Integrated fundal assessment pathway for patients with suspected shunt malfunction via digital retinal images.

Introduction: Papilloedema is an important clinical sign in the assessment of neurosurgical patients presenting with suspected shunt malfunction.Methods: We describe our 18-month experience using a newly acquired nonmydriatic digital retinal camera to acquire fundal photographs for this purpose.Results: It was used to take digital photographs in 67 patients presenting with suspected shunt malfunction and 54% of these images were discussed with the on-call ophthalmology team for advice. Of these 81% had instant input provided by ophthalmology and the remainder were sent to the ophthalmology department for formal assessment. Of all shunt related regional referrals in the same time period, we found that only 13% of the referred patients were discussed with the on-call ophthalmology team. The rest had decisions made by the on-call neurosurgical team.Conclusions: We believe this new integrated pathway is clinically and cost-effective and recommend it as a useful tool in other neurosurgical units.

Extreme lateral interbody fusion (XLIF) as a treatment for acute spondylodiscitis: Leeds spinal unit experience.

Extreme lateral interbody fusion (XLIF) is a minimally invasive lateral trans-psoas approach to the thoraco-lumbar spine that enables surgical debridement of the disc space and facilitates fusion. Previous reports are limited to case series, which have no outcomes measuring improvement. We aim to determine the effectiveness of XLIF in the treatment of patients with spondylodiscitis. We performed a cohort study over four years (2008-2011). Patients were treated with XLIF if they met our selection criteria - symptoms suggestive of discitis with consistent imaging and intractable back pain making patients bedbound. Patients were excluded if medically unfit for surgery. Pre and post-operative VAS and ODI scores were used as formal outcome measures. 14 patients were included and at 12 months, median VAS and ODI scores had improved 4.0 (95% CI, 1.9-6.5) (p = 0.005) and 37.0% (95% CI, 10.7-53.7) (p = 0.015) respectively. All patients with available imaging showed evidence of fusion. Patients typically received 6-8 weeks of antibiotics and all showed normalisation of inflammatory markers. At 5 year follow-up, median VAS and ODI were still improved at 3.0 (95% CI, 1.7-4.4) (p = 0.01) and 40% (95% CI, 10-52) (p = 0.028) respectively. The median length of inpatient stay was 10 days (range 4-40 days). This is the first study to demonstrate that the XLIF technique can significantly improve pain in discitis patients using validated formal outcome measurements. This technique could therefore potentially be used to reduce pain in patients with discitis, help them to mobilise earlier and reduce the duration of their hospital stay.