Neurotrauma admissions and COVID-19: a National Centre experience.

BACKGROUND: To investigate the impact of COVID-19 on trauma admissions to a National Neurosurgical Centre in Ireland. METHODS: Retrospective analysis of a prospectively maintained database of all trauma admissions to the National Neurosurgical Centre at Beaumont Hospital, Dublin, during the period March 1 to May 31, 2019 and 2020. Primary outcome was 30-day mortality rate. Secondary outcomes included time transfer time, time from admission to time of surgery, and intensive care unit (ICU) admissions. Patients under the age of 16 were excluded. RESULTS: A total of 32 and 39 patients were admitted to the National Neurosurgical Centre following trauma over the 3-month period in 2020 and 2019 respectively, giving a 17.9% reduction in admissions. The 30-day mortality rate increased from 7.7% in 2019 to 15.6% on 2020 (p = 0.45). Mean transfer time was 4 h 58 min in 2019 and 3 h 55 min in 2020 (0.22). Mean time from admission to time of surgery was 9 h 10 min in 2019 and 5 h 37 min in 2020 respectively (p = 0.35). In 2019, 20 patients (51.3%) were admitted to ICU. This increased to 23 patients (69.7%) in 2020 (p = 0.08). CONCLUSIONS: Traumatic brain injury 30-day mortality rates increased during the first COVID-19 lockdown period. Trauma admission rates to ICU remained unchanged despite an overall reduction in trauma admissions. Transfer time, time to surgery, and length of stay were impacted by COVID-19. Despite the challenges COVID-19 has posed, it is important to maintain a fully functioning neurosurgical and neurocritical care service during the pandemic.

S100B, GFAP, UCH-L1 and NSE as predictors of abnormalities on CT imaging following mild traumatic brain injury: a systematic review and meta-analysis of diagnostic test accuracy.

Biomarkers such as calcium channel binding protein S100 subunit beta (S100B), glial fibrillary acidic protein (GFAP), ubiquitin c-terminal hydrolase L1 (UCH-L1) and neuron-specific enolase (NSE) have been proposed to aid in screening patients presenting with mild traumatic brain injury (mTBI). As such, we aimed to characterise their accuracy at various thresholds. MEDLINE, SCOPUS and EMBASE were searched, and articles reporting the diagnostic performance of included biomarkers were eligible for inclusion. Risk of bias was assessed using the QUADAS-II criteria. A meta-analysis was performed to assess the predictive value of biomarkers for imaging abnormalities on CT. A total of 2939 citations were identified, and 38 studies were included. Thirty-two studies reported data for S100B. At its conventional threshold of 0.1 µg/L, S100B had a pooled sensitivity of 91% (95%CI 87-94) and a specificity of 30% (95%CI 26-34). The optimal threshold for S100B was 0.72 µg/L, with a sensitivity of 61% (95% CI 50-72) and a specificity of 69% (95% CI 64-74). Nine studies reported data for GFAP. The optimal threshold for GFAP was 626 pg/mL, at which the sensitivity was 71% (95%CI 41-91) and specificity was 71% (95%CI 43-90). Sensitivity of GFAP was maximised at a threshold of 22 pg/mL, which had a sensitivity of 93% (95%CI 73-99) and a specificity of 36% (95%CI 12-68%). Three studies reported data for NSE and two studies for UCH-L1, which precluded meta-analysis. There is evidence to support the use of S100B as a screening tool in mild TBI, and potential advantages to the use of GFAP, which requires further investigation.

The 'swirl sign' as a marker for haematoma expansion and outcome in intra-cranial haemorrhage: A meta-analysis.

The 'swirl sign' is a CT imaging finding associated with haematoma expansion and poor prognosis. We performed a systematic review and meta-analysis to determine its prognostic value. PubMed/MEDLINE and EMBASE were searched until 16/12/2020 for related articles. Articles detailing the relationship between the swirl sign and any of haematoma expansion (HE), neurological outcome in the form of Glasgow Outcome Score (GOS) or mortality were included. A meta-analysis was performed and the pooled sensitivity, specificity, positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were calculated for each of HE, GOS and mortality. 15 papers were assessed. Nine papers related to HE, for which the pooled sensitivity was 50% (95% CI 30-71), specificity was 77% (95%CI 67-85) and PLR was 2.16 (95%CI 1.89-2.42). There was significant heterogeneity (I2 = 70%, Q = 26.9). Three papers related to GOS, for which the pooled sensitivity was 45% (95%CI 20-74), specificity was 78.3% (95%CI 40-95.2) and PLR was 1.77 (95%CI 1.04-2.62). Three papers related to mortality, for which the pooled sensitivity was 65% (95% CI 32-88), specificity was 75% (95%CI 42-92) and pooled PLR was 2.64 (95%CI 1.60-4.13). Our findings indicated that the swirl sign is a useful prognostic marker in the radiological evaluation of intracranial haemorrhage. However, more research is needed to assess its independence from other risk factors for haematoma expansion.

Primary intradural/extradural Ewing's sarcoma of the sacral spine: A case report and literature review.

BACKGROUND: Ewing's sarcoma (ES) is a malignant mesenchymal tumor, most often found in the long bones, and usually affecting children and adolescents in the second decade of life. ES of the spine is a clinical rarity. CASE DESCRIPTION: A 45-year-old male presented with a 3-month history of lower back pain which acutely worsened in conjunction with urinary retention. The magnetic resonance imaging revealed a mass extending from L5 to S2 with additional extension through the left S2-3 neural foramen. The metastatic workup was negative. At surgery, the lesion was both intradural and extradural. Following complete surgical resection, the patient was later treated with radiation and chemotherapy. CONCLUSION: Here, we report an adult male who acutely presented with low back pain attributable to primary intradural/extradural sacral ES.

The impact of COVID-19 on trauma referrals to a National Neurosurgical Centre.

BACKGROUND: To investigate the impact of COVID-19 on trauma referrals to a National Neurosurgical Centre during the first wave of COVID-19 in Ireland. METHODS: Retrospective analysis of a prospectively maintained database of all trauma referrals to the National Neurosurgical Centre at Beaumont Hospital, Dublin, during the period March 1-May 31, 2019 and 2020. Patient characteristics including age, sex, alcohol use, anticoagulant/antiplatelet use and initial Glasgow Coma Scale (GCS) were recorded. Patients were grouped based on trauma aetiology and diagnosis. RESULTS: There were 527 and 437 trauma referrals in 2019 and 2020 respectively. Overall, there was a 17.1% reduction in trauma referrals between 2019 and 2020. Traumatic brain injury, spinal injury and cranial fractures referrals reduced 25% (375 vs 283), 59% (32 vs 13) and 18% (39 vs 32) respectively from 2019 to 2020. Low-energy falls below 2 m was the most common mechanism of injury and accounted for 60 and 61% of referrals in 2019 and 2020. No reduction in road traffic collision (33 vs 34) and assault (40 vs 40) referrals were observed between years. CONCLUSIONS: COVID-19 has had a significant impact on both the volume and mechanism of trauma referrals to the National Neurosurgical Centre in Ireland, with falls below 2 m the most common mechanism of trauma referral across both years. The workload remains substantial and a fully resourced neurosurgical department is essential in any future COVID-19 waves.

Bilateral laminotomy through a unilateral approach (minimally invasive) versus open laminectomy for lumbar spinal stenosis.

PURPOSE: To compare the outcomes of minimally invasive (MI) bilateral laminotomy via unilateral approach versus open laminectomy in the treatment of lumbar spinal stenosis (LSS). MATERIALS AND METHODS: In this prospective study, 62 patients were treated for LSS and were assigned to one of two groups over a 6-month period. Group A comprised 37 patients that underwent MI bilateral laminotomy. Group B comprised 25 patients that underwent open laminectomy. Follow-up duration was 3 years. The primary outcomes were the visual analogue scale (VAS) pain outcome score for back and leg, the Oswestry Disability Index (ODI) and complications. RESULTS: MI methods were superior in most primary outcomes compared to open laminectomy. VAS back pain outcome was reduced from close to 7 to 4 in both groups. VAS leg pain was reduced from 6.8 to 3.2 in MI group and from 8.7 to 3.5 in the open group (p > 0.05 between groups, p < 0.05 comparing pre- to post-operative back and leg pain). ODI improved from 56.5 to 13 and 58 to 24 in MI and open groups, respectively (p > 0.05 between groups, p < 0.05 comparing pre- to post-operative disability). Complication and revision rates were lower in the MI technique than open laminectomy (8 versus 56%, p < 0.05; 3 versus 12%, p > 0.05). Length of stay ranges were less in MI than open group (1-3 versus 7-30 days, p > 0.05). CONCLUSIONS: Bilateral laminotomy through a unilateral approach (minimally invasive) and open laminectomy are both effective in improving pain and disability in LSS. MI procedures have an advantage in shorter hospital stays, sparing of more bony structures and lower complication rates. MI unilateral decompression is at least as good as laminectomy in the treatment of LSS.

The provision of neuro-oncology and glioma neurosurgery during the SARS-CoV-2 pandemic: a single national tertiary centre experience.

BACKGROUND: The COVID-19 pandemic has resulted in a significant disruption in the provision of healthcare globally. The aim of this study was to assess the implications of the COVID-19 pandemic on the provision of neuro-oncology surgery and comparison with a similar 3-month period in 2019. METHODS: Retrospective review of prospectively curated database of patients requiring neuro-oncology surgery at our tertiary referral centre between 1st March 2020 and 31st May 2020. We also analysed data for the same time period (1st March-31st May) in 2019 for comparison. Number and type of tumours operated on, postoperative morbidity and mortality, COVID-19-related complications and delays in treatment were recorded. RESULTS: During the 3-month periods studied in 2020 and 2019, there were 127 and 139 admissions for neuro-oncological surgery, respectively. Sixty patients underwent surgery for gliomas during the 2020 period vs 56 in the 2019 period. We observed no increase in mean length of time from referral to inter-hospital transfer (mean of 76 h in 2020 vs 93 h in 2019 (p = 0.10)) or in mean length of time from admission to surgery in the acute admissions (2.39 days in 2020 vs 2.89 days in 2019). The postoperative 30-day morbidity and mortality rates were lower in 2020; 8.7% (n = 11) compared with 10.1% (n = 14) in 2019. There was one COVID-19-related death which occurred in a patient with B cell lymphoma with negative preoperative COVID-19 test. CONCLUSION: The provision of neuro-oncological surgery can be safely continued during respiratory illness epidemic or pandemic if a rigorous testing and staffing framework is implemented.

Technical outcome of atlantoaxial transarticular screw fixation without supplementary posterior construct for rheumatoid arthritis.

BACKGROUND: transarticular screw (TAS) fixation without a supplementary posterior construct, even in rheumatoid arthritis (RA) patients, provides sufficient stability with acceptable clinical results. Here, we present our experience with 15 RA patients who underwent atlantoaxial (AA) TAS fixation without utilizing a supplementary posterior fusion. METHODS: To treat AA instability, all 15 RA patients underwent C1-C2 TAS fixation without a supplementary posterior construct. Patients were followed for at least 24 months. Pre- and postoperative sagittal measures of C1- C2, C2-C7, and C1-C7 angles, atlanto-dens interval (ADI), posterior atlanto-dens interval (PADI), and adjacent segment (i.e., C2-C3) anterior disc height (ADH) were retrospectively recorded from lateral X-ray imaging. The presence or absence of superior migration of the odontoid (SMO), cervical subaxial subluxation, C1-C2 bony fusion, screw pull-out, and screw breakage were also noted. RESULTS: There was little difference between the pre- and postoperative studies regarding angles measured. Following TAS fixation, the mean ADI shortened, and mean PADI lengthened. There was no difference in the mean measures of C2-C3 ADH. There was no evidence of SMO pre- or postoperatively. Two patients developed anterior subluxation at C5-C6; one of the two also developed anterior subluxation at C2-C3. All patients subsequently showed C1-C2 bony fusion without screw pull-out or breakage. CONCLUSION: In RA patients who have undergone C1-C2 TAS fixation, eliminating a supplementary posterior fusion resulted in adequate stability.