Adductor tenotomy in the management of groin pain in athletes.

This study evaluates the efficacy of adductor longus tenotomy in athletes with chronic tendinopathy refractory to conservative management. In a retrospective case series we report our experience with 109 male athletes who underwent unilateral adductor tenotomy during the period 2000-2005, all of whom responded to a detailed questionnaire. The criterion for tenotomy was chronic adductor origin pain which prevented training or playing (Level 4), limited training or playing (Level 3), or affected performance (Level 2)and which had failed to respond to conservative management including rest, rehabilitation and/or local steroid injection. Level 1 performance is classified as optimal performance with no pain. 99 of the 109 patients (91%) reported improvement. Best results were achieved in patients with maximum discomfort preoperatively (Level 4) with 32 of 38 (84%) patients returning to Level 1 performance. In conclusion, adductor tenotomy in athletes with severely incapacitating pain (Level 3/4) which fails to respond to conservative management offers the best opportunity of returning to competitive sport.

An evaluation of Irish general surgical research publications from 2000 to 2009.

BACKGROUND: Maintaining a high standard of research, and being competitive in the funding application process requires a coordinated and focused research strategy. The first step in the formulation of such a strategy is the identification of those centres, and specifically those areas of study, in which Irish surgical research has previously performed strongly. The aim of this paper was to evaluate all surgical research produced in the Republic of Ireland in the first ten years of the new millennium. METHODS: All publications originating from adult Irish general surgical units between the years 2000-2009 were identified from Pubmed and Medline databases. All publications were examined for senior author, originating institute, theme, research model and publishing journal. RESULTS: There were a total of 590 publications in Irish general surgical units during the study period. The top publishing hospitals were Institution 1 (129:21%), Institution 2 (82:13.9%) and Institution 3 (81:13.7%). One hundred and thirty three papers were published in journals with impact factors > 4.5. Papers were more likely to be published in journals with impact factors > 4.5 if they came from Institution 1 (38 papers) p = 0.001, published on breast (50 papers) p < 0.001 or upper gastrointestinal topics (35 papers) p < 0.001, or published on bench research (76 papers) p < 0.001. Publications increased from the first half of the decade to the second, with the largest increases seen in Institution 1 (40-89), Institution 4 (21-42) and Institution 6 (11-37). CONCLUSIONS: Ireland continues to produce high quality surgical research, characterised by number of articles produced per 106 inhabitants. This study shows that the number of articles published in the second half of the decade almost doubled from 221 to 369 and that the mean journal impact factor for all articles published was 2.87.

'Scapula alata' as a consequence of park bench position for a retro-mastoid craniectomy.

We report on a patient who developed winged scapula on the contralateral side to the approach for a cerebellopontine tumour excision, an unreported complication following this procedure. We think this was due to damage of the long thoracic nerve in the dependant side, while in the park bench position.

Supratentorial intraventricular schwannoma.

A rare case of supratentorial intraventricular schwannoma is described. A 16-year-old male with asymptomatic papilloedema was found to have a 5-cm intraventricular tumour arising from the trigone of the right lateral ventricle. A craniotomy and total macroscopic excision was performed.

The role of neuroendoscopy in the management of brain tumours.

Neuroendoscopy is increasingly used in the management of brain tumours and tumour related hydrocephalus and this study reviews the efficacy of neuroendoscopic interventions in this unit in patients with brain tumours. A series of 87 neuroendoscopic operations carried out in 77 patients with brain tumours over a 6-year period is reported. The age range of the patients was from 5 months to 70 years (median 13 years). In 56 cases (64%) presentation was with a newly-diagnosed tumour and hydrocephalus. The majority of the remaining patients had varying degrees of worsening hydrocephalus on the background of a previously diagnosed tumour. Neuroendoscopic third ventriculostomy (NTV) was successful in relieving hydrocephalus in the short term in 63/66 cases (95%) and in the longer term in 55/66 cases (83%). Neuroendoscopic tumour biopsies were successful in providing a tissue diagnosis in 17/28 cases (61%) and four extensive and three partial resections of tumour were carried out. There were two deaths within 30 days of the procedure with only one of these, secondary to intraventricular haemorrhage, directly related to neuroendoscopy. Few significant complications were noted otherwise. For selected intraventricular and paraventricular tumours neuroendoscopy offers the opportunity to combine relief of hydrocephalus with tumour biopsy and sampling of CSF in a single procedure.

Endoscopic management of basal encephaloceles.

Encephaloceles have been traditionally treated by a transcranial or external approach. The advent of endoscopic sinus surgery has allowed a new intranasal approach for the treatment of basal encephaloceles, minimising patient morbidity. We discuss the classification and presentation of encephaloceles, and present our experience in the repair of six cases. We believe transnasal endoscopic repair is the method of choice in dealing with selected basal encephaloceles.

CSF rhinorrhoea: the place of endoscopic sinus surgery.

Cerebrospinal fluid (CSF) rhinorrhoea has been managed by both neurosurgeons and otorhinolaryngologists, with neurosurgeons often choosing an intracranial approach and otorhinolaryngologists an extracranial approach. Recently, transnasal endoscopic techniques have been introduced that significantly reduce the morbidity of surgical repair when compared with previous techniques. The sense of smell was preserved in all patients who underwent an endoscopic repair of their CSF leak where it was present preoperatively. The results of transnasal endoscopic repair now make it the treatment of choice for most anterior cranial and sphenoid CSF leaks, with the exception of defects in posterior wall of the frontal sinus or defects larger than 5 cm. It is vital that a diagnosis of a CSF leak is confirmed by immunofixation of beta 2 transferrin as unilateral rhinorrhoea can masquerade as a CSF leak. We illustrate our experience with 78 patients who were referred with a diagnosis of CSF rhinorrhoea.

Third ventricular cysts and membranes unsuspected on conventional CT and MRI.

Three cases are presented of symptomatic cysts or membranes within the third ventricle interfering with CSF flow and presenting as non-communicating triventricular hydrocephalus. None was visible on conventional CT or MRI, two being discovered at neuroendoscopy and one only with a specific MRI sequence designed to show CSF partitioning.

An algorithm for the management of CSF rhinorrhoea illustrated by 36 cases.

The diagnosis of cerebrospinal fluid (CSF) rhinorrhoea should be established beyond reasonable doubt before surgical intervention is embarked upon. It is important not to miss the diagnosis in view of the real potential complication of meningitis if it is left untreated. We describe a management algorithm which centers around the selective use of nasal endoscopy, immunofixation of beta2 transferrin, high resolution coronal CT scans, and fluorescein lumbar puncture. This management strategy is illustrated with 36 cases. We have developed a minimally invasive endoscopic technique to repair CSF leaks, and in 30 patients we had a success rate of 93% after one procedure.

Osteomyelitis of the skull vault from a human bite.

We report a case of extensive osteomyelitis of the skull vault from a human bite. The presentation and surgical management of this unusual condition is described. The microbiological findings are comparable to known patterns of infection after human bites. Surgical management and prophylaxis after this injury are discussed.

The endoscopic treatment of cerebrospinal fluid rhinorrhoea: the Nottingham experience.

The conventional neurosurgical management of cerebrospinal fluid (CSF) rhinorrhoea has been by intracranial access. Otorhinolaryngologists have undertaken extracranial approaches where access has been possible, and more recently an endoscopic approach has been advocated. We report 17 patients with confirmed CSF rhinorrhoea treated with endoscopic techniques between 1993 and 1996. Follow-up ranged from four to 32 months and showed an overall closure rate of 16 out of 17 patients with no complications. No patient undergoing primary endoscopic repair developed anosmia. The use of fluorescein helped localize the site of the CSF leak in four patients in whom the computed tomography (CT) scan had not identified the site of the defect. We conclude that the endoscope is a valuable tool in the evaluation and subsequent treatment of CSF rhinorrhoea. Where the skull base defect is accessible to the endoscope, we propose that an endoscopic approach should be considered as the preferred method.

Multiple subpial transection: a review of 21 cases.

Multiple subpial transection (MST) is a novel technique in surgery for epilepsy, employed in patients where some or all of the epileptogenic zone cannot be resected because it lies in a vital cortical area. Twenty one patients subjected to MST were reviewed. Eighteen patients had medically intractable epilepsy and three patients had Landau-Kleffner syndrome. Their ages ranged from 6 to 47 (mean 15-9) and duration of epilepsy ranged from 0.33 to 42 (mean 8.6) years. Preoperative MRI showed focal abnormalities in eight cases. Detailed electrophysiological examination was carried out on all patients. Brain resection was performed in addition to MST in 12 patients. A further six patients underwent brain biopsy. Three patients with Landau-Kleffner syndrome were subjected neither to resection nor to biopsy. Histopathological examination showed Rasmussen's syndrome in six patients, cortical dysplasia in six, cerebral tumour in one, and non-specific changes in five. Multiple subpial transection was carried out mainly in precentral and postcentral regions. Eighteen patients have been followed up for one to five years, and three for 10 months. The three patients with Landau-Kleffner syndrome were mute before operation and have shown substantial recovery of speech. Of the other 18, 11 showed a worthwhile decrease in seizure frequency. None of the patients developed chronic neurological deficits attributable to MST. It is concluded that MST leads to worthwhile seizure control without major neurological deficit in patients who would otherwise be inoperable.

Cerebral vasospasm following subarachnoid hemorrhage: effect of calcitonin gene-related peptide on middle cerebral artery velocities using transcranial Doppler sonography.

The case of a middle cerebral artery vasospasm following subarachnoid hemorrhage is discussed. The effectiveness of treating the vasospasm with calcitonin gene-related peptide is illustrated.

Effect of calcitonin-gene-related peptide on postoperative neurological deficits after subarachnoid haemorrhage.

An infusion of calcitonin-gene-related peptide (CGRP) at progressively increased concentrations was given to 15 patients with neurological deficits after intracranial aneurysm surgery for subarachnoid haemorrhage. In 9 of the patients the deficits, quantified by a modified Glasgow coma scale, improved with no adverse effects; after a placebo infusion only 2 of the 15 patients showed improvement. If CGRP can reverse cerebral ischaemia after early intracranial aneurysm surgery, its use may improve the safety of such early surgery, remove the need for late surgery with its increased risk of death from rebleeding, and reduce overall morbidity and mortality of aneurysmal subarachnoid haemorrhage.

Aqueduct stenosis--presentation and prognosis.

In the 14-year period from 1974-1987 during which CT scanning was available in Edinburgh, 36 patients with benign, non-tumour related aqueduct stenosis were identified from a group of 342 patients with hydrocephalus. In terms of age at presentation, the patients separate into two groups, 9 cases diagnosed during the first year of life and 27 patients aged from 7 to 72 years. The presentation in the early cases was fairly acute, the diagnosis was secure and the operative treatment by ventricular peritoneal shunt was relatively free of complications. In the older patients, the first presentation was more chronic, and further investigation required a change of diagnosis in 5 of the 27 patients. More than half of the patients had recurrent symptoms which were much more acute and operative treatment was attended by a significant number of complications including death from intraventricular haemorrhage in one case.