Fat in the Fossa and the Sphenoid Sinus: A Simple and Effective Solution to CSF Leaks in Transsphenoidal Surgery. Cohort Study and Systematic Review.

Objectives Cerebrospinal fluid (CSF) leak following endoscopic transsphenoidal surgery (TSS) remains a challenge and is associated with high morbidity. We perform a primary repair with f at in the pituitary f ossa and further fat in the s phenoid sinus (FFS). We compare the efficacy of this FFS technique with other repair methods and perform a systematic review. Design, Patients, and Methods This is a retrospective analysis of patients undergoing standard TSS from 2009 to 2020, comparing the incidence of significant postoperative CSF rhinorrhea (requiring intervention) using the FFS technique compared with other intraoperative repair strategies. Systematic review of current repair methods described in the literature was performed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Results In all, there were 439 patients, with 276 patients undergoing multilayer repair, 68 patients FFS repair, and 95 patients no repair. No significant differences were observed in baseline demographics between the groups. Postoperative CSF leak requiring intervention was significantly lower in the FFS repair group (4.4%) compared with the multilayer (20.3%) and no repair groups (12.6%, p < 0.01). This translated to fewer reoperations (2.9% FFS vs. 13.4% multilayer vs. 8.4% no repair, p < 0.05), fewer lumbar drains (2.9% FFS vs. 15.6% multilayer vs. 5.3% no repair, p < 0.01), and shorter hospital stay (median days: 4 [3-7] FFS vs. 6 (5-10) multilayer vs. 5 (3-7) no repair, p < 0.01). Risk factors for postoperative leak included female gender, perioperative lumbar drain, and intraoperative leak. Conclusion Autologous fat on fat graft for standard endoscopic transsphenoidal approach effectively reduces the risk of significant postoperative CSF leak with reduced reoperation and shorter hospital stay.

Spontaneous rupture of malignant papillary craniopharyngioma with CSF seeding and metastatic deposits: A case report and literature review.

Introduction: Craniopharyngiomas are benign tumours mainly confined to the cranial cavity in the suprasellar region. Research Question and Case Description: We present a rare case of an aggressive papillary craniopharyngioma with disseminated spinal intradural disease. A 67-year-old woman presented with a 4-month history of headache, visual disturbance, acute confusion and radicular leg pain. Previous history of breast carcinoma (ER â€‹+ â€‹PR â€‹+ â€‹HER2-) was noted. The importance of histological diagnosis prior to treatment of sellar or suprasellar lesions with atypical or aggressive features is explored. Materials and methods: MRI demonstrated a partly solid and partly cystic pituitary mass lesion in the sellar and suprasellar region with chiasmal compression and hypothalamic involvement. The sella was mildly enlarged and there were no calcifications. Whole neuraxis MRI revealed intradural deposits involving the ventricular system, spinal cord and conus. Within a month, the lesion rapidly increased in size. The patient underwent a craniotomy and transventricular resection of the sellar and suprasellar mass. Cranial lesion histology favoured papillary craniopharyngioma, confirmed by BRAF V600 mutation. Lumbar puncture CSF cytology confirmed craniopharyngioma with BRAF mutation and no evidence of metastatic breast cancer. Results: The patient remained confused postoperatively without focal neurological deficit and underwent palliative whole brain radiotherapy. She died 4 months later. A review of the literature identified 29 reports of ruptured craniopharyngioma. Discussion and Conclusion: Ruptured craniopharyngioma presents with a suprasellar mass and drop lesions in the spinal canal, characteristics radiologically indistinguishable from metastatic disease. The importance of histological diagnoses in directing the management of these cases is highlighted.

Fully Endoscopic Microvascular Decompression for Trigeminal Neuralgia: Technical Note Describing a Single-Center Experience.

BACKGROUND: Microscopic microvascular decompression (MVD) of the trigeminal nerve is the gold standard surgical treatment for medically refractory classical trigeminal neuralgia. Endoscopy has significantly advanced surgery and provides enhanced visualization of the cerebellopontine angle and its critical neurovascular structures. We present our initial experience of fully endoscopic microvascular decompression (e-MVD). METHODS: This retrospective case series investigated e-MVD performed from September 2016 to February 2020 at a single institution. Clinical data including presenting symptoms, medications, operative findings, postoperative complications, and outcomes were recorded. The 5-point Barrow Neurological Institute (BNI) pain intensity score was used to quantify patients' pain relief. RESULTS: During the study period, 25 patients with trigeminal neuralgia (10 males, 15 females; mean [SD] age = 63 [10.4] years) underwent e-MVD. All patients had a preoperative BNI score of V. The left side was affected in 15 patients. Complications occurred in 2 patients: both experienced hearing loss, and one experienced transient facial weakness 7 days after surgery. The facial weakness had resolved by the last follow-up. All patients were completely pain-free (BNI score I) immediately postoperatively. On latest follow-up, 22 patients have remained pain-free, and 3 patients have recurrent pain that is being controlled with medication (BNI score III). CONCLUSIONS: Our study demonstrated that e-MVD is a safe, possibly effective method of performing MVD with the added benefit of improved visualization of the operative field for the operating surgeon and the surgical team. Larger prospective studies are required to evaluate whether performing e-MVD confers any additional benefits in long-term clinical outcome of patients with trigeminal neuralgia.

Prognostic factors for surgically managed intramedullary spinal cord tumours: a single-centre case series.

PURPOSE: Intramedullary spinal cord tumours (IMSCTs) are comparatively rare neoplasms. We present a single-centre clinical case series of adult patients with surgically managed IMSCTs. METHODS: We performed a retrospective analysis of electronic patient records in the time period spanning July 2010 to July 2021. All adult patients that had undergone surgical management for IMSCTs were eligible for inclusion. Baseline and post-operative clinical and radiological characteristics, along with follow-up data, were assessed. We also performed a literature review with a focus on surgical outcomes for IMSCTs. RESULTS: Sixty-six patients matched our selection criteria, with a median age of 42 years (range 23-85). Thirty-four ependymomas, 17 haemangioblastomas, 12 astrocytomas, 2 lymphomas and 1 teratoma were included. Statistical analysis yielded several significant findings: IMSCTs spanning a greater number of vertebral levels are significantly associated with poor McCormick outcomes (p = 0.03), presence of gait disturbance before surgery is significantly associated with poor outcome for both post-operative McCormick and Nurick scores (p = 0.007), and radicular pain present pre-operatively is significantly associated with a good post-operative McCormick score (p = 0.045). Haemangioblastomas are significantly more likely to have a clear intra-operative dissection plane compared to ependymomas and astrocytomas (p = 0.009). However, astrocytomas have a significantly higher prevalence of good McCormick outcomes compared to ependymomas and haemangioblastomas (p = 0.03). CONCLUSION: Histological diagnosis, cranio-caudal extent of the tumour and the presence or absence of baseline deficits-such as gait impairment and radicular pain-are significant in determining neurological outcomes after surgery for IMSCTs.

Do All Notochordal Lesions Require Proton Beam Radiotherapy? A Proposed Reclassification of Ecchordosis Physaliphora as Benign Notochord Cell Tumor.

Objectives Ecchordosis physaliphora (EP) is a benign notochord lesion of the clivus arising from the same cell line as chordoma, its malignant counterpart. Although usually asymptomatic, it can cause spontaneous cerebrospinal fluid (CSF) rhinorrhea. Benign notochordal cell tumor (BNCT) is considered another indolent, benign variant of chordoma. Although aggressive forms of chordoma require maximal safe resection followed by proton beam radiotherapy, BNCT and EP can be managed with close imaging surveillance without resection or radiotherapy. However, while BNCT and EP can be distinguished from more aggressive forms of chordoma, differentiating the two is challenging as they are radiologically and histopathologically identical. This case series aims to characterize the clinicopathological features of EP and to propose classifying EP and BNCT together for the purposes of clinical management. Design Case series. Setting Tertiary referral center, United Kingdom. Participants Patients with suspected EP from 2015 to 2019. Main Outcome Measures Diagnosis of EP. Results Seven patients with radiological suspicion of EP were identified. Five presented with CSF rhinorrhea and two were asymptomatic. Magnetic resonance imaging features consistently showed T1-hypointense, T2-hyperintense nonenhancing lesions. Diagnosis was made on biopsy for patients requiring repair and radiologically where no surgery was indicated. The histological features of EP included physaliphorous cells of notochordal origin (positive epithelial membrane antigen, S100, CD10, and/or MNF116) without mitotic activity. Conclusion EP is indistinguishable from BNCT. Both demonstrate markers of notochord cell lines without malignant features. Their management is also identical. We therefore propose grouping EP with BNCT. Close imaging surveillance is required for both as progression to chordoma remains an unquantified risk.

Systematic Review Comparing Open versus Endoscopic Surgery in Clival Chordomas and a 10-Year Single-Center Experience.

Objectives Chordomas are rare, slow-growing, and osteo-destructive tumors of the primitive notochord. There is still contention in the literature as to the optimal management of chordoma. We conducted a systematic review of the surgical management of chordoma along with our 10-year institutional experience. Design A systematic search of the literature was performed in October 2020 by using MEDLINE and EMBASE for articles relating to the surgical management of clival chordomas. We also searched for all adult patients surgically treated for primary clival chordomas at our institute between 2009 and 2019. Participants Only articles describing chordomas arising from the clivus were included in the analysis. For our institution experience, only adult primary clival chordoma cases were included. Main Outcome Measures Patients were divided into endoscopic or open surgery. Rate of gross total resection (GTR), recurrence, and complications were measured. Results Our literature search yielded 24 articles to include in the study. Mean GTR rate among endoscopic cases was 51.9% versus 41.7% for open surgery. Among the eight cases in our institutional experience, we found similar GTR rates between endoscopic and open surgery. Conclusion Although there is clear evidence in the literature that endoscopic approaches provide better rates of GTR with fewer overall complications compared to open surgery. However, there are still situations where endoscopy is not viable, and thus, open surgery should still be considered if required.

Infected cephalhaematoma causing osteomyelitis: case report and literature review.

Infected cephalhaematomas are rare and can lead to complications such as sepsis, meningitis and osteomyelitis. We present an infected cephalhaematoma in a neonate with resultant underlying osteomyelitis and a review of the literature. Our patient presented 6 days following birth with a fever and a swelling consistent with cephalhaematoma. He was managed with intravenous antibiotics and early surgical intervention. Imaging demonstrated underlying osteomyelitis. The patient made a full recovery and was discharged home on completing his antibiotic course. On reviewing the literature, it is clear that early diagnosis and treatment with surgical intervention and antibiotic therapy are associated with improved outcome and can reduce the possibility of osteomyelitis developing.

A novel case of paravertebral glomangiomyomatosis.

Glomangiomyomatosis is an extremely rare variant of glomus tumours. We describe the first known case of paravertebral glomangiomyomatosis in the literature to cause spinal cord compression. A 45-year old female patient presented with sudden onset of left leg pain and progressive weakness in left-sided hip flexion. An MRI spine revealed a large, lobulated, heterogeneous mass cantered on the left L2/3 foramen, mimicking a dumbbell nerve sheath tumour. The mass was invading the psoas muscle and displayed evidence of recent haemorrhage. The patient underwent debulking of the lesion via a left retroperitoneal approach. Surgery was uneventful, with clinical improvement and resolution of leg pain post-operatively. Histopathology of the tumour revealed delineated glomus-like cells and foci of spindled shaped cells resembling myoid differentiation. Immuno-histochemical features of the tumour confirmed the diagnosis of glomangiomyomatosis. The patient continued under close follow up, representing 18 months later with clinical and radiological progression of the disease with similar symptoms of leg pain but no weakness. Follow up MRI revealed progression of the intraspinal and paraspinal components of the tumour with thecal compression. A posterior approach was utilized in order to decompress the intraspinal component, which again was uneventful, and improved the patient's symptoms. This is the first known case of paravertebral glomangiomyomatosis in the literature and this rare entity should be considered in the differential diagnosis of nerve sheath tumours due to risk of progression and recurrence.

Evidence-based surveillance protocol for vestibular schwannomas: a long-term analysis of tumor growth using conditional probability.

OBJECTIVE: The growth characteristics of vestibular schwannomas (VSs) under surveillance can be studied using a Bayesian method of growth risk stratification by time after surveillance onset, allowing dynamic evaluations of growth risks. There is no consensus on the optimum surveillance strategy in terms of frequency and duration, particularly for long-term growth risks. In this study, the long-term conditional probability of new VS growth was reported for patients after 5 years of demonstrated nongrowth. This allowed modeling of long-term VS growth risks, the creation of an evidence-based surveillance protocol, and the proposal of a cost-benefit analysis decision aid. METHODS: The authors performed an international multicenter retrospective analysis of prospectively collected databases from five tertiary care referral skull base units. Patients diagnosed with sporadic unilateral VS between 1990 and 2010 who had a minimum of 10 years of surveillance MRI showing VS nongrowth in the first 5 years of follow-up were included in the analysis. Conditional probabilities of growth were calculated according to Bayes' theorem, and nonlinear regression analyses allowed modeling of growth. A cost-benefit analysis was also performed. RESULTS: A total of 354 patients were included in the study. Across the surveillance period from 6 to 10 years postdiagnosis, a total of 12 tumors were seen to grow (3.4%). There was no significant difference in long-term growth risk for intracanalicular versus extracanalicular VSs (p = 0.41). At 6 years, the residual conditional probability of growth from this point onward was seen to be 2.28% (95% CI 0.70%-5.44%); at 7 years, 1.35% (95% CI 0.25%-4.10%); at 8 years, 0.80% (95% CI 0.07%-3.25%); at 9 years, 0.47% (95% CI 0.01%-2.71%); and at 10 years, 0.28% (95% CI 0.00%-2.37%). Modeling determined that the remaining lifetime risk of growth would be less than 1% at 7 years 7 months, less than 0.5% at 8 years 11 months, and less than 0.25% at 10 years 4 months. CONCLUSIONS: This multicenter study evaluates the conditional probability of VS growth in patients with long-term VS surveillance (6-10 years). On the basis of these growth risks, the authors posited a surveillance protocol with imaging at 6 months (t = 0.5), annually for 3 years (t = 1.5, 2.5, 3.5), twice at 2-year intervals (t = 5.5, 7.5), and a final scan after 3 years (t = 10.5). This can be used to better inform patients of their risk of growth at particular points along their surveillance timeline, balancing the risk of missing late growth with the costs of repeated imaging. A cost-benefit analysis decision aid was also proposed to allow units to make their own decisions regarding the cessation of surveillance.

Surgical Management of Spinal Chordoma: A Systematic Review and Single-Center Experience.

OBJECTIVE: Chordoma is a rare neoplasm of the neuraxis derived from remnants of the primitive notochord. The importance of wide margins and use of adjuvant therapy in spinal chordomas are still contentious points in the management of spinal chordomas. We conducted a systematic review of the surgical management of spinal chordomas alongside our 10-year institutional experience. METHODS: A systematic search of the literature was performed in November 2020 using Embase and MEDLINE for articles regarding the surgical management of chordomas arising from the mobile spine and sacrum. We also searched for all adult patients who were surgically managed for spinal chordomas at our institute between 2010 and 2020. In both the systematic review and our institutional case series, data on adequacy of resection, use of adjuvant therapy, complications, recurrence (local or metastatic), and survival outcomes were collected. RESULTS: We identified and analyzed 42 articles, yielding 1531 patients, from which the overall gross total or wide resection rate was 54.9%. Among the 8 cases in our institutional experience (4 sacral, 3 cervical, and 1 lumbar), we achieved gross total resection in 50% of initial operations. The recurrence rate was 25% in our gross total resection group and 50% where initial resection was subtotal. Of patients, 75% had no evidence of recurrence at most recent follow-up. CONCLUSIONS: Albeit difficult at times because of the proximity to neurovascular tissue, achieving a wide resection followed by adjuvant therapy for spinal chordomas is of great importance. Multidisciplinary discussion is valuable to ensure the best outcome for the patient.

CSF rhinorrhoea after endonasal intervention to the anterior skull base (CRANIAL): proposal for a prospective multicentre observational cohort study.

BACKGROUND: The endonasal transsphenoidal approach (TSA) has emerged as the preferred approach in order to treat pituitary adenoma and related sellar pathologies. The recently adopted expanded endonasal approach (EEA) has improved access to the ventral skull base whilst retaining the principles of minimally invasive surgery. Despite the advantages these approaches offer, cerebrospinal fluid (CSF) rhinorrhoea remains a common complication. There is currently a lack of comparative evidence to guide the best choice of skull base reconstruction, resulting in considerable heterogeneity of current practice. This study aims to determine: (1) the scope of the methods of skull base repair; and (2) the corresponding rates of postoperative CSF rhinorrhoea in contemporary neurosurgical practice in the UK and Ireland. METHODS: We will adopt a multicentre, prospective, observational cohort design. All neurosurgical units in the UK and Ireland performing the relevant surgeries (TSA and EEA) will be eligible to participate. Eligible cases will be prospectively recruited over 6 months with 6 months of postoperative follow-up. Data points collected will include: demographics, tumour characteristics, operative data), and postoperative outcomes. Primary outcomes include skull base repair technique and CSF rhinorrhoea (biochemically confirmed and/or requiring intervention) rates. Pooled data will be analysed using descriptive statistics. All skull base repair methods used and CSF leak rates for TSA and EEA will be compared against rates listed in the literature. ETHICS AND DISSEMINATION: Formal institutional ethical board review was not required owing to the nature of the study - this was confirmed with the Health Research Authority, UK. CONCLUSIONS: The need for this multicentre, prospective, observational study is highlighted by the relative paucity of literature and the resultant lack of consensus on the topic. It is hoped that the results will give insight into contemporary practice in the UK and Ireland and will inform future studies.

Neurosurgery and coronavirus: impact and challenges-lessons learnt from the first wave of a global pandemic.

INTRODUCTION AND OBJECTIVES: The novel severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic has had drastic effects on global healthcare with the UK amongst the countries most severely impacted. The aim of this study was to examine how COVID-19 challenged the neurosurgical delivery of care in a busy tertiary unit serving a socio-economically diverse population. METHODS: A prospective single-centre cohort study including all patients referred to the acute neurosurgical service or the subspecialty multidisciplinary teams (MDT) as well as all emergency and elective admissions during COVID-19 (18th March 2020-15th May 2020) compared to pre-COVID-19 (18th of January 2020-17th March 2020). Data on demographics, diagnosis, operation, and treatment recommendation/outcome were collected and analysed. RESULTS: Overall, there was a reduction in neurosurgical emergency referrals by 33.6% and operations by 55.6% during the course of COVID-19. There was a significant increase in the proportion of emergency operations performed during COVID-19 (75.2% of total, n=155) when compared to pre-COVID-19 (n = 198, 43.7% of total, p < 0.00001). In contrast to other published series, the 30-day perioperative mortality remained low (2.0%) with the majority of post-operative COVID-19-infected patients (n = 13) having underlying medical co-morbidities and/or suffering from post-operative complications. CONCLUSION: The capacity to safely treat patients requiring urgent or emergency neurosurgical care was maintained at all times. Strategies adopted to enable this included proactively approaching the referrers to maintain lines of communications, incorporating modern technology to run clinics and MDTs, restructuring patient pathways/facilities, and initiating the delivery of NHS care within private sector hospitals. Through this multi-modal approach we were able to minimize service disruptions, the complications, and mortality.

Atypical Cauda Equina Syndrome with Lower Limb Clonus: A Literature Review and Case Report.

BACKGROUND: Cauda equina syndrome (CES) is a neurosurgical emergency warranting urgent surgical decompression. Treatment delay may precipitate permanent adverse neurological sequelae. CES is a clinical diagnosis, corroborated by radiological findings. Atypical presentations should be acknowledged to avoid inappropriately rejected diagnoses. CASE DESCRIPTION: We report the case of a woman exhibiting bilateral lower limb weakness, perineal numbness, sphincter disturbance, and lower limb clonus. Classically, CES displays lower motor neuron signs in the lower limbs. The presence of clonus, an upper motor neuron sign, brought the diagnosis into doubt. The history included chronic fatigue, difficulty mobilizing, and intermittent blurred vision. A lumbosacral magnetic resonance imaging (MRI) scan demonstrated a large disc prolapse at L5/S1. The cord was not low-lying or tethered. Therefore, the possibility of second diagnoses, including of inflammatory or demyelinating nature, was raised. An urgent MRI scan of the brain and cervicothoracic cord identified no other lesions. On balance, the clinical presentation could overwhelmingly be attributed to the L5/S1 disc prolapse. Given the time-critical nature of cauda equina (CE) compression, an urgent laminectomy and discectomy was offered with continued postoperative investigation of the clonus. Intraoperatively, significant CE compression was found. The operation proceeded uneventfully and the patient recovered fully. In the immediate postoperative period, the clonus persisted yet subsequently resolved completely. CONCLUSIONS: We conclude that the clonus was attributable to CE compression and not a second pathology. The corresponding neuroanatomical correlate remains nondelineated. The presence of clonus does not preclude a diagnosis of CES. If the clinicoradiological information otherwise correlate, surgery should not be delayed while alternative diagnoses are sought. The literature is also reviewed.

Adult Parasellar Capillary Hemangioma with Intrasellar Extension.

BACKGROUND: Capillary hemangiomata are benign vascular tumors that typically occur in children. They rarely occur in the central nervous system. Intracranial capillary hemangiomata in adults are very rare entities with only 18 cases reported in the literature. We report a case of parasellar capillary hemangiomata that extended into the sella in a 64-year-old woman as well as a review of the literature in adults. CASE DESCRIPTION: We report a 64-year-old patient who presented with a headache, left-sided paresthesia, and weakness. Initial computed tomography of her brain showed a left-sided 3 cm × 2.5 cm parasellar lesion with intrasellar extension and no mass effect. Subsequent magnetic resonance imaging (MRI) showed a lesion that was homogenously hyperintense on T2-weighted MRI and fluid-attenuated inversion recovery, isointense with adjacent brain parenchyma on T1-weighted MRI, and which demonstrated enhancement after contrast administration. The patient initially underwent an endoscopic transsphenoidal biopsy, which was inconclusive, followed by a craniotomy, biopsy, and debulking. Histologic examination showed fibrous tissue containing numerous thin-walled and irregular vascular channels of varying sizes. There was a very mild associated inflammatory infiltrate, mainly formed of small mononuclear chronic inflammatory cells and occasional histiocytes. The histologic appearances were in keeping with capillary hemangiomata. CONCLUSIONS: Capillary hemangiomata related to the sella are very rare and can easily be misdiagnosed on imaging alone. The present case highlights capillary hemangiomata as an important, albeit rare, differential when considering a sellar or parasellar mass.

Pre-emptive intrathecal vancomycin therapy reduces external ventricular drain infection: a single centre retrospective case-control study.

OBJECTIVES: External ventricular drain (EVD)-related infection is a significant source of morbidity in neurosurgical patients. Recently, there has been a drive to adopt new catheters with bactericidal properties to reduce infection rates. We propose that the use of standard catheters combined with pre-emptive intrathecal vancomycin (ITV) 10 mg daily provides an effective alternative. DESIGN: Retrospective study of all patients with EVDs between 2010 and 2012, comparing infection rates in those who did and did not receive pre-emptive ITV. All EVDs were of the standard silicon catheter type. CSF infection was defined, as per Centre for Disease Control (CDC) guidelines, as clinical suspicion ± positive CSF gram stain/culture or leucocytosis. Infection rates were compared using Pearson's chi-squared test. RESULTS: 262 EVDs were included in the study, of which 111 were managed with pre-emptive ITV. The infection rate was 2.7% in the vancomycin group and 11.9% in the control group (p<.01). There were no cases of vancomycin-resistant infection in either group. CONCLUSION: The use of pre-emptive ITV is associated with a significantly lower EVD infection rate. This compares favourably with those reported in the literature for bactericidal catheters.

Surgical access rather than method of pleurodesis (pleurectomy or pleural abrasion) influences recurrence rates for pneumothorax surgery: systematic review and meta-analysis.

AIM: Surgery for recurrent spontaneous pneumothoraces is one of the most commonly performed procedures in thoracic surgery, but few studies have evaluated the efficacy of the surgical treatment options. We aimed to evaluate the influence of the type of pleurodesis on recurrence whilst adjusting for surgical access by systematic review and meta-regression of randomised and non-randomised trials. METHODS: A systematic literature search undertaken for studies on pneumothorax surgery in MEDLINE, EMBASE, Cochrane Library, Internet trial registers and conference abstracts identified 29 studies (4 randomised and 25 non-randomised) eligible for inclusion. Meta-regression was performed adjusting for access to screen for evidence of a difference in recurrence rates. RESULTS: Access remained the principal determinant of recurrence rates after surgery. The relative risk of recurrence was 4.731 (2.699-8.291; p < 0.001) using video-assisted thoracoscopic surgery compared to open access. After adjusting for access, the relative risk of recurrence of pleural abrasion compared to pleurectomy was observed to be 2.851 (95 % CI 0.478-17.021), but this was not statistically (p = 0.220). CONCLUSION: Surgical access remains the most important factor that influences outcome after surgery for recurrent pneumothoraces. Although the relative risk of recurrence was higher with pleural abrasion compared to pleurectomy, it was not statistically significant, and more work needs to be conducted to address this question.

Psychological distress does not compromise outcome in spinal surgery.

SUMMARY OF BACKGROUND DATA: Physical outcomes following surgery for degenerative spine disease have been well studied whereas the importance of psychological factors has only recently been acknowledged. Previous studies suggest that pre-operative psychological distress predicts poor outcome from spinal surgery. In the drive to identify patients who will not benefit, these patients risk being denied surgery. STUDY DESIGN: This is a prospective series from a spinal surgical register. AIM: The study examines the relationship between the physical symptoms, pre-operative psychological distress and outcome following surgery. METHODS: The Short Form 36 (SF36) Health Survey Questionnaire and the Hospital Anxiety and Depression Scale (HADS) were administered to patients undergoing elective surgery for degenerative spine disease pre-operatively and at 3 and 12 months post-operatively. Levels of physical disability (SF-36 physical functioning (SF36PF) and bodily pain (SF36BP) scores) and psychological distress (HADS-anxiety and HADS-depression scores) before and after surgery were compared. RESULTS: A total of 302 patients were included (169 men, 133 women, mean age 55 years). Pre-operatively patients had worse physical scores than age-matched controls (SF36PF normative mean (S.D.) 80.97 (12.69) vs. pre-op 33.31 (24.7) P < 0.05). Of the 302 patients, 117 (39%) had significant anxiety or depression. Increased levels of anxiety or depression pre-operatively correlated with worse physical (SF-36PF and SF-36BP) scores pre-operatively (Spearman's r P < 0.05). Levels of anxiety and depression were reduced post-operatively and physical outcomes improved post-operatively. Physical function remained worse in those groups who had high levels of anxiety and depression pre-operatively but when matched for pre-operative physical function, psychological distress did not have any additional effect on outcome. CONCLUSIONS: Poor physical function pre-operatively correlates with psychological distress. Both physical and psychological symptoms improve after surgery. Physical outcome after surgery is strongly influenced by pre-operative physical functioning but not independently by psychological distress. Anxious and depressed patients should continue to be offered surgery if clinically indicated.

Lipomatosis of the trigeminal nerve causing trigeminal neuralgia: case report and literature review.

UNLABELLED: Cerebellopontine angle lipomas are rare and attempts at surgical excision are associated with significant morbidity. Lipomatosis of nerve, the fatty infiltration of nerves, is a distinct entity. We present a case of intractible trigeminal neuralgia caused by lipomatosis of the trigeminal nerve. CLINICAL CASE: A 25-year-old male presented with severe right-sided trigeminal neuralgia. Imaging showed a lesion involving the trigeminal nerve with signal characteristics of fat. At surgery the lesion was found to be a fatty infiltration of the nerve itself. Surgery was therefore limited to arachnoid adhesiolysis. The patient remains symptom-free and neurologically intact to date. Correctly identifying these lesions as lipomatosis of nerve rather than lipoma of the cerebellopontine angle make it clear that even partial surgical excision will inevitably result in neurological deficit and should not be attempted. However, in the case of intractable trigeminal neuralgia we demonstrate that surgery can still play a role.

Recurrence rates of video-assisted thoracoscopic versus open surgery in the prevention of recurrent pneumothoraces: a systematic review of randomised and non-randomised trials.

BACKGROUND: Evidence supporting similar recurrence rates between video-assisted and open surgery for the treatment of recurrent pneumothorax is questionable, because the number of randomised trials is sparse and they are underpowered to detect any meaningful difference. Our aim was to do a systematic review of randomised and non-randomised studies to compare recurrence rates between the two forms of surgical access. METHODS: We did a systematic literature search for studies on pneumothorax surgery in Medline, Embase, Cochrane Library, trial registers on the internet, and conference abstracts, and identified 29 studies (four randomised and 25 non-randomised) eligible for inclusion. Meta-analysis was done by combining the results of reported recurrence rates in patients undergoing video-assisted thoracoscopic surgery compared with those having open surgery. Both fixed and random effects models were applied to the results pooled for analysis. RESULTS: In studies that did the same pleurodesis through two different forms of access, the relative risk (RR) of recurrences in patients undergoing video-assisted surgery compared with open surgery was similar between non-randomised and randomised studies (RR 4.880 [95% CI 2.670-8.922] vs 3.951 [0.858-18.193]), yielding an overall RR of 4.731 (2.699-8.291; p<0.0001). There was no evidence to suggest heterogeneity of trial results (p=0.88). The high RR of recurrence for video-assisted surgery remained robust to a random effects model (4.051 [1.996-7.465]; p<0.0001), by including all comparative studies (3.991 [2.584-6.164]; p<0.0001), with only high-quality studies used (4.016 [1.8468.736]; p<0.0001), and on a simulation biased in favour of video-assisted surgery when there were no events in either group (3.559 [2.165-5.852]; p<0.0001). INTERPRETATION: Both randomised and non-randomised trials are consistent in recurrence of pneumothoraces and show a four-fold increase when a similar pleurodesis procedure is done with a video-assisted approach compared with an open approach.

Effect of pulsatile administration of levodopa on dyskinesia induction in drug-naïve MPTP-treated common marmosets: effect of dose, frequency of administration, and brain exposure.

Levodopa (L-dopa) consistently primes basal ganglia for the appearance of dyskinesia in parkinsonian patients and 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine hydrochloride (MPTP) -treated primates. This finding may reflect its relatively short duration of effects resulting in pulsatile stimulation of postsynaptic dopamine receptors in the striatum. We have compared the relationship between L-dopa dose and frequency of administration on dyskinesia initiation in drug-naïve, MPTP-treated common marmosets. We have also studied the effect of increased brain exposure to pulsatile administration by combining a low-dose of L-dopa with the peripheral catechol-O-methyltransferase inhibitor (COMT-I), entacapone. Pulsatile administration of a low (dose range, 5.0-7.5 mg/kg p.o.) or a high (12.5 mg/kg) dose of L-dopa plus carbidopa b.i.d. produced a dose-related reversal of motor deficits. Repeated administration of low and high doses of L-dopa for 26 days to drug-naïve, MPTP-treated animals also caused a dose-related induction of peak-dose dyskinesia. Repeated administration of high-dose L-dopa b.i.d. compared to once daily caused a frequency-related improvement of motor symptoms, resulting in a more rapid and initially more intense appearance of peak-dose dyskinesia. Administration of low-dose L-dopa b.i.d. for 26 days in combination with entacapone enhanced the increase in locomotor activity and reversal of disability produced by L-dopa alone, but with no obvious change in duration of L-dopa's effect. However, combining entacapone with L-dopa resulted in the more rapid appearance of dyskinesia, which was initially more severe than occurred with L-dopa alone. Importantly, increasing pulsatile exposure of brain to L-dopa by preventing its peripheral breakdown also increases dyskinesia induction.