A perspective on the use of an enhanced recovery program in open, non-instrumented day surgery for degenerative lumbar and cervical spinal conditions.

BACKGROUND: A means of significantly shortening patients' length of hospital stay, improving their outcome and thereby also reducing costs is to use an enhanced recovery program (ERP) which is increasingly being used in a number of surgical sub-specialties. This paper provides a perspective on its prospective use in a wide-ranging, unselected cohort of patients undergoing open spinal surgery for degenerative lumbar and cervical spinal conditions. Selected spinal cases undergoing day surgery have been increasingly reported. METHODS: A prospective, unselected, consecutive cohort of 246 cases, over an 18-month period, undergoing open, non-instrumented decompression spinal surgery and using ERP (and the concept of "bundles of care") was analyzed. RESULTS: Nine cases could not be included as they did not fully meet the entry criteria. No routine follow-up was arranged for the study group. The ages ranged widely, from 23-90 years (mean 57). In 187 the surgery for degenerative conditions was lumbar and in 50 cervical. The ASA (American Association of Anesthesiologists) ratings were 108=1; 107=2 and 22=3. Using the United Kingdom (UK) National Health Service (NHS) definitions of length of stay 225 (95%) could be finally classified as "ambulatory" and 12 (5%) were "short stay". A sub-cohort of 126 (53.2%) were "day cases". The follow-up was >1 year for all. There were no wound infections reported; 5 postdischarge cases (2.1%) needed to be seen in the Accident and Emergency (A&E) Department (less than 4 days postsurgery), but none needed re-admission; and there were 7 re-admissions (2.5%), between 4 and 30 days, and of these 6 required a further surgical procedure. There were no long-term instability complications reported in this cohort. CONCLUSIONS: ERP can be used for spinal surgery. There were identifiable and correctable medical and social factors found on analysis which could significantly increase the "day cases" number to over 90%.

Taming an old enemy: a profile of intracranial suppuration.

Intracranial suppurative disorders (ICSDs; brain abscess, empyema, and purulent ventriculitis), have been a scourge through the ages and attempts at curative surgery, as for cranial trauma, are considered to be one of the first true neurosurgical interventions performed. ICSDs, seen initially as a consequence of poor socioeconomic conditions and neglected otorhinogenic infections, predominantly manifest today as postsurgical complications, and/or in immunocompromised patients where they continue to result in significant neurologic morbidity and death. The reduction in the incidence of "old world" classic ICSDs can be attributed to the modernization of society, driven inter alia by a shift from an agricultural to an industrial economic society. It can also be coupled with pivotal achievements in public health and the dramatic developments in medicine in the 20th century. This trend was first noted in developed countries but now, with improved socioeconomic circumstances and globalization of medical technology, it is occurring in the developing regions of the world as well. Although ICSDs have undergone a metamorphosis in their clinical profile and despite their rarity in contemporary "developed world" neurosurgical practice, they still have undoubted potential for fatal consequences and continue to pose a significant challenge to the 21st-century neurosurgeon.

Brain abscess: management and outcome analysis of a computed tomography era experience with 973 patients.

OBJECTIVE: Brain abscess (BA) is a neurosurgical emergency and despite significant medical advances, it remains a surgical challenge. A single institution's two decade computed tomography era management experience with BA is reported. METHODS: A retrospective analysis of patients with BA, admitted to the Department of Neurosurgery, Wentworth Hospital, Durban, KwaZulu-Natal, South Africa, was performed. The medical records were analyzed for demographic, clinical, neuroimaging, neurosurgical and otolaryngology management, microbiological characteristics, and their relationship to outcome. RESULTS: During a 20-year period (1983-2002), 973 patients were treated. The mean age was 24.36 ± 15.1 years (range: 0.17-72 years) and 74.2% (n = 722) were men. The mean admission Glasgow Coma Score was 12.5 ± 2.83. The majority of BAs were supratentorial (n = 872, 89.6%). The causes were otorhinogenic (38.6%), traumatic (32.8%), pulmonary (7%), cryptogenic (4.6%), postsurgical (3.2%), meningitis (2.8%), cardiac (2.7%), and "other" (8.6%). Surgical drainage was performed in 97.1%, whereas 19 patients had nonoperative management. The incidence of BA decreased during the study period. Patient outcomes were good in 81.3% (n = 791), poor in 5.3% (n = 52), and death (13.4%, n = 130) at discharge. The management morbidity, which included postoperative seizures, was 24.9%. Predictors of mortality were cerebral infarction (odds ratio [OR] 31.1), ventriculitis (OR 12.9), coma (OR 6.8), hydrocephalus (OR 5.1), dilated pupils (OR 4.8), bilateral abscesses (OR 3.8), multiple abscesses (OR 3.4), HIV co-infection (OR 3.2), papilledema (OR 2.6), neurological deterioration (OR 2.4), and fever (OR 1.7). CONCLUSIONS: Optimal management of BA involves surgical drainage for medium-to-large abscesses (≥2.5 cm) with simultaneous eradication of the primary source, treatment of associated hydrocephalus, and administration of high doses of intravenous antibiotics. The incidence of BA is directly related to poor socioeconomic conditions and therefore, still poses a public health challenge in developing countries.