Psycho-socio-economic outcomes in acoustic neuroma patients and their carers related to tumour size.

The objective was to explore psycho-socio-economic outcomes of a 2-year cohort of patients having surgery for an acoustic neuroma, and carers and their relationship to tumour size after surgery. The Wessex Patient Carer Questionnaire was designed in conjunction with Patients and Carers, to determine psycho-socio-economic outcomes. The results were juxtaposed against clinical profiles. The House-Brackman (HB) scale was used to assess facial function at 6 and 12 months after operation. The cohort contained 102 patients. There were 87% effective responders. Half were aged below 54 years and 30% had school-aged children. The majority (93%) of patients were operated via the translabyrinthine approach. Patients with large tumours, i.e. greater than 3 cm (28%), had most post-treatment physical problems, including hearing and balance difficulties, and 42% reported difficulty eating in public. Thirty-four per cent felt 'stressed' and 18%'depressed'. After 6 months, facial function was recorded as HB scale 5/6 in 21% of patients but by 1 year only 8% of patients were HB 5/6. Patients and carers were generally very satisfied with their in-patient neurosurgical care, but significantly dissatisfied with post-discharge care - particularly the shortcoming of the community services. The majority of families felt 'unsupported' and only 20% of patients had confidence in their General Practitioner's knowledge. Families faced severe socio-economic disruption and patients"time-off-work' was estimated to cost pound 954,000. Carers carried considerable post-discharge psychological burdens and costs to the public purse were calculated to be pound 52,000.

Two-year prospective study of psychosocial outcomes and a cost-analysis of 'treatment-as-usual' versus an 'enhanced' (specialist liaison nurse) service for aneurysmal sub arachnoid haemorrhage (ASAH) patients and families.

An 18-month retrospective study of 'treatment-as-usual' of aneurysmal subarachnoid haemorrhage (ASAH, n = 142) used as control to compare prospective study (n = 184) of an 'enhanced' ('Specialist Liaison Nurse'-SLN) service to reduce psychosocial trauma. Consultant notes, Glasgow Coma Scores and 'High Risk' bleeds scores provided clinical data. A standardized patient/carer designed questionnaire provided psychosocial data, plus a cost-analysis. The cohorts were good clinical and social matches. Sixty-five per cent of patients had 'high risk' bleeds, and 81% were Grade 1 and 2 on the GCS, 54% aged less than 55 years, 83% belonged to social classes 1-3 and 32% had school-aged children. Satisfaction with SLN inpatient and discharge care increased significantly, with reduced psychosocial trauma. The SLN produced net 'savings' of pounds sterling 155,000 p.a., from reduced time-off work, medical time and re-admissions. Prospectively, pounds sterling 1.6 + million annual 'savings' were identified on 80% of employed patients returning to work. Long-term dysfunctional stress is not inevitable for most ASAH patients as a SLN is clinically and fiscally cost-effective.

Visual function following neurosurgical optic nerve decompression for compressive optic neuropathy.

AIMS: To assess the course of visual function after neurosurgical decompression of the optic nerve during resection of intracranial tumours. To obtain information that may be used to counsel patients. METHODS: A retrospective review of the acuity and visual fields of 27 patients undergoing neurosurgical decompression of 36 optic nerves in a regional neurosurgical centre. Two groups were considered, those undergoing craniotomy for sphenoid wing meningioma en plaque, and those undergoing an extended transbasal approach to intracranial tumours. RESULTS: At the last follow-up (1-97 months), improvement in acuity was seen in 47% of eyes with decompressed nerves. One-third of these showed late improvement, and two-thirds showed immediate improvement. In total, 20% of eyes had worse acuity at the last follow-up compared with preoperative values, just under one-third of these showed late deterioration, and the remainder showed immediate deterioration. In total, 33% of eyes achieved acuities equal to those recorded preoperatively, 6% improving to this level postoperatively. CONCLUSIONS: The majority of eyes in this study maintained or improved acuity after decompression. A proportion of eyes continue to improve after surgery, and a proportion deteriorate. There is no relation between duration of preoperative symptoms or the level of preoperative acuity and the change in acuity achieved.

Team working: a report from the Society of British Neurological Surgeons.

Despite the obvious advantages of team-working these early pilot studies have provided an opportunity to see how difficult it is to formalize this concept in the current neurosurgical environment. The team approach and the patient database have often demonstrated the problems of patient management due to lack of resources, insufficient staff and pressure to deliver volume, rather than quality with inadequate levels of staff--precisely the criticism levelled at Bristol. If team working in neurosurgery is to succeed in developing quality standards for the continuity of patient care then the infrastructure has to be developed, support guaranteed and some aspects of culture within the service changed.

The repeatability of cerebral autoregulation assessment using sinusoidal lower body negative pressure.

A forced periodic variation in blood pressure produces a similar variation in cerebral blood velocity. The amplitudes and phases of the pressure and velocity waveforms are indicative of the dynamic response of the cerebral autoregulation. The phase of the velocity leads the pressure; the greater the phase difference the faster the autoregulation response. Various techniques have been employed to oscillate arterial blood pressure but measurement reproducibility has been poor. The purpose of this study was to assess the reproducibility of phase measurements when sinusoidal lower body negative pressure is used to vary blood pressure. Five healthy volunteers were assessed at two vacuum levels on each of eight visits. For each measurement a 12 s sinusoidal cycle was maintained for 5 min. The Fourier components of blood pressure and the middle cerebral artery velocity were determined at the oscillation frequency. The phase of velocity consistently led the pressure. The mean phase difference was 42+/-13 degrees for the stronger vacuum and 36+/-42 degrees for the weaker vacuum. The variation given is the within-subjects standard deviation estimated from a one-way analysis of variance. Sinusoidal lower body negative pressure is a useful stimulus for investigating autoregulation; it has advantages over other methods. High vacuums show good reproducibility but are too uncomfortable for patient use.

Sphenoid wing meningioma en plaque: a clinical review.

OBJECTIVE: To review the role of craniofacial resection and reconstruction in the treatment of patients with sphenoid wing meningioma en plaque. DESIGN: 15 patients were reviewed. The presenting features, operative details and complications were documented. The adequacy of resection was reviewed and postoperative scans were analyzed to assess orbital reconstruction. Patients were assessed regarding aesthetics and craniofacial function. The Glasgow outcome scale and the SF36 questionnaire were used to assess outcome. RESULTS: The majority (92%) presented with proptosis and had disease extending from the sphenoid wing into the orbital roof (71%) and the middle fossa (71%). The transzygomatic approach was the most commonly used approach (85%). 14 patients were examined on an outpatient basis, one patient has died. In the majority of patients visual acuity was unchanged (85%) and in most cases (85%) there was significant improvement in globe position. Ptosis (57%) and upper eyelid swelling (50%) were a persistent problem. Craniofacial function and cosmesis were well maintained. Two patients have had clinical recurrences (14%). 14 have had a good outcome adjudged by the Glasgow outcome scale and most patients have satisfactory outcomes adjudged by the SF36 questionnaire. CONCLUSIONS: Meningioma en plaque represents a difficult surgical challenge requiring a multidisciplinary approach. By using well established craniofacial techniques good disease control can be achieved with minimal morbidity and good functional and cosmetic results.

Intra-aortic balloon counterpulsation: augmentation of cerebral blood flow after aneurysmal subarachnoid haemorrhage.

OBJECTIVE: To measure cerebral blood flow before and after intra-aortic balloon counterpulsation (IABC) in patients at high risk of developing delayed cerebral ischaemia after aneurysm surgery following subarachnoid haemorrhage. METHODS: Six prospectively selected patients at high risk of developing delayed ischaemia had elective IABC after clipping of their cerebral aneurysm(s). The IAB inflates in early diastole and deflates at the end of diastole to increase cardiac perfusion and decrease afterload. This results in enhanced cardiac efficiency. It also augments cerebral blood flow (CBF). RESULTS: We demonstrated a significant increase in the mean hemispheric CBF from the preoperative (preIABC) value of 35.6 mls/100 g/min to 50.9 +/- 12.3 mls/100 g/min (p = 0.0042) as a result of balloon augmentation. Each patient developed a neurological deficit as a result of delayed cerebral ischaemia. These were reversed in 5 patients with increased CBF. There were minimal balloon related complications. CONCLUSION: IABC consistently enhanced CBF in these patients and resulted in stable cardiovascular parameters. This represents a possible new technique in the management of cerebral ischaemia following subarachnoid haemorrhage and needs further assessment to ascertainlits role.

The realities of postoperative disability and the carer's burden.

Outcome after high-risk, complex neurosurgery for progressive skull base pathology, and its effect on carers, has been examined. Two different outcome measures were used. The Glasgow Outcome Score (GOS) assesses overall social capability and dependence of the patient, while the 36 item short-form health survey (SF-36), a generic quality of life measure, can be compared directly with the general population. Overall outcome using the GOS indicated a favourable outcome for 13 of the 17 patients studied. The SF-36 demonstrated that more than half the patients were functioning at a level below the accepted norm. The reasons for this discrepancy and the validity of outcome scales have been analysed. In addition, the effect upon carers, its relevance to assessment of outcome, and the need to involve potential carers in the process of informed consent was stated. Our conclusions are applicable throughout the surgical specialities, and especially to high-risk complex surgery.

Prospective study of omental transposition in patients with chronic spinal injury.

OBJECTIVES: This prospective study was designed to assess the effects of omental transposition in patients with a chronic spinal injury. METHODS: Neurological status was established to be stable and multiple baseline across patient studies were done preoperatively and repeated postoperatively. Assessments included activities of daily living (ADL), functional ability, degree of spasticity, motor power, sensation, pain perception, urodynamic studies, electromyography, sensory evoked potentials (SEPs), and infrared thermography to measure peripheral and general skin vascular responses. Each patient had MRI. Assessments were done at 3, 6, and 12 months after omental transposition in 17 patients. RESULTS: The detailed assessments failed to show significant improvement, although some patients showed minor objective and subjective change in some categories. Neurological deterioration occurred in one patient. There were 20 surgical complications including urinary tract infection, deep vein thrombosis, wound infection, and incisional hernia. CONCLUSIONS: Omental transposition has not been shown to improve neurological function in 17 patients with chronic spinal cord injury, and continued use of this operation in this situation is not supported by this study. Further advances in spinal cord repair may utilise the pedicled omental graft to provide an alternative vascular supply, but its current use should be limited to experimental models.

Patient-assessed outcomes after excision of acoustic neuroma: postoperative symptoms and quality of life.

OBJECT: The aim of this study was to assess whether outcomes from excision of acoustic neuroma vary among patients and have a material impact on their quality of life (QOL). METHODS: A questionnaire concerning postoperative symptoms and the Short Form 36 (SF-36) QOL instrument were mailed to 97 consecutive patients who had undergone acoustic neuroma surgery via the translabyrinthine approach. The survey response rate was 78% and the symptomatology was consistent with other reports, supporting the representativeness of the sample. The respondents' QOL was rated significantly below published norms and their work capacity was reportedly reduced. Specifically, the following SF-36 dimensions were reduced: physical functioning and role-physical, together with vitality, general health, and social functioning. Greater numbers of postoperative symptoms and larger tumors were associated with a worse rating of physical functioning. More severe balance problems were associated with lower ratings of social functioning. The disparity between the patient's self-estimate and self-measurement and the clinician's assessment of the patient's facial functioning raises doubts about the validity of subjective reports and assessment. CONCLUSIONS: The present study supports the use of generic QOL measures to assess outcome and to draw comparisons between different populations.

Mechanisms to improve teamworking in neurosurgery.

Team-working has been seen as an important essential in the delivery of modern medical care and quality. It should increase the range of skills and knowledge in dealing with clinical problems and needs to make better use of scarce professional resources. In addition many see the team as reducing the risk of the harmful consequences of idiosyncratic practice. Team-working requires a named consultant to be responsible for individual patients with corporate responsibility for the practice. Doctors and managers will need to work together. The structure of teams will by necessity change but the requirements are constant. These are to provide a basis for continuing professional development, the monitoring of standards of performance and capacity, and above all, to improve patient care and outcome. An essential prerequisite is the provision of resources to provide a supportive environment if clinical excellence is to be the norm.

Principles and problems of assessing the results of medical treatment.

The integration of clinical expertise with the best available evidence from systematic research is the foundation of evidence-based medicine (EBM). The results from a well-designed randomised controlled trial (RCT) is regarded as the best evidence on which to base treatment. In neurosurgical practice fewer treatments are based on the results of RCTs than in medical practice. The reasons are historical, ethical, practical and can be compounded by the surgical learning curve. In neurosurgical practice treatment protocols and surgical indications vary widely. In addition there is a lack of patient orientated, disease specific and generic outcome measures. However, it is a neurosurgical responsibility to provide hierarchical evidence upon which treatment can be based. Comparative audit may offer a solution provided there is high quality data collection, relevant measures of outcome, a defined case-mix and a representative population. Comparative audit can produce bias but neurosurgeons will need to meet the challenge of EBM. Their patients will expect it.

Psychosocial outcomes for patients and carers after aneurysmal subarachnoid haemorrhage.

As part of a 'clinical governance' initiative, a patient/carer led study was designed to determine the psychosocial outcome of a consecutive cohort of 137 aneurysmal sub-arachnoid haemorrhage (ASAH) patients of whom 45% had experienced a severe haemorrhage. Most patients were middle class (51%), female (63%), aged under 54 years (53%) and 30% had school-age children. Information booklets did not meet the need for case-specific answers and communication problems were identified despite the high rating of in-patient treatment. Substantial problems occurred after discharge because of a hiatus in care and support by community-based services. Carers carried major psychosocial burdens, fifty-one per cent reporting that their work was negatively affected, and after a year, employment cost to carers was pounds sterling 182,000 and pounds sterling 590,000 for patients. 11% of patients lost their jobs as a direct consequence of the ASAH. A cost-feasible solution to improve the communication-support problems was identified by these 'consumers'.

Outcome from complex neurosurgery: an evidence based approach.

BACKGROUND: The aim of this study was to determine outcome, including quality of life, after surgery for petroclival meningioma using a standard skull base approach and to carry out an evidence based appraisal of the relevant literature. METHOD: Pre- and post-operative data including adverse events were prospectively recorded in 19 patients (15 females, age range 29-63) undergoing a transpetrous approach for a petroclival meningioma. Patients were assessed using the GOS and SF-36 post operatively. FINDINGS: 24 operations were done. 6 patients developed a new permanent neurological deficit and 10 experienced a temporary deficit or exacerbation of existing deficits. At 1 year 15 patients had made a good/moderate recovery, 3 were severely disabled and 1 died--in keeping with other studies. By contrast the SF-36 showed that in all 8 categories of the SF-36 between 39-72% of surviving patients were functioning below the accepted norms. INTERPRETATION: After transpetrous excision of a petroclival meningioma the quality of life for the patient is worse than that indicated in surgeons' reported results. This paper represents an attempt to address the issue of evidence-based medicine and finds that such an approach is not apparent in the medical literature on this pathology. While we argue that methods for measuring outcome should be refined and carers input recognised it does raise certain philosophical considerations. It is the counsel of perfection and if achieved may lead to surgeons operating on fewer patients, more petroclival cases being viewed as inoperable because of the higher morbidity, despite there being an inescapable pathway to surgical intervention.

Ventriculo-atrial shunt insertion: pressure monitoring as an aid to accurate placement.

The objective of this paper is to describe a new method to ensure accurate placement of a ventriculo-atrial shunt distal catheter. A technique is described using pressure waveform changes within the right side of the heart. Pressure monitoring is a new method of placing atrial catheters and is easy to perform.

Outcome after complex neurosurgery: the caregiver's burden is forgotten.

OBJECT: The goals of this study were twofold: 1) to determine outcome, including quality of life, in patients who have undergone surgery for petroclival meningioma in which a standard skull base approach was used; and 2) to assess the impact of the patients' surgical treatment on their caregivers. METHODS: Seventeen patients (13 women and four men ranging in age from 29 to 63 years) who underwent a transpetrosal approach for a petroclival meningioma during a 5-year period were prospectively included in this study. Pre- and postoperative data including adverse events were noted. The patients were assessed at 3, 6, and 12 months postoperatively, and annually thereafter, and they completed a postoperative SF-36 questionnaire. In addition, each patient's caregiver was interviewed to determine the effect of the patient's illness on the caregiver's life and responsibilities. Twenty-two operations were performed. A new permanent neurological deficit developed in five patients and in eight a temporary deficit or exacerbation of existing deficits occurred. Two patients underwent surgery to create a facial-hypoglossal nerve communication; five required a temporary percutaneous gastrostomy and/or tracheostomy; three required a shunt; and one underwent successful squint surgery. At 1 year postoperatively 13 patients had made a good or moderate recovery, three were severely disabled, and one had died--outcomes in keeping with other studies. By contrast, responses to the SF-36 questionnaire showed that, in all eight of its categories, between 43% and 75% of surviving patients were functioning below accepted norms. Fifty-six percent of caregivers experienced a major change in lifestyle and 38% experienced a major change with respect to their work. CONCLUSIONS: After transpetrosal excision of a petroclival meningioma, the quality of life for the patient is worse than that indicated in surgeons' reported results. The impact on the patient's caregiver is profound-a burden perhaps not fully appreciated by the surgeon.

The extended transbasal approach: a quantitative anatomical and histological study.

Since its introduction in 1972 the transbasal approach to the anterior fossa and sphenoethmoidal region has undergone a number of modifications. The extended transbasal approach with preservation of olfaction not only improves exposure of the anterior fossa, but also provides access to the clivus as far inferiorly as the foramen magnum. An anatomical study has been undertaken to photographically demonstrate and quantify the varying degrees of exposure that this technique provides. The pituitary stalk was used as an intracranial target. The amount of exposure was compared using a standard subfrontal approach, a transbasal approach and an extended transbasal with preservation of olfaction. In addition, a histological study was carried out to investigate the level to which identifiable olfactory nerves extended into the nasal mucosa. The anatomical study demonstrates the area of the "external window of exposure" can be doubled using a transbasal approach and more than quadrupled using the extended transbasal approach, when gaining access to the pituitary stalk. In addition, the study highlights the exposure of other anatomical areas, such as the medial orbit, the cavernous sinus, the clivus and the vertebrobasilar complex. The histological study establishes that the olfactory nerves extend only 10 mms below the cribriform plate.

The extended transbasal approach: clinical applications and complications.

OBJECTIVES: To describe in detail key technical aspects of the extended transbasal approach which involves en-bloc mobilisation of the supraorbital rim, the orbital roof and the nasoethmoidal complex. In some patients osteotomies were performed around the cribriform plate with a view to maintaining olfaction. To review 18 patients with deep seated lesions located in the central skull base region (including 6 recurrences) to highlight patient selection, presentation, surgical morbidity and outcome. METHODS: Prospective data recording and clinical chart review. RESULTS: Outcome was assessed at a minimum of 1 year after operation using the Glasgow Outcome Score. Thirteen patients had made a good recovery, 1 was moderately disabled, 2 were severely disabled (both had been severely disabled before operation), and 2 died. By contrast, quality of life assessment indicated that only 7 of the surviving 14 adults had returned to normal levels of activity and perceived health; although 6 of the other 7 patients had resumed their former occupations, their follow up assessments showed a reduced quality of life. Of the 13 patients who had an olfaction preservation procedure, 6 showed appreciation of smell on formal testing. CONCLUSIONS: In patients with progressive and extensive deep seated lesions this technique provides wide exposure in a shallow surgical field. Complication rates although acceptable were significantly higher in patients with intradural lesions. In some selected patients it was possible to preserve olfaction. Specific surgical outcome assessments pointed to satisfactory results, but failed to reflect the degree of patient disability. There is a need for outcome measures that take into account the patient's expectations and which address his quality of life in order to validate the benefits of these procedures.