ObjectivesExternal ventricular drain (EVD) insertion is a common neurosurgical procedure. EVD-related infection (ERI) is a major complication that can lead to morbidity and mortality. In this study, ...we aimed to establish a national ERI rate in the UK and Ireland and determine key factors influencing the infection risk.MethodsA prospective multicentre cohort study of EVD insertions in 21 neurosurgical units was performed over 6 months. The primary outcome measure was 30-day ERI. A Cox regression model was used for multivariate analysis to calculate HR.ResultsA total of 495 EVD catheters were inserted into 452 patients with EVDs remaining in situ for 4700 days (median 8 days; IQR 4–13). Of the catheters inserted, 188 (38%) were antibiotic-impregnated, 161 (32.5%) were plain and 146 (29.5%) were silver-bearing. A total of 46 ERIs occurred giving an infection risk of 9.3%. Cox regression analysis demonstrated that factors independently associated with increased infection risk included duration of EVD placement for ≥8 days (HR=2.47 (1.12–5.45); p=0.03), regular sampling (daily sampling (HR=4.73 (1.28–17.42), p=0.02) and alternate day sampling (HR=5.28 (2.25–12.38); p<0.01). There was no association between catheter type or tunnelling distance and ERI.ConclusionsIn the UK and Ireland, the ERI rate was 9.3% during the study period. The study demonstrated that EVDs left in situ for ≥8 days and those sampled more frequently were associated with a higher risk of infection. Importantly, the study showed no significant difference in ERI risk between different catheter types.
Management of cervical spine trauma in children Copley, Phillip Correia; Tilliridou, Vicky; Kirby, Andrew ...
European journal of trauma and emergency surgery (Munich : 2007),
10/2019, Letnik:
45, Številka:
5
Journal Article
Recenzirano
Odprti dostop
Purpose
Paediatric cervical spine injuries are fortunately a rare entity. However, they do have the potential for devastating neurological sequelae with lifelong impact on the patient and their ...family. Thus, management ought to be exceptional from the initial evaluation at the scene of the injury, through to definitive management and rehabilitation.
Methods
We set out to review cervical spine injuries in children and advise on current best practice with regards to management.
Results
Epidemiology, initial management at the scene of injury, radiological findings and pitfalls of cervical spine trauma are outlined. Strategies for conservative and surgical management are detailed depending on the pattern of injury. The management of spinal cord injuries without radiological abnormality (SCIWORA) and cranio-cervical arterial injuries is also reviewed.
Conclusions
Due to a paucity of evidence in these rare conditions, expert opinion is necessary to guide best practice management and to ensure the best chance of a good outcome for the injured child.
Highlights•Minimally invasive surgical approaches are safe treatments for paediatric lumbar disc herniation. •No particular surgical approach shows clear superiority of outcomes. •Lumbosacral ...anatomic variants likely predispose patients to disc herniation. •Surgery for lumbar disc herniation is equally or more efficacious for paediatric patients in comparison with adults.
Suprasellar meningiomas often invade the optic canals (OCs). The feasibility of removing these tumors through a minimal-access endonasal route has been demonstrated, but the importance, safety, and ...timing of OC exploration and decompression are not well described.
To create a simple decision-tree algorithm for OC exploration and decompression in the endonasal endoscopic surgery for planum sphenoidale and tuberculum sella meningiomas.
We identified a consecutive series of 8 planum sphenoidale and tuberculum sella meningiomas resected endonasally. "Late" OC exploration and decompression was performed in 4 of 8 patients. The extent of resection, visual outcome, and complications were recorded.
Five patients had OC invasion on magnetic resonance imaging. Endoscopic inspection did not reveal additional OC invasion. The OC was opened bilaterally in 2 patients and unilaterally in 2 patients. Gross total resection was achieved in 6 of 7 patients in whom it was the goal. Vision improved in 3 patients (3 of 3 OCs opened) and was stable in 4 (1 of 4 OCs opened). In 1 patient, the bitemporal hemianopsia improved, but there was unilateral deterioration (no OC invasion) because the tumor was extremely adherent to 1 optic nerve. After an average follow-up of 20.9 months, all patients had an Glasgow Outcome Scale score of 5, and there were no cerebrospinal fluid leaks.
Exploration and decompression of the OC are feasible, safe, and important to optimize visual outcome and to minimize recurrence in planum sphenoidale and tuberculum sella meningiomas resected endonasally. It may not be important to open the canal early during surgery because tumor debulking can be performed without manipulating the optic nerves. Early decompression, however, is technically feasible.
Objective To evaluate the feasibility of reaching the interpeduncular cistern (IC) through an endoscopic endonasal approach that leaves the pituitary gland in place. Methods In a series of 10 ...injected cadaver heads, the transtuberculum (“above”) and transclival (“below”) approaches were combined, without pituitary transposition. Using 0-degree, 30-degree, and 45-degree endoscopes, the extent of overlap and if a blind spot occurred were determined. Also, the visualization of the IC was compared with the transposition of the pituitary gland approach. Nonparametric statistics were used to evaluate the results. The approach was implemented in 2 patients. Results For both the “above” and “below” views, there was a statistically significant increase in field of view when comparing the 0-degree endoscope with either the 30-degree endoscope ( P < 0.05) or the 45-degree endoscope ( P < 0.05). There was no difference between the 30-degree endoscope and the 45-degree endoscope ( P > 0.05) in the “below” approach, but there was a difference ( P < 0.05) in the “above” approach. There was no blind spot with any combination of endoscopes. There was no practical statistically significant difference between the transposition approach and the “above and below” approach. The “above and below” approach was used successfully in 2 surgeries. Conclusions It is possible to work both “above” and “below” the pituitary gland to reach the IC through an endoscopic endonasal approach. The advantages are the maintenance of normal pituitary and parasellar anatomy and the minimization of the size of the skull base defect. There is no blind spot using this approach that would be revealed with a pituitary transposition. The feasibility of this approach has been confirmed in 2 patients.
Objective To evaluate the efficacy of combining an endonasal endoscopic skull-base approach and repair with a transcranial orbitozygomatic approach for spheno-orbital meningiomas (SOMs). Methods ...Three patients with recurrent SOMs underwent combined orbitozygomatic and endonasal endoscopic surgery. In 2 patients both procedures were done in 1 operation and in 1 patient the endonasal surgery was done 2.5 months after the craniotomy. Extent of resection, complications, morbidity, and mortality were evaluated. Results Gross total resection was achieved in 1 patient and near total resection in the other 2 patients with tumor left in the cavernous sinus and parapharyngeal space. Two patients suffered cranial neuropathy from the transcranial surgery and the other developed a pseudomeningocele. There were no complications from the endonasal surgery. Patients having combined single setting cranionasal surgery were discharged on day 6 and 8, whereas the patient having only the endonasal component on a later date was discharged on day 2. Conclusions A combined cranionasal approach involving transcranial orbitozygomatic and endonasal endoscopic approaches is an effective 2-stage surgery for resecting SOMs invading into the sinuses and paranasal compartments. The ability to perform a multilayer closure involving a vascularized nasoseptal flap additionally decreases the risk of postoperative cerebrospinal fluid leak.
Objective The optimal management of medically refractory idiopathic intracranial hypertension (IIH) remains a point of debate. The senior author's practice evolved after a review of our units' ...practice in placing lumboperitoneal shunts revealed an unacceptably high rate of complication and revision. We now preferentially perform custom-designed electromagnetic (EM) image-guided ventriculoperitoneal shunt placement instead of lumboperitoneal shunting in treating medically refractory IIH and present our outcome data with this technique. Patients and Methods Retrospective case note review was carried out with prospective follow-up of 17 patients treated consecutively over a 3-year period. Outcome Measures The article aims to assess the implication of using EM image–guided tracking technology in ventricular catheter placement in patients with IIH and to assess outcome. Results All of the patients improved clinically at the last follow-up compared to their preoperative condition. None of the patients experienced intra- or perioperative complications. All patients underwent ventriculoperitoneal shunt placement using EM guidance navigation. All patients in the EM subgroup were cannulated with a single pass, and satisfactory catheter placement was confirmed on a postoperative CT scan with concordant patient symptom improvement. Conclusion Our series suggests that EM image-guided ventriculoperitoneal cerebrospinal fluid (CSF) shunting for IIH is a safe and effective procedure for ventricular cannulation and placement.
Object. Chiari-syringomyelia is a heterogeneous condition that may be treated by decompression of the foramen magnum. Raised intracranial pressure (ICP) and/or hydrocephalus is a rare complication of ...this treatment. We aim to describe the incidence, clinical presentation, radiographic findings, management and outcome of patients developing raised ICP and/or hydrocephalus after hindbrain decompression for Chiari I malformation. Methods. Retrospective analysis of 138 consecutive adult and paediatric patients with Chiari I malformation who underwent foramen magnum decompression. Results. The incidence of post-operative symptomatic raised ICP and/or hydrocephalus in this series was 8.7%. Overall, 9 of 12 patients developing raised ICP or hydrocephalus required a VP shunt, an overall incidence of 6.5%. However, 3 of 12 patients were successfully managed with external ventricular drainage or conservatively. Presentation was with headache or CSF wound leak at a median of 13 days post-operatively. Subdural hygromata were observed in five cases in association with hydrocephalus and urgent drainage to relieve mass effect was required in two cases. At a mean follow up of 36 months, 9 of 12 patients were asymptomatic. Conclusions. There is a risk of requiring a permanent VP shunt associated with decompression for Chiari I even in the absence of ventriculomegaly or signs of raised ICP pre-operatively. Patients presenting with new symptoms or CSF wound leak following FMD mandate investigation to exclude hydrocephalus, raised ICP or subdural hygroma.
Cerebrospinal fluid (CSF) leakage is a challenging complication of intradural cranial surgery, and children are particularly at risk. The use of dural sealants confers protection in adults, but ...pediatric studies are scarce. We evaluated the safety and efficacy of Evicel
fibrin sealant as an adjunct to primary dural suturing in children undergoing cranial surgery.
A multicenter trial prospectively enrolled pediatric subjects (< 18 years) undergoing cranial neurosurgery who, upon completion of primary sutured dural repair, experienced CSF leakage. As agreed by the EMA Evicel
Pediatric Investigation Plan, 40 subjects were intra-operatively randomized 2:1 to Evicel
or additional sutures ('Sutures'). Data analysis was descriptive. The efficacy endpoint was treatment success rate, with success defined as intra-operative watertight closure after provocative Valsalva maneuver (primary endpoint). Safety endpoints were postoperative CSF leakage (incisional CSF leakage, pseudomeningocele or both) and surgical site complications (secondary endpoints).
Forty subjects (0.6-17 years) were randomized to Evicel
(N = 25) or Sutures (N = 15) (intention-to-treat). Intracranial tumor was the most common indication and procedures were mostly supratentorial craniotomies. Success rates were 92.0% for Evicel
and 33.3% for Sutures, with a 2.76 estimated ratio of success rates (Farrington-Manning 95% CI 1.53, 6.16). Sensitivity analyses in per-protocol and safety sets showed similar results. Despite a higher rescue treatment rate, the frequencies of postoperative CSF leakage and wound complications were higher for Sutures than for Evicel
.
This small-scale prospective study shows Evicel
treatment to be safe and effective as an adjunct to primary sutured dura mater closure in a pediatric population. Compared to additional sutures, Evicel
was associated with reduced postoperative CSF leakage and surgical site complications. (Trial registration: The trial was registered as NCT02309645 and EudraCT 2013-003558-26).
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