Unaccounted for enteral volume loss linked to delayed cerebral ischemia after subarachnoid hemorrhage.

OBJECTIVE: Delayed ischemic neurological deficit (DIND) is seen as a clinical manifestation of cerebral vasospasm and is a significant cause of morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH). Currently, the standard of care for DIND prevention in patients who have sustained aSAH is prophylactic nimodipine therapy and ensuring adequate fluid intake, alongside other treatments such as bowel care. Osmotic laxatives trap water within the bowel lumen to accelerate the transport of the gut contents through the bowel. Given the potential for DIND secondary to cerebral vasospasm, it is perhaps counterintuitive that gastrointestinal fluid loss and use of osmotic laxatives are not commonly considered in many aSAH management protocols. METHODS: A retrospective case note analysis was performed for all adult patients (aged > 16 years) admitted to the Department of Neurosurgery at Leeds General Infirmary with a diagnosis of aSAH between August 2019 and September 2020. RESULTS: A total of 105 patients were included, 62% of whom were female, with a mean and median age of 54 years (range 24-84 years). Diarrhea was noted in 12 patients (11.4%), 58% of whom subsequently developed DIND (OR 15.30, CI 3.92-59.14; p = 0.0001). All patients received osmotic laxatives (97% having received ≥ 2 laxative agents). CONCLUSIONS: Patients with aSAH who subsequently developed diarrhea had significantly increased odds of developing DIND. Enteral volume loss due to osmotic laxative use is a potential risk factor for DIND after aSAH.

Lumbar microdiscectomy with intraspine® - a case series / Microdiscectomía lumbar con intraspine® - serie de casos / Microdiscectomia lombar com intraspine® - série de casos

ABSTRACT Objective To assess postoperative outcomes following lumbar microdiscectomy (LMD) with and without the use of a dynamic intralaminar device IntraSPINE ® . Methods A non-randomized single-surgeon retrospective analysis. Consecutive elective surgery was performed on patients with lumbar disc disease over a 16-month period. The study group was determined by electronic theatre database. Ninety-two (62 LMD and 30 ILD) of the 95 eligible patients were included in the study, with three being excluded due to incomplete data sets. The pain scores were assessed pre- and postoperatively using a 4-point scale (0 - pain free; 1 - mild; 2- moderate; 3 - severe). Results The reduction in postoperative leg pain was similar (LMD 1.9 vs. IntraSPINE® 1.8) but the reduction in postoperative back pain was greater in the IntraSPINE® group (LMD 0.5 vs. IntraSPINE® 1.0; p = 0.17). Early recurrence of disc herniation (< 8 months) was lower in the IntraSPINE® group (6.7% vs. 19.4%; p = 0.097). The need for revision surgery was significantly lower in the IntraSPINE® group (p = 0.015). None of the IntraSPINE® recurrences required revision surgery, compared to 97% of the recurrences in the LMD group. Conclusions This case series raises the possibility that in selected patients, the use of the IntraSPINE® may improve back pain and reduce recurrent disc herniation/revision surgery rates in lumbar microdiscectomy. A prospective randomized trial on the use of the IntraSPINE® should be considered, given the clinical and cost implications of revision surgery. Level of Evidence IV; Case series.

RESUMO Objetivo Avaliar os resultados pós-operativos de microdiscectomia lombar (MDL) usando ou não o dispositivo intralaminar dinâmico IntraSPINE®. Métodos Análise retrospectiva simples não randomizada feita por um único cirurgião de cirurgias eletivas consecutivas em pacientes com hérnia de disco lombar no período de 16 meses. O grupo de estudo foi determinado por um banco de dados eletrônicos de centro cirúrgico. Noventa e dois (62 MDL e 30 com dispositivos intralaminares, ILD) dos 95 pacientes elegíveis foram incluídos na pesquisa, sendo que três foram excluídos porque os dados eram incompletos. Os escores de dor foram avaliados no pré e pós-operatório com uma escala de 4 pontos (sendo 0 - sem dor, 1 - leve, 2 - moderada e 3 -severa). Resultados A redução da dor nas pernas no pós-operatório foi similar (MDL 1,9 vs. IntraSPINE® 1,8), mas a redução da dor nas costas no pós-operatório foi melhor no grupo IntraSPINE® (MDL 0,5 vs. IntraSPINE® 1,0; p = 0,17). A reincidência precoce de hérnia de disco (< 8 meses) foi menor no grupo IntraSPINE® (6,7% vs. 19,4%; p = 0,097). A necessidade de cirurgia de revisão foi significativamente menor no grupo IntraSPINE® (p= 0,015). Nenhuma das reincidências no grupo com IntraSPINE® exigiu cirurgia de revisão em comparação com 97% das reincidências do grupo MDL. Conclusões Esta série de casos levanta a possibilidade de que, em pacientes selecionados, o uso de IntraSPINE® pode reduzir a dor nas costas e as taxas de recidiva de hérnia de disco e de cirurgias de revisão na microdiscectomia lombar. Um estudo prospectivo e randomizado do uso do IntraSPINE® deve ser considerado, dadas as implicações clínicas e o custo da cirurgia de revisão. Nível de Evidência IV; Série de casos.

RESUMEN Objetivo Evaluar los resultados postoperatorios de la microdiscectomía lumbar (MDL) utilizando o no el dispositivo intralaminar dinámico IntraSPINE®. Métodos Análisis retrospectivo simple y no aleatorio realizado por uno solo cirujano de cirugías electivas consecutivas en pacientes con hernia de disco lumbar durante un período de 16 meses. El grupo de estudios fue determinado por una base de datos electrónicos de centro quirúrgico. Noventa y dos (62 MDL y 30 con dispositivos intralaminares, ILD) de los 95 elegibles fueron incluidos en el estudio, siendo que tres fueron excluidos porque los datos estaban incompletos. Las puntuaciones de dolor se evaluaron antes y después de la operación con una escala de 4 puntos (0: sin dolor, 1: leve, 2: moderado, 3: grave). Resultados La reducción del dolor postoperatorio de pierna fue similar (MDL 1,9 versus IntraSPINE® 1,8). Sin embargo, la reducción del dolor postoperatorio de la espalda fue mayor en el grupo con IntraSPINE® (MDL 0,5 versus IntraSPINE® 1,0; p = 0,17). La recurrencia temprana de hernia del disco (< 8 meses) fue menor en el grupo IntraSPINE® (6,7% versus 19,4%; p = 0,097). La necesidad de cirugía de revisión fue significativamente menor en el grupo IntraSPINE® (p = 0,015). Ninguna de las recurrencias en el grupo IntraSPINE® requirió cirugía de revisión en comparación con 97% de las recurrencias en el grupo MDL. Conclusiones Esta serie de casos plantea la posibilidad de que, en pacientes seleccionados, el uso de IntraSPINE® pueda reducir el dolor de espalda y reducir las tasas de recurrencia de hernia de disco y las cirugías de revisión en la microdiscectomía lumbar. Se debe considerar un estudio prospectivo y aleatorizado del uso de IntraSPINE®, dadas las implicaciones clínicas y el costo de la cirugía de revisión. Nivel de Evidencia IV; Serie de casos.

Diffuse intrinsic pontine glioma ventricular peritoneal shunt metastasis: a case report and literature review.

Dissemination of diffuse intrinsic pontine glioma (DIPG) outside the central nervous system is exceptional. Here, we present a child diagnosed with DIPG who developed seeding along the track of the ventriculoperitoneal shunt and review the literature on this unusual occurrence.