeon. The rate of delayed intracerebral hematoma or intraventricular hemorrhage after VP shunt placement was documented by routine neuroradiological follow up to be 4%. CONCLUSIONS: In adult patients with no coagulopathy or occult vascular lesions, the rate of bleeding after VP shunt insertion may be low if the procedure is uncomplicated by multiple attempts at perforation, puncture of the choroid plexus, or improper placement of the tubing within the parenchyma of the brain.

Topical irrigation with polymyxin and bacitracin for spinal surgery.

BACKGROUND: The purpose of the present study was to evaluate constant irrigation with saline containing 50,000 units each of polymyxin and bacitracin in a regimen of antimicrobial prophylaxis for clean spinal surgery at two community hospitals with a zero infection rate. METHODS: The focus was on the bactericidal effects of prophylactic topical antibiotics by assessing random contamination in neurosurgical wounds from: 1) the flora of the integument and nares of the operating team, 2) the surgical apparel, 3) the patient's skin, 4) air-borne organisms in the operating theater, and 5) the surgeon's gloves. RESULTS: Based on individual biotyping of bacteria and antimicrobial sensitivity testing, no consistent source or pattern could be uncovered for the organisms recovered from the operative site. Relying on longitudinal data, the incidence of intraoperative bacterial growth with continuous saline lavage was reduced from 64 to 4% when the combination of topical polymyxin and bacitracin was added. CONCLUSIONS: Although the virtual elimination of bacterial growth in the surgical site was accomplished, the efficacy of topical antibiotics in the prevention of wound infection remains unproven.

Percutaneous lumbar discectomy with a working endoscope and laser assistance.

The authors describe percutaneous disc surgery performed via the unilateral monoportal method with a C-arm image intensifier, a working endoscope, and an yttrium-aluminum-garnet laser in 300 patients at three community hospitals over a 6-year period. Visualizing the area of the annulus to be fenestrated, verifying the status of the nerve root, inspecting the cavity created, and monitoring laser hemostasis and vaporization all contributed to patient safety. Fewer than 2% of the cases required a second surgery. The only postoperative sequelae recorded were one psoas hematoma, which resolved, and sympathetic mediated pain in 5% of the patients who responded to appropriate treatment. For treatment of a prolapsed lumbar disc, a 1-hour endoscopic procedure performed while the patient receives a neuroleptanalgesic continues to be a significant surgical alternative.

Soft disc herniation in patients with lumbar stenosis.

Over a period of 25 years, a surgical technique has evolved for removal of a soft disc herniation in patients with sciatica and lumbar stenosis demonstrated on neuroradiological studies. Initially emphasis was placed on decompression of the entire narrow spinal canal when there was evidence of single nerve root involvement and no history of neurogenic claudication. The author has performed 12 microsurgical discectomies since 1984 and eight percutaneous endoscopic discectomies over the past 6 years that have been successful in relieving radiculitis and radiculopathy in cases of a single herniated nucleus pulposus, even in the presence of a stenotic canal. No patient complained of generalized numbness, weakness, or pain in the lower extremities while walking. After at least 1 year of follow up, the 20 patients who underwent microsurgical or arthroscopic procedures limited to removing the ruptured disc have not required more extensive decompression.

Another look at ventriculosubgaleal shunting procedures.

Ventriculosubgaleal shunts were available at the turn of the century as a treatment for hydrocephalus. Almost 80 years later, Perret and Graf advocated such shunting for the temporary decompression of ventricles enlarged by tumors or by hydrocephalus. The use of a subgaleal shunt in acute head trauma was first published in 1983. No direct measurement of intracranial pressure was attempted in 30 cases. Evidence by computed tomography of compressed ventricles and cerebral contusion correlated well with elevated pressure. When the Camino intracranial pressure monitor became available, the device was inserted before placement of the shunt to assess the appropriateness and efficacy of the method in 21 patients. An additional 22 cases of intraventricular hemorrhage with acute hydrocephalus were treated over a 17-year period. The simple method of shunting into the subgaleal space has broad application for the temporary relief of increased intracranial or high-pressure hydrocephalus.