Current epidemiology of cerebrospinal fluid shunt surgery in the UK and Ireland (2004-2013).

OBJECTIVES: To determine current epidemiology and clinical characteristics of cerebrospinal fluid (CSF) shunt surgery, including revisions. METHODS: A retrospective, multicentre, registry-based study was conducted based on 10 years' data from the UK Shunt Registry, including primary and revision shunting procedures reported between 2004 and 2013. Incidence rates of primary shunts, descriptive statistics and shunt revision rates were calculated stratified by age group, geographical region and year of operation. RESULTS: 41 036 procedures in 26 545 patients were submitted during the study period, including 3002 infants, 4389 children and 18 668 adults. Procedures included 20 947 (51.0%) primary shunt insertions in 20 947 patients, and 20 089 (49.0%) revision procedures. Incidence rates of primary shunt insertions for infants, children and adults were 39.5, 2.4 and 3.5 shunts per 100 000 person-years, respectively. These varied by geographical subregion and year of operation. The most common underlying diagnoses were perinatal intraventricular haemorrhage (35.3%) and malformations (33.9%) in infants, tumours (40.5%) and malformations (16.3%) in children, and tumours (24.6%), post-haemorrhagic hydrocephalus (16.2%) and idiopathic normal pressure hydrocephalus (14.2%) in adults. Ninety-day revision rates were 21.9%, 18.6% and 12.8% among infants, children and adults, respectively, while first-year revision rates were 31.0%, 25.2% and 17.4%. The main reasons for revision were underdrainage and infection, but overdrainage and mechanical failure continue to pose problems. CONCLUSIONS: Our report informs patients, carers, clinicians, providers and commissioners of healthcare, researchers and industry of the current epidemiology of shunting for CSF disorders, including the potential risks of complications and frequency of revision.

Fixed, dilated pupils following traumatic brain injury: historical perspectives, causes and ophthalmological sequelae.

Pupillary abnormalities are commonly seen in patients presenting with severe traumatic brain injury (TBI). The objectives of this study were to determine the underlying condition responsible, the natural history of recovery of third nerve palsy and the ultimate clinical outcome in 60 patients admitted to a regional neurosurgical centre with a diagnosis of TBI and unilateral or bilateral fixed, dilated pupils (FDP). In approximately three-quarters of cases, some form of road traffic incident was the mechanism of injury. In patients presenting with a unilateral FDP, the CT-defined condition was most commonly diffuse brain injury (49%) with no obvious lateralising condition. In 34% of cases CT demonstrated a lateralising condition ipsilateral to the side of the FDP and in 9% cases the FDP was contralateral to the side of the CT abnormality. Of those patients who survived an FDP, 72% were left with some form of ophthalmological deficit. Most patients with bilateral FDP did not survive (88%); however, of those who did survive, none was left in a persistent vegetative state or with any ophthalmological sequelae. A FDP is a grave prognostic sign following TBI commonly resulting in long term ophthalmological sequelae; however, a favourable outcome is still attainable.

Assessing quality of life after traumatic brain injury: examination of the short form 36 health survey.

Measuring health-related quality of life (HRQoL) has an important role in the comprehensive assessment of patient recovery following traumatic brain injury (TBI). We examined the validity of domain and summary scores derived from the Medical Outcomes Survey 36-Item Short Form Health Questionnaire (SF-36) as outcome measures for TBI in a prospective study of 514 patients with a range of functional impairment (Glasgow Outcome Scale-Extended [GOSE] scores 3-8). Item scaling criteria for the eight domain scores were tested and principal component analysis was used to examine if physical and mental component summary scores were valid. External validity was assessed by comparison with GOSE. Mean response, variance, and distribution of the items were largely equivalent, and item-own scale correlations corrected for overlap all exceeded the threshold for equivalent contribution to domain scores and convergent validity. All corrected item-own scale correlations were greater than the respective item-other correlations indicating no scaling failures, and reliability coefficients for the domain scores were high and substantially more than the inter-domain correlations. Overall, criteria for summing items into domain scores were satisfied, and there was a significant relationship of increasing score with more favorable GOSE class across all domains. However, there were floor and/or ceiling effects in four of the eight domains, and principal component analysis of the domain scores demonstrated only a unidimensional structure to the data. We conclude that individual SF-36 domain scores are valid measures of HRQoL in TBI patients, but that the physical and mental component summaries should be interpreted with caution.

A modified Roland-Morris disability scale for the assessment of sciatica.

BACKGROUND: The Roland-Morris disability scale (RMS) for disability secondary to low back pain is a validated and popular instrument in clinical practice and research. We have made a simple modification to the questionnaire to increase sensitivity to sciatica (RMS-L) and validated this in patients with lumbar disc prolapse and radiculopathy. METHODS: The original RMS and modified RMS-L were prospectively administered to 203 patients presenting with lumbar radiculopathy and intervertebral disc prolapse demonstrated on MRI. Scores at pre-operative assessment and follow-up at 3 months and 12-24 months were compared against visual analogue scores (VAS) and Short Form 36 generic health domains. FINDINGS: Correlation between RMS-L and VAS leg pain was significantly greater than between original RMS and VAS leg pain pre-operatively (r = 0.57 vs. 0.17, p < 0.001) and at 3 months follow-up (r = 0.78 vs. 0.49, p < 0.001). Conversely, correlation between RMS and VAS back pain was significantly higher (r = 0.58 vs. 0.15, p < 0.001). Compared with RMS, at pre-operative assessment, RMS-L showed greater correlation with SF-36 physical function (PF; r = -0.57 vs. -0.32, p < 0.001) and bodily pain (r = -0.58 vs. -0.35, p < 0.001). Similarly, the change in PF to 3 months follow-up showed significantly higher correlation with change in RMS-L compared with the change in RMS (r = -0.60 vs. -0.37, p < 0.001). Effect sizes were good for RMS-L (1.19-1.24) but only moderate for RMS (0.69-0.79). CONCLUSIONS: The original and modified RMS can discriminate disability due to low back pain and sciatica, respectively. Separate assessment of these symptoms and their contribution to functional impairment is useful in assessing suitability for surgery and predicting outcome.

Efficacy of antibiotic-impregnated shunt catheters in reducing shunt infection: data from the United Kingdom Shunt Registry.

OBJECT: In recent years CSF shunt catheters impregnated with rifampicin and clindamycin have been introduced to the United Kingdom (UK) market. These catheters have been shown to be effective in vitro against cultures of Staphylococcus epidermidis. The authors used data collected by the UK Shunt Registry to assess the efficacy of antibiotic-impregnated catheters (AICs) against shunt infection by using a matched-pair study design. METHODS: The UK Shunt Registry contains data on nearly 33,000 CSF shunt-related procedures. The authors identified 1139 procedures in which impregnated catheters had been used, and accurate information was known about diagnosis, number of revisions, sex, and age in these cases. The database was ordered chronologically and searched forward and backward for cases with these same characteristics but involving conventional catheters. Matches were found for 994 procedures. RESULTS: Among the 994 procedures in which AICs had been used, 30 shunts were subsequently revised because of shunt infection. Among the 994 controls, 47 were subsequently revised for infection (p = 0.048, chi-square test). CONCLUSIONS: The UK Shunt Registry does not collect data on causative organisms, and the surgeon is relied on entirely for the diagnosis of infection. However, with the large number of matched pairs evaluated, the authors attempted to reduce bias to a minimum. Their data suggest that AICs have the potential to significantly reduce shunt infections.

Head injury rehabilitation: the role of a neurotrauma clinic.

Survivors of head injury are often left with varying degrees of disability and complex and varied needs, necessitating prolonged periods of rehabilitation and continuing care. Advances have been made in the acute management of these patients, but continuing management in terms of rehabilitation remains deficient with lack of specialist resources and a fragmented service. For head-injured patients, lack of access to appropriate ongoing rehabilitation may have profound effects on outcome and social re-integration. There are also considerable economic implications for planning and provision of services. The aims of this paper are to describe, review and evaluate the role of a Neurotrauma clinic within the Head Injury Service at Addenbrooke's Hospital, Cambridge. The multidisciplinary Neurotrauma clinic commenced in June 2003 following an extensive collaborative research programme to assess current regional head injury service provision and address deficiencies and management issues. Patients of all ages with ongoing problems following varying severity of head injury are followed up at 2 months + post-injury for as long as appropriate. Patients complete an SF-36 and GOSE questionnaire at each clinic appointment and this self-reported data is complemented by neuropsychological assessments, and demographic data entered on a database. The clinic acts as a 'gateway' to access appropriate ongoing rehabilitation and a source of information and support. The routine collection of outcome data enables tracking of individual patient progress and outcome and provides an information resource for further research. The findings highlight deficiencies in rehabilitation both in general service provision and specific patient need. Evidence in support of demand, need and effectiveness of rehabilitation for head injury is particularly relevant within the limited resources of the NHS. Early indications show that a specialist clinic can assist in providing continuity of patient care, in improving coordination of services, and act as a resource for further research on epidemiology, outcome and impact of rehabilitation.

Developing services for head injury: obtaining the data.

The aim of this article is to propose standards for data collection in head injury, the commonest cause of death and disability in young people. The objectives include evaluation of an audit methodology. The retrospective review conducted for the Eastern Head Injury Study in the UK identified a variety of problems, notably ambiguous terminology, inadequacies in ICD-10 codes, and inconsistent practices in recording data on head injury. Conclusions are that the standards developed through the review should improve data collection practice, and rehabilitation codes should assist in tracking patient pathways through care.