Predictors of Compensatory Sweating Following Video-Assisted Thoracoscopic Sympathectomy in Primary Palmar Hyperhidrosis.

BACKGROUND: Compensatory sweating (CS) is a frequent health concern following treatment of palmar hyperhidrosis using video-assisted thoracoscopic sympathectomy (VATS) and can reduce level of patient satisfaction. METHODS: A retrospective cohort study including consecutive patients who underwent VATS for primary palmar hyperhidrosis (HH) over a 5-year period was conducted. Various demographic, clinical, and surgical variables were tested for their correlation to postoperative CS through univariate analyses. Variables with significant correlation to outcome were included in a multivariable logistic regression for determining significant predictors. RESULTS: The study included 194, predominantly male (53.6%), patients. About 46% of patients developed CS, mostly during the first month after VATS. Variables with significant correlation (P < 0.05) to CS included age (20 ± 3.6 years), body mass index (BMI) (mean 27 ± 4.9), smoking (34%), associated plantar HH (50%), and laterality of VATS (40.2% in dominant side). Only level of activity showed a statistical trend (P = 0.055). In multivariable logistic regression, BMI, plantar HH, and unilateral VATS were significant predictors for CS. Using receiver operating characteristic curve, the best cutoff point of BMI for prediction was 28.5, with sensitivity 77% and specificity 82%. CONCLUSIONS: CS is a frequent health concern early after VATS. Patients with BMI >28.5 and no plantar HH are at higher risk of postoperative CS, and a unilateral dominant side VATS as an initial management step may lessen the risk of CS. Bilateral VATS can be provided for patients with low risk of CS and patients with low satisfaction after unilateral VATS.

Risk Assessment and Prevalence of Work-Related Musculoskeletal Disorders Among Cranial and Spinal Neurosurgeons.

OBJECTIVE: To assess the risk and prevalence of work-related musculoskeletal disorders (WMSDs) in spine and cranial surgeons. METHODS: A cross-sectional analytic study composed of a risk assessment and a questionnaire-based survey was conducted. The risk assessment for WMSDs was performed on young volunteer neurosurgeons using the Rapid Entire Body Assessment tool. The survey-based questionnaire was distributed using the Google Forms software among the relevant official WhatsApp groups of the Egyptian Society of Neurological Surgeons and the Egyptian Spine Association. RESULTS: Thirteen volunteers with a median service of 8 years were assessed for the risk of WMSDs, showing moderate to very high risk of WMSDs, with a Risk Index >1 for all assessed postures. A total of 232 respondents completed the questionnaire, 74% of whom reported WMSD symptoms. Pain was experienced by most (96%), with neck pain being the most common (62.8%), followed by low back pain (56.0%), shoulder pain (44.5%), and wrist/finger pain (43.9%). Pain was experienced for 1-3 years by most respondents; however, most did not reduce their case volume, seek medical advice, or stop working when they experienced pain. The survey showed shortage in the literature studying ergonomics, calling for more ergonomic education and furnishing of working environment of neurosurgeons. CONCLUSIONS: WMSDs are prevalent among neurosurgeons, affecting their ability to work. Ergonomics need further awareness, education, and interventions to reduce WMSDs, especially neck and low back pain, which proved to substantially interfere with work ability.

A Proposed Protective Protocol Predicting Reduction of Shunt Infection.

OBJECTIVE: To identify the best protective interventions against shunt infection and, hence, to find an appropriate protocol assumed to be associated with reduction of infection rates. METHODS: A combined prospective-retrospective cohort study was conducted over a period of 5 years in 3 referral hospitals. Twelve interventions against infection practiced by blinded surgeons during ventriculoperitoneal shunt operations were surveyed and their association with the outcome of interest (i.e., shunt infection) was tested. Interventions proved to be associated with the outcome entered a multivariate logistic regression to identify the protective interventions. RESULTS: Among a total of 392 cases, shunt infection was diagnosed in 11.5% with a median onset of 55 days. Patients' demographics, etiology of hydrocephalus, shunt-related factors, and type of preoperative antibiotics were not associated with shunt infection. Two-thirds of infected shunts revealed Staphylococcus species. Among the tested interventions, double-gloving and device and wound irrigation using vancomycin solution and the use of incision adhesive drapes proved to exhibit a significant protective effect against shunt infection, whereas operative time <40 minutes revealed a marginal protective benefit. CONCLUSIONS: Shunt infection is a significant complication that occurs early during the first 2 months after surgery. According to the study findings, an appropriate protocol against shunt infection is assumed to be composed of double-gloving, device and wound irrigation using vancomycin solution, and the use of incision adhesive drapes. Reduced operative time had a beneficial effect against shunt infection, although it was of marginal significance in the current study.

Flexion/Extension Cervical Magnetic Resonance Imaging: A Potentially Useful Tool for Decision-Making in Patients with Symptomatic Degenerative Cervical Spine.

OBJECTIVE: To evaluate the reliability and usefulness of cervical flexion/extension magnetic resonance imaging (MRI) as a tool for decision-making regarding treatment of symptomatic cervical spondylosis. METHODS: We prospectively collected demographic, clinical, and flexion/neutral/extension MRI data for consecutive 24 patients who had presented with symptomatic cervical degenerative disease. From the survey responses, we analyzed the agreement between clinical interpretation and judgment when neutral MRI (nMRI) versus flexion/extension MRI (fMRI/eMRI) had been provided. Additionally, the mean cervical canal diameter (MCCD), as measured by 2 independent radiologists, was tested for intra- and interobserver reliability. The differences in MCCD between nMRI, fMRI, and eMRI and the correlation with the qualitative assessment by spine surgeons were also evaluated. RESULTS: Using nMRI only, 16.7%-33.3% of the surgical candidates were missed. Neurosurgeons were significantly more likely to use a posterior approach and instrumentation when fMRI/eMRI studies were available compared with nMRI studies alone. More levels had undergone surgery when the providers had been presented with the fMRI/eMRI studies. The raters expressed a preference for the use of fMRI/eMRI in their future practice. The MCCD was significantly different when measured on the nMRI studies compared with the fMRI/eMRI studies and correlated with the qualitative assessments. CONCLUSIONS: Flexion/extension MRI studies were useful for assessing patients with cervical degenerative spine disorders regarding the surgical indication, direction of the approach, and use of multilevel instrumentation, especially for patients with early cervical myelopathy.

Efficacy and Outcome Prediction of Unilateral Video-Assisted Thoracoscopic Sympathectomy in Primary Palmar Hyperhidrosis: A Comparative Study with Bilateral Sympathectomy.

OBJECTIVE: To compare unilateral dominant-side video-assisted thoracoscopic sympathectomy (U-VATS) with bilateral procedures (B-VATS) in terms of efficacy and complications and to identify predictors of outcome after U-VATS. METHODS: A prospective multicenter cohort study in which patients presented with primary palmar hyperhidrosis were treated by either U-VATS (82 cases) or B-VATS (112 cases). The demographic, clinical, operative, and postoperative findings were collected for all patients and compared in both groups. The factors associated with outcome were identified, and predictors of outcome in U-VATS were investigated to identify best candidates for unilateral sympathectomy. RESULTS: Both groups were balanced regarding demographic and preoperative clinical data. U-VATS was associated with significantly less postoperative pain and shorter hospital stays. Compensatory sweating was significantly less frequent in U-VATS with significantly better improvement in planter hyperhidrosis. Both groups were comparable as regards recurrence rate, patient satisfaction, and quality of life at 1 year. Preoperative Hyperhidrosis Quality of Life Questionnaire scores predicted outcome in U-VATS, and the best cutoff point was identified. CONCLUSIONS: U-VATS proved to be equally effective as B-VATS with less postoperative pain, shorter hospital stay, less frequent compensatory sweating, and better improvement of planter hyperhidrosis. The results suggest that patients with preoperative Hyperhidrosis Quality of Life Questionnaire scores >80 are better operated via B-VATS, whereas lower scores are indicated for U-VATS.

Candidates for Percutaneous Screw Fixation Without Fusion in Thoracolumbar Fractures: A Retrospective Matched Cohort Study.

STUDY DESIGN: Retrospective matched cohort study. OBJECTIVES: Identifying candidates for isolated percutaneous screw fixation (PSF) in thoracolumbar fractures based on Thoracolumbar Injury Classification and Severity (TLICS) score. METHODS: Patients underwent PSF were split into 3 TLICS-score categories, then matched with groups having similar scores managed either non-operatively or via open screw fixation (OSF). Each category was assessed for corrective power and loss of correction by comparing initial and 1-year Cobb angles as well as Oswestry Disability Index and rates of fracture healing at 1 year. RESULTS: A total of 102 patients (40 females) with age range 19 to 51 years, were admitted 1 to 25 hours following trauma. Each of TLISC categories consisted of matched treatment groups for comparison. In TLICS-3 fractures (2 treatment groups, n = 12 each), PSF showed similar outcomes but longer time to ambulation and length of stay (LOS) compared with nonoperative management. In TLICS-4 fractures (3 treatment groups, n = 18 each), PSF showed comparable corrective power and outcomes as OSF but was better in terms of operative time, blood loss, time to ambulation, LOS, and cosmesis. Despite higher LOS when compared with nonoperative cases, PSF showed superior radiologic and functional outcomes. In TLICS-5 fractures (2 treatment groups, n = 12 each), PSF showed shorter admissions and time to ambulation but lower corrective power, functional recovery, and tendency to lower healing rates. CONCLUSIONS: Isolated PSF is a valid choice in managing TLICS-4 thoracolumbar fractures; however, it did not surpass conventional methods in TLICS-3 or TLICS-5 fracture types. Further studies are needed before the generalization of findings.

Outcome of Early versus Delayed Evacuation of Spontaneous Lobar Hematomas in Unconscious Adults.

OBJECTIVE: To explore the difference in outcomes of medium-sized lobar hematomas evacuated in early versus delayed fashion among unconscious noncomatose individuals. METHODS: A retrospective analysis of demographic, clinical, and radiological data of unconscious patients admitted with lobar hematomas during 18 years was performed. Time to surgery was compared in various patient variables and characteristics. Outcome groups (favorable and poor) were also compared to find out any association with surgery timing, as well as potential indicators of outcome and mortality. RESULTS: The mean follow-up period in this study was 7.5 months after discharge. Two-thirds of the patients carried favorable prognosis at final follow-up with mortality (7.3%) included among poor cases. Time to surgery was not associated to any of the patient characteristics, except for international normalized ratio and associated chest problems which represented the main indicators of delayed surgery. Rebleeding after evacuation was associated with shorter time to surgery in clots ≤35 cc but not in the whole group. Poor outcome was significantly associated with higher basal glucose levels, bigger hematomas, rebleeding after surgery, and delayed evacuation of clots >35 cc. The presence of mild intraventricular hemorrhage (IVH) per se was not associated with increased mortality or poor outcome; however, its volume was. CONCLUSION: Smaller lobar hematomas (≤35 cc) in unconscious adults (Glasgow Coma Scale 8-13) may be managed with initial conservative treatment, while larger hematomas (>35 cc) are better evacuated as early as possible. Basal glucose levels and volume of mild IVH should be considered in the future management planes.

Spontaneous Cerebellar Hematoma: Decision Making in Conscious Adults.

OBJECTIVE: To detect predictors of the clinical course and outcome of cerebellar hematoma in conscious patients that may help in decision making. METHODS: This study entails retrospective and prospective review and collection of the demographic, clinical, and radiologic data of 92 patients with cerebellar hematoma presented conscious and initially treated conservatively. Primary outcome was deterioration lower than a Glasgow Coma Scale score of 14 and secondary outcome was Glasgow Outcome Scale score at discharge and 3 months later. Relevant data to primary outcome were used to create a prediction model and derive a risk score. The model was validated using a bootstrap technique and performance measures of the score were presented. Surgical interventions and secondary outcomes were correlated to the score to explore its use in future decision making. RESULTS: Demographic and clinical data showed no relevance to outcome. The relevant initial computed tomography criteria were used to build up the prediction model. A score was derived after the model proved to be valid using internal validation with bootstrapping technique. The score (0-6) had a cutoff value of ≥2, with sensitivity of 93.3% and specificity of 88.0%. It was found to have a significant negative association with the onset of neurologic deterioration, end point Glasgow Coma Scale scores and the Glasgow Outcome Scale scores at discharge. The score was positively correlated to the aggressiveness of surgical interventions and the length of hospital stay. CONCLUSIONS: Early definitive management is critical in conscious patients with cerebellar hematomas and can improve outcome. Our proposed score is a simple tool with high discrimination power that may help in timely decision making in those patients.

Predictors of Long-Term Outcome of Thoracic Sympathectomy in Patients with Complex Regional Pain Syndrome Type 2.

BACKGROUND AND OBJECTIVE: Long-term results of sympathectomy in patients with complex regional pain syndrome (CRPS) type 2 varies widely among studies due to nonspecific or vague criteria of diagnosis and absence of outcome predictors that help good patient selection. The objective was to determine the predictors of long-term outcome of sympathectomy in patients with upper limb CRPS type 2. METHODS: A retrospective cohort, in which those who underwent thoracic sympathectomy for upper limb CRPS type 2 from 2007 to 2014, were included. Demographic and clinical data of patients, in addition to stellate ganglion block (SGB) details and percent of pain relief at the end of follow-up, were collected and used for statistical analysis. RESULTS: Our study included 53 patients, with a mean age of 47 ± 7 years, and 60% females. Using bivariate correlations; age, sex, nerve injured, type of injury, and occupation were not significantly correlated to outcome. Multiple linear regression analysis of correlated variables revealed that duration of pain relief after SGB and degree of sympathetic overactivity were positive predictors (ß = 0.286, P = 0.027, and ß = 0.257, P = 0.003, respectively), whereas presence of allodynia was a negative predictor (ß = -0.280, P = 0.041) of the final pain relief. Final pain relief was better in those patients who experienced extended relief of their pain >2 days after SGB (P = 0.001, Kruskal Wallis test). CONCLUSIONS: Thoracic sympathectomy may prove more effective than reported in carefully selected CRPS patients with prominent sympathetic overactivity, no or early allodynia, and pain relief >2 days after SGB.

Role of Lumbopleural Shunt in Management of Idiopathic Intracranial Hypertension.

BACKGROUND: Idiopathic intracranial hypertension (IIH) denotes the condition of increased intracranial pressure without a clear underlying pathologic condition of the brain. The treatment plan should be conducted to save vision. Treatment options include medications, serial lumbar punctures, and surgical intervention. Surgery is indicated once visual loss continues despite optimum medical therapy. METHODS: This is a prospective study carried out during a period of 2 years. Cases were those who fulfilled the modified Dandy criteria for the diagnosis of IIH. All cases experienced a previously failed lumboperitoneal shunt. This study was approved by The Ethical Committee of Mansoura Faculty of Medicine. The following data were gathered for analysis: age, sex, presenting symptoms, number of shunt failures, apparent causes of failure, cerebrospinal fluid opening pressure on lumbar puncture, visual acuity before surgery, operative time, visual acuity at 3 and 6 months and 1 year, and any procedure-related or device-related complication. RESULTS: Our study included 12 patients with lumboperitoneal shunt failure, all of which were women with mean age of 33 years. The major presenting symptom was headache. The main cause of failure was shunt migration (n = 10, 83.3%). Mean cerebrospinal fluid opening pressures was 37 cmH2O. The mean operative time was 42.5 minutes. CONCLUSIONS: The lumbopleural shunt is a potentially effective technique in terms of symptoms control and vision improvement in treatment of IIH. The technique is safe, less time-consuming, and more suitable for morbid obese patients with high body fat percentages.