Complete third nerve palsy as a presenting feature of an interpeduncular lipoma.

BACKGROUND: Intracranial lipomas are rare, benign lesions, of congenital origin commonly found incidentally on imaging studies. METHODS: We describe a case of interpeduncular lipoma in an 18 year-old female presenting with a painful left complete oculomotor (IIIrd) nerve palsy and associated headache, which to the best of our knowledge has not been reported in an adult patient. RESULTS: Following eye patching and steroid treatment, at 6-week follow-up the patient's pain had significantly improved however the complete IIIrd nerve palsy remained. CONCLUSIONS: Evidence suggests improvement will occur regardless with conservative management independent of radiological changes to the lipoma.

C-reactive protein kinetics post elective cranial surgery. A prospective observational study.

Introduction: Post cranial surgery readmission, largely caused by surgical site infection (SSI), is a marker of patient-care quality requiring comprehensive discharge planning. Currently, discharge assessment is based on clinical recovery and basic laboratory tests, including C-reactive protein (CRP). Although CRP kinetics have been examined postoperatively in a handful of papers, the validity of CRP as a standalone test to predict SSI is yet to be explored.Methods: A prospective observational study was performed on adult patients undergoing elective cranial surgery over a 3-month period. Laboratory data; CRP, white cell count (WCC), neutrophil cell count (NCC), and clinical data were assessed pre and post-operatively and were evaluated as predictors for safe discharge. Readmission rates within 1 month were recorded.Results: In this study, 68 patients were included. About 8.6% were readmitted due to SSI. A postoperativepeak in CRP was seen on day 2 with a value of 57 in the non-readmitted group, and 115 in the readmitted group. CRP dropped gradually to normal levels by day 5 in the non-readmitted group. A secondary CRP rise at day 5 was noted in the readmitted group with a sensitivity, specificity, and negative predictive value of 71%, 90%, and 96%, respectively. Interestingly, our ROC analysis indicates that a CRP value of less than 65 predicts safe discharge with a sensitivity of 86%, specificity of 89% and negative predictive value of 98% of safe discharge (area under the curve, AUC: 0.782). No significant difference in other inflammatory markers was found between both groups.Conclusions: CRP increases postoperatively for 4-5 d which could be a physiological response to surgery, however, prolonged elevation or a secondary increase in CRP may indicate an ongoing infection. Our data validate the potential use of CRP levels to predict SSI. A multicentre study is warranted to investigate the role of CRP in predicting SSI.

Ventriculo-peritoneal shunt independence following successful treatment of Gram negative (E. coli) ventriculitis: Case report and review of the literature.

We report a case of tumour-related hydrocephalus in a child treated with a ventriculo-peritoneal shunt which subsequently became infected with gram negative bacteria (Escherichia coli). After successful treatment of the infection the patient became shunt independent and has remained so for over 2 years. Gram negative ventriculitis is associated with diminished cerebro-spinal fluid production and we discuss the literature to date regarding this phenomenon.

Patient dependant on ventriculo-atrial shunt after 49 years.

The insertion of ventriculo-atrial (VA) shunts has been performed for the treatment of hydrocephalus since the 1950s. Thrombosis, infection, pulmonary hypertension, tricuspid stenosis, shunt nephritis, intra-cardiac migration due to displacement or fracture are reported complications. (1) We present the case of a 49-year-old female who had a VA shunt as a baby, that was never revised, who presented with a neck abscess related to the shunt tubing.

Adverse financial and clinical burden of the use of prophylactic antibiotics in neurosurgical patients.

Background: Current guidance does not support the administration of prophylactic antibiotics in non-infected post-operative surgical cases including neurosurgery. Materials and methods: This paper is a qualitative assessment, highlighting the economic cost of excessive antimicrobial prescription and the healthcare costs of the extra days of admission in hospital. Results: One hundred and one neurosurgical cases were analysed in a single institution over a one-year period. The additional course of post-operative antibiotics has a cost of £56.72 and receiving prolonged post-operative antibiotics added on average £1121.10 to their admission bill. Up to 13.4 patients may have experienced an adverse drug event. Conclusion: This paper reinforces the adherence to guidelines can aid in the reduction of adverse drug events, improve patient outcomes, and reduce costs associated with unnecessary drug prescriptions and administration.

The Environmental Footprint of Neurosurgery Operations: An Assessment of Waste Streams and the Carbon Footprint.

Healthcare in England generates 24.9 million tonnes of carbon dioxide equivalents (CO2e), equating to approximately 4% of the total national output of greenhouse gases (GHG), and of this, 10% is from the manufacturing of medical equipment. Operating theatres are a major contributor of biomedical waste, especially consumables, and are three-to-six times more energy intensive than the rest of the hospital. This study seeks to quantify and evaluate the carbon cost, or footprint, of neurosurgery at a single institution in England. A single neurosurgical operation generates, on average, 8.91 kg of waste per case, equivalent to 24.5 CO2e kg per case, mostly from single-use equipment. Per annum, 1300 neurosurgical operative cases are performed with total waste generation of 11,584.4 kg/year and a carbon footprint of 31,859 (kg) CO2e. The challenge of achieving net zero GHG presents an opportunity to catalyse innovation and sustainability in neurosurgery, from how care is delivered, through to equipment use and surgical methodologies. This should improve the quality of healthcare provision to patients and yield potential cost savings.

Lumbar discal cyst and post-operative discal pseudocyst: a case series.

Four cases of lumbar cyst (2 discal cysts and 2 post-operative discal pseudocysts) who presented predominantly with features of sciatica without any motor, sensory or sphincteric disturbances. The patients were treated conservatively, and the management was aimed to avert any untoward surgical intervention taking into consideration patient safety and care. Two had previous lumbar decompressive discectomy. During the mean follow-up period of 13 months, there was progressive recovery of symptoms in all our 4 patients. All our patients were successfully managed by conservative approach. An intervertebral disc cyst should be considered in young patients in the differential diagnosis of any extradural intraspinal mass ventral to the thecal sac, notwithstanding its rarity. Alongside, conservative management can be offered as first line of management with appropriate patient selection that is absence of any motor/sensory/sphincteric disturbances. Facetal micro-instability could be one of the aetiologies of this pathology which necessitates further study.

A Retrospective Study on the Impact of COVID-19 on Emergency General Surgery.

Background The coronavirus pandemic has caused global disruption to all aspects of life. This disturbance has been most notable in the medical world. Political, societal, medical, and behavioral alterations have forced emergency surgical practices to adapt. This study investigated the impact of coronavirus 2019 (COVID-19) at a busy surgical center. Methodology This is a retrospective observational study. Three study periods were analyzed: pre-COVID, first wave, and second wave. Data were collected on referrals, diagnoses, investigations, management pathways, outcomes, patient behavior, and consultant practice. A one-way analysis of variance (ANOVA test) was used for the analysis of parametric data and the Mann-Whitney U test for non-parametric data. Results Declining numbers of patients presented across the three periods. There was a severe disruption in performing emergency general surgeries during the first wave, propagated by alterations in clinical decision-making, as well as fluctuations in societal and patient behavior. Despite the effects of the second wave being significantly more profound in terms of hospitalization and COVID-related mortality, a paradoxical, gradual return to the norm was noted, which was seen in referral pathways, imaging decisions, and management strategies. Conclusion Our data is suggestive of society, both within and outside the medical sphere, adjusting to life with COVID-19.

Cervical arthropathy caused by gout: stabilisation without decompression.

The cervical spine is a rare site where tophaceous gout has been identified. There are currently 15 described cases in the literature of gouty involvement of the cervical spine with only three cases involving only the atlanto-axial region. We add the fourth of such cases and only the second to be managed operatively.

The incidence of avascular necrosis following a cohort of treated developmental dysplasia of the hip in a single tertiary centre.

PURPOSE: Avascular necrosis (AVN) may occur following treatment for developmental dysplasia of the hip (DDH). The primary aim of this study was to identify the incidence of AVN in a cohort of patients treated for DDH. Secondary aims were to classify AVN using available classification systems, analyze the correlation between the systems and investigate their relationship with the age at diagnosis of DDH. METHODS: An 11-year retrospective study was carried out at a single tertiary centre, using data from the clinical portal (patient records database) and IMPAX (system used to store plain radiographic images). Clinical details (patient demographics and outcomes) and plain radiographic images were used to identify cases of DDH and categorize cases of AVN using available classification systems: Tonnis and Kuhlmann, Kalamchi and McEwen, Bucholz and Ogden and Salter. Severin was used to assess final clinical outcome. RESULTS: In total, 405 (522 hips) cases of DDH were identified, of which 213 resolved without treatment, 93 were treated conservatively and 99 surgically. Only treated cases were included in the analysis (n = 192). AVN (45/99; 45.5%) was found to occur only postoperatively. A positive correlation was present between age at presentation and severity of AVN as classified according to Salter's criteria (chi-squared p value < 0.01). CONCLUSION: AVN incidence was 23.4% (45/192) and only occurred in surgically treated patients. Older age at diagnosis was associated with a higher incidence of AVN, as defined according to Salter's criteria. The classification systems appeared to show no correlation amongst each other (p-value < 0.01). LEVEL OF EVIDENCE: III - Retrospective cohort study.

Factors affecting the survival following surgical treatment of chronic subdural haematoma: Single institutional experience.

BACKGROUND: Chronic subdural haematoma (CSDH) is one of the most commonly treated condition in neurosurgery. It affects elderly populations who often have significant medical co-morbidities resulting in poor prognosis. The study aimed at identifying clinical factors influencing the survival following surgical management of CSDH. METHODS: Retrospective study included 267 cases that underwent surgery for CSDH and followed over 5-year period (2010-2015); data retrieved with reference to operation details, radiology reports and discharge. Using logistic and Cox regression analysis, the patient survival data was analysed with respect to patient demographics, type of surgery, co-morbidities, anticoagulation treatment, and discharge destination. RESULTS: The overall survival in the cohort was 37.0months (IQR: 20.0-60.0). The median age of the patients was 76years (IQR: 66-82) and the median length of hospital stay was 10days (range 1-126days; IQR: 6-17days). The recurrence rate was 6.37% (n=17). Fifty-three (19.85%) patients recorded deceased on the IPM database as of October 2016 and of those 11 died in hospital. Univariate Cox-regression analysis revealed increased age (HR: 1.80; 95%CI: 1.04-3.11), length of hospital stay (HR: 2.50; 95%CI: 1.41-4.41) and number of co-morbidities (HR: 2.19; 95%CI: 1.26-3.79) were associated with poor prognosis. Glasgow coma scale (GCS) at discharge was found to be significantly associated with survival whilst anticoagulation treatment did not. Multivariate analysis confirmed similar findings significant statistically. CONCLUSION: Age at admission, median length of hospital stay, number of co-morbidities, GCS at discharge and discharge destination have been found to influence survival significant statistically.

Postoperative cervical cord compression induced by hydrogel (DuraSeal): a possible complication.

STUDY DESIGN: A retrospective case report. OBJECTIVE: To raise the issue of DuraSeal for dural tear repair; to raise the issue of the potential for fatal consequences, if not considered to be an issue around and after surgery; and to illustrate this with a case. SUMMARY OF BACKGROUND DATA: Cerebrospinal fluid leak is a potential complication of spinal, and posterior fossa surgery. Leakage may be caused by inadvertent dural tears during decompressive laminectomy or extradural spinal approaches, for spinal surgery. We present the case of a complication as a result of repair for dural tear with hydrogel. METHODS: History, focused neurologic examination with pre- and postoperative magnetic resonance scan images. RESULTS: C5-C6 anterior cervical discectomy, and fusion with a standard commercial PEEK space cage. Intraoperatively there was a small cerebrospinal leak when excising the posterior longitudinal ligament. Surgicel and DuraSeal were used to seal this. The patient developed a quadriparesis after surgery which was a result of expansion of the hydrogel seen on MRI and at re-exploration. CONCLUSION: Hydrogel is now described for the second time to cause potentially fatal expansion.