Effectiveness and outcomes of surgery for cerebral metastases.

INTRODUCTION: The main treatment modalities for single brain metastases are whole brain radiotherapy (WBRT), surgery and stereotactic radiosurgery. Current guidelines recommend complete surgical excision for single cerebral metastases and two randomised controlled trials (RCT) have also found survival benefit of surgery. However, a more recent RCT and a Cochrane review have challenged the effectiveness of surgery for cerebral metastases. This study aims to assess the effectiveness of surgery for cerebral metastases in current practice. MATERIALS AND METHODS: A retrospective review was performed for a single surgeon series of consecutive patients undergoing primary surgery for cerebral metastases between June 2005 and April 2010. The main outcome measure was the survival time after surgery. RESULTS: One hundred and twenty three patients (61 males, 62 females) were identified with a mean age of 58.4 years. Eighty three patients (67%) were under 65 years. The overall 30-day mortality rate was 2.4%. The overall median survival was 10 months. There were 26 (21%) breast cancers with median survival of 13.5 months, 32 (26%) NSCLC with 8.3 months, 24 (19%) melanomas with 6.7 months, 13 (11%) colorectal cancers with 6.4 months, and 11 (9%) renal cell cancers with 13.6 months. The differences were not significant (p > 0.05). However, when the breast cancer group was compared to the NSCLC group, the difference was significant (p = 0.005). The median survival differences were not significant (p > 0.05) with regard to the RPA class, the site (supratentorial or infratentorial) and the number of metastases (single or two). CONCLUSIONS: Median survival in this cohort was identical to those in the two RCTs that showed survival benefits from surgery. This was significantly longer than that (5.6 months) in the single series demonstrating no benefit. Therefore, our results support the previous evidence of improved outcomes with surgery.

Patient experience and satisfaction with awake craniotomy for brain tumours.

Awake craniotomy is increasingly used to facilitate safe maximal resection of brain tumours. Very little published data is available to determine patient experiences and satisfaction. This knowledge may lead to improvement in technique and enhance future patient care. In 2006, we began to use conscious sedation ('full awake technique') for craniotomies for tumour resection. A questionnaire designed with reference to Royal College of Surgeons (RCS) guidelines was sent out to 60 consecutive patients. Four areas of care were explored. These included the out-patient consultation with the neurosurgeon, anaesthetic consultation, operation and the post-operative period. Fourty-five responses were received. Ninety-three percent of the patients in our study felt involved sufficiently in the decision for awake surgery and felt they were given enough information when seen in the surgical consultation. However, only 64% of patients received written information in advance of their surgical date. Ninety-one percent of patients were confident that they would be looked after during surgery following their anaesthetic consultation. Eighty-seven percent of patients felt at ease during surgery. Twenty-four percent experienced some discomfort during surgery, some of which was related to positioning of the patient rather than surgical technique. Fifty-six percent of our patients reported no post-operative pain. Eighty-four percent of patients were happy with timing of their discharge. Eighty percent felt well supported post-discharge. This study demonstrates high levels of patient satisfaction and provides surgeons with useful data for consenting patients. We identified no difference in levels of patient satisfaction comparing day-case patients with those admitted. We identified areas for improvement including provision of written information, enhancing post-discharge support and allowing more time for anaesthetic discussion before surgery.

Day-case neurosurgery for brain tumours: the early United Kingdom experience.

Day-case biopsy and craniotomy for brain tumours have been reported as safe and feasible options for selected patients. The incidence and timing of complications after such procedures has also been characterized in recent publications. However, more widespread adoption of day-case cranial neurosurgery has not taken place. We report the first UK series of day-case surgery for intra-axial tumours, consisting of 30 image-guided biopsies and 11 craniotomies, taking place over 1 year from October 2006. Patients were studied prospectively and 27/30 biopsy and 9/11 craniotomy patients were discharged 6 h postoperatively. One biopsy case was admitted due to increased headache postoperatively, but with a normal CT and one craniotomy case had transient worsening of lower limb paresis requiring overnight admission. The three other overnight admissions were for patient preference. One biopsy patient was readmitted 30 h postoperatively with a seizure and discharged the following day. No patients suffered an adverse outcome. The results are presented together with the Toronto series of 284 cases over 11 years, also with no patients suffering an adverse outcome because of planned early discharge. These results suggest that day-case surgery for brain tumours is a safe and feasible option for patients in the UK.

Multiple gangliogliomas of the optic pathway.

We report a case of multiple gangliogliomas of the optic pathway in an 18-year-old boy. He presented with visual disturbance mainly in his left eye, non-specific headaches, and episodes of sensory disturbance in his left arm. Visual acuity was 6/9 and 6/24 in his right and left eye respectively. He did not have any Lisch nodules. Optic atrophy was noted in his left eye. MRI scan revealed multiple enhancing lesions involving the optic chiasm, left optic tract, right lateral geniculate body, and right optic radiation in the temporal lobe. Stereotactic biopsy of the temporal tumour confirmed ganglioglioma. Multiple gangliogliomas of the optic pathway has not been hitherto described.

Glucocorticoids modulate the NGF mRNA response in the rat hippocampus after traumatic brain injury.

Nerve growth factor (NGF) expression in the rat hippocampus is increased after experimental traumatic brain injury (TBI) and is neuroprotective. Glucocorticoids are regulators of brain neurotrophin levels and are often prescribed following TBI. The effect of adrenalectomy (ADX) and corticosterone (CORT) replacement on the expression of NGF mRNA in the hippocampus after TBI has not been investigated to date. We used fluid percussion injury and in situ hybridisation to evaluate the expression of NGF mRNA in the hippocampus 4 h after TBI in adrenal-intact or adrenalectomised rats (with or without CORT replacement). TBI increased expression of NGF mRNA in sham-ADX rats, but not in ADX rats. Furthermore, CORT replacement in ADX rats restored the increase in NGF mRNA induced by TBI. These findings suggest that glucocorticoids have an important role in the induction of hippocampal NGF mRNA after TBI.

The hypothalamo-pituitary-adrenal axis response to experimental traumatic brain injury.

Alterations in the hypothalamo-pituitary-adrenal (HPA) axis following traumatic brain injury have not been documented in detail. We used fluid percussion injury (FPI) to evaluate the early changes in components of the HPA axis following experimental traumatic brain injury. Wistar rats were sacrificed at 2 or 4 h following sham or FPI surgery. In situ hybridization histochemistry was used to determine the expression of mRNAs of corticotrophin releasing hormone (CRH) and arginine vasopressin (AVP) in the hypothalamus and pro-opiomelanocortin (POMC) in the pituitary. A group of animals undergoing no surgery were used as control. Repeated blood sampling from an indwelling catheter demonstrated that plasma corticosterone (CORT) levels peaked 30 min following surgery in sham and FPI animals but there was no significant difference in CORT concentration between these groups at any time. Pituitary POMC expression was increased following sham and FPI surgery (compared with control non-operated animals) but with no significant difference between the two groups undergoing surgery. Hypothalamic CRH mRNA expression was significantly higher in animals undergoing FPI compared with sham surgery. Hypothalamic AVP mRNA expression was not significantly increased when compared with control nonoperated animals. These data indicate that the anaesthesia and/or surgery associated with FPI or sham surgery induces a generalised activation of the HPA axis. The selective increase in CRH mRNA in animals undergoing FPI may be due to specific effects of traumatic brain injury rather than a general stress response and may suggest an additional neurotransmitter role for CRH following head injury. The absence of an AVP response suggests that the effects of FPI may be mediated through the CRH-alone-containing subpopulation of neurons.

Glucocorticoids modulate BDNF mRNA expression in the rat hippocampus after traumatic brain injury.

Brain-derived neurotrophic factor (BDNF) expression in rat hippocampus is increased after experimental traumatic brain injury (TBI) and may be neuroprotective. Glucocorticoids are important regulators of brain neurotrophin levels and are often prescribed following TBI. The effect of adrenalectomy (ADX) on the expression of BDNF mRNA in the hippocampus after TBI has not been investigated to date. We used fluid percussion injury (FPI) and in situ hybridization to evaluate the expression of BDNF mRNA in the hippocampus 4 h after TBI in adrenal-intact or adrenalectomized rats (with or without corticosterone replacement). FPI and ADX independently increased expression of BDNF mRNA. In animals undergoing FPI, prior ADX caused further elevation of BDNF mRNA and this upregulation was prevented by corticosterone replacement in ADX rats. These findings suggest that glucocorticoids are involved in the modulation of the BDNF mRNA response to TBI.

New approach to cervical flexion deformity in ankylosing spondylitis. Case report.

The treatment of cervical fixed flexion deformity in ankylosing spondylitis presents a challenging problem that is traditionally managed by a corrective cervicothoracic osteotomy. The authors report a new approach to this problem that involves performing a two-level osteotomy at the level of maximum spinal curvature, thereby achieving complete anatomical correction in a one-stage procedure. This 48-year-old woman with ankylosing spondylitis presented with a 30-year history of progressive neck deformity that left her unable to see ahead and caused her to experience difficulty eating, drinking, and breathing on exertion. On examination, she exhibited a 90 degrees fixed flexion deformity of the cervical spine, which was maximum at C-4; this was confirmed on imaging studies. A two-level osteotomy was performed at C3-4 and C4-5 around the area of maximum spinal curvature, and the deformity was corrected by extending the head on its axis of rotation through the uncovertebral joints. The spine was stabilized using a Ransford loop. An excellent anatomical position was achieved, as was complete correction of the deformity. A two-level midcervical osteotomy performed at the level of maximum spinal curvature in ankylosing spondylitis enables complete correction of severe fixed flexion deformity in a single procedure. Preservation of the uncovertebral joints allows smooth and safe correction of the deformity about their axis of rotation.

Transpedicular approaches to cervical uncovertebral osteophytes causing radiculopathy.

OBJECT: The anterolateral and posterior transpedicular foraminotomies were developed to enhance the treatment of cervical spondylotic radiculopathy secondary to uncovertebral osteophytes. These novel surgical approaches may be advantageous because they allow direct decompression of the nerve root while preserving normal movement and stability of the motion segment. The use of the pedicle to obtain access to compressive uncovertebral osteophytes, without causing damage to the motion segment, has not been previously reported. METHODS: The authors present the early outcome data obtained in 27 patients who underwent an anterolateral or posterior foraminotomy. Eighty-eight percent of patients who underwent anterolateral foraminotomy and 94% of those who underwent a posterior transpedicular procedure experienced complete or significant relief of brachialgia. Postoperatively none of the patients were symptomatically or neurologically worse. CONCLUSIONS: The transpedicular approach is an effective and potentially improved method of treating symptomatic cervical uncovertebral osteophytes compared with techniques previously described.

Odontoid process and C1-C2 corrective osteotomy through a posterior approach: technical case report.

OBJECTIVE AND IMPORTANCE: To demonstrate a new posterior approach to the anterior elements of the atlas and the axis including the odontoid process. CLINICAL PRESENTATION: A 36-year-old woman presented with ankylosing spondylitis and severe flexion deformity of the cervical spine. She had sustained a trauma 5 years previously, causing the inability to look forward or to open the jaw adequately. An examination demonstrated fixed flexion and rotation of the cervical spine, with no neurological deficit. Radiologically, there was fusion of C1, C2, and the clivus. TECHNIQUE: The upper cervical vertebrae were exposed via a midline posterior incision, the posterior arch of C1 was excised, and the vertebral arteries were mobilized. A wedge osteotomy was performed through the lateral masses of C1 and subsequently through the odontoid. The head was repositioned, and C1-C2 lateral mass screws and a Ransford loop were inserted. CONCLUSION: It is possible to gain sufficient surgical access to the odontoid process via a posterior approach. The technique described is of benefit when the alternative anterior approaches to the upper cervical spine are technically difficult or impossible.

A randomized controlled trial evaluating the use of sterile water as an irrigation fluid during transurethral electrovaporization of the prostate.

OBJECTIVE: To compare the safety of sterile water and glycine when used as bladder irrigation during transurethral electrovaporization of the prostate (TUVP) in a randomized controlled trial. PATIENTS AND METHODS: The study comprised 50 consecutive patients admitted for transurethral prostatic surgery who were randomly allocated to receive bladder irrigation with either sterile water or 1.5% glycine during TUVP. After surgery, serum electrolytes and the presence of free plasma haemoglobin (suggesting haemolysis) were determined and the patients observed for clinical evidence of the transurethral resection (TUR) syndrome. RESULTS: There was no significant difference in the level of free plasma haemoglobin between the groups and no difference in serum sodium levels. None of the patients developed any signs of the TUR syndrome. CONCLUSIONS: Water is a safe irrigant for use during TUVP and has several advantages over 1.5% glycine.