Spinal anaplastic ganglioglioma.

Anaplastic gangliogliomas of the spinal cord are extremely rare with only four cases reported in the literature. Here we present the case of a 22-year-old female who presented acutely with quadraparesis and urinary retention. Radiographic imaging demonstrated an intramedullary lesion within the cervical spine. She underwent a cervical laminectomy and resection of the lesion under neurophysiological monitoring. Post-operatively, she regained some function, but remained paraparetic. Histopathology demonstrated an anaplastic ganglioglioma (WHO Grade 3). She subsequently underwent radiotherapy. Following surgery, she remained stable and had MRC Grade 3 Power in all four limbs. Herein, we describe a previously undescribed case of cervical anaplastic ganglioglioma and review the existing literature.

Dural tear repair surgery comparative analysis: a stitch in time saves nine.

PURPOSE: A dural tear is a common iatrogenic complication of spinal surgery associated with a several post-operative adverse events. Despite their common occurrence, guidelines on how best to repair the defect remain unclear. This study uses five post-operative outcomes to the compare repair methods used to treat 106 dural tears to determine which method is clinically favourable. METHODS: Data were retrospectively collected from Southampton General Hospital's online databases. 106 tears were identified and grouped per repair method. MANOVA was used to compare the following five outcomes: Length of stay, numbers of further admissions or revision surgeries, length of additional admissions, post-operative infection rate and dural tear associated neurological symptoms. Sub-analysis was conducted on patient demographics, primary vs non-primary closure and type of patch. Minimal clinically important difference (MCID) was calculated via the Delphi procedure. RESULTS: Age had a significant impact on patient outcomes and BMI displayed positive correlation with three-fifth of the predefined outcome measures. No significant difference was observed between repair groups; however, primary closure ± a patch achieved an MCID percentage improvement with regards to length of original stay, rate of additional admissions/surgeries and post-operative infection rate. Artificial over autologous patches resulted in shorter hospital stays, fewer readmissions, infections and neurological symptoms. CONCLUSION: This study reports primary closure ± dural patch as the most efficient repair method with regards to the five reported outcomes. This study provides limited evidence in favour of artificial over autologous patches and recommends that dural patches be used in conjunction with primary closure. LEVEL OF EVIDENCE I: Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.

Posterior fossa ICP monitoring: a tale of two compartments.

AIM: Measuring the intracranial pressure (ICP) of the infra-tentorial, posterior fossa compartment has long been avoided due to a lack of precedent and interpretability, as well as concern of damage to the underlying vital structures. In cases of posterior fossa insults however, the supra-tentorial compartment ICPs can be falsely reassuring. We aimed to measure the posterior fossa ICP in such a case and analyse the resulting data. METHODS: We present a case of posterior fossa ICP monitoring and discuss its safety profile, rationale and possible indications. RESULTS: Our comparison of the supra and infra-tentorial ICPs showed that there was a statistically significant difference in the two compartments. The infra-tentorial compartment had ICPs averaging 11.02 ± 2.24 mmHg whilst the supra-tentorial compartment averaged 4.94 ± 1.80 mmHg in the first 72 hours post-op (p < .01 on paired t-testing). After 72 hours, the pressures seemed to equilibrate and were 4.71 ± 2.6 and 3.88 ± 2.89 for the infra and supra-tentorial compartments respectively. CONCLUSION: We propose that where a patient with a posterior fossa insult exhibits signs and symptoms consistent with raised ICP but the supra-tentorial readings are normal, posterior fossa ICP monitoring can be considered.

Straight to the point: an updated technique for performing lumbar puncture safely in obese patients.

Introduction: Lumbar puncture is an essential tool in any medical practitioner's repertoire - both surgeon and physician alike. With a rising trend in obesity, the procedure can be technically challenging.Methods: Here we present 12 cases where an updated version of lumbar puncture using an introducer is used for patients with a large body habitus.Results: The procedure was successful in all 12 patients with only one patient requiring a second attempt. All 12 patients gave positive feedback for the procedure.Conclusion: Performing lumbar puncture in obese patients using this updated technique is a safe, successful and cost-effective technique.

Pedunculopontine and Subthalamic Nucleus Stimulation Effect on Saccades in Parkinson Disease.

BACKGROUND: Deep brain stimulation (DBS) of the pedunculopontine nucleus (PPN) has been explored as a target to treat axial motor symptoms of advanced Parkinson disease (PD). The aim of this study was to consider relative effects of bilateral subthalamic nucleus (STN) and PPN DBS on both initiation and inhibition of saccades in advanced PD. METHODS: Five patients with advanced PD performed 2 different oculomotor tasks off stimulation, with bilateral STN DBS, with bilateral PPN DBS, and with simultaneous bilateral STN and PPN DBS. The first task involved visually guided saccades, and the second task involved antisaccades (ASs). Saccadic latency, accuracy, and velocity were recorded for both the visually guided saccade and AS tasks, and prosaccades were measured for the AS task alone. Control subjects included patients with advanced PD without DBS, age-matched healthy subjects, and young healthy subjects (n = 12 in each group). RESULTS: Simultaneous bilateral STN and PPN DBS produced the greatest improvement in mean latencies, velocities, and accuracies for visually guided saccades and ASs compared with DBS off (P < 0.001). Bilateral STN and PPN DBS caused a significant additional improvement compared with STN DBS alone by reducing the number of prosaccades (P < 0.01). CONCLUSIONS: It is known that the frontal lobe is involved in saccadic inhibition during AS tasks. Hence, our novel finding of an improvement in the AS task suggests an ascending, frontally mediated effect of PPN DBS. This implies that there may be PPN-to-frontal lobe connections that may partly explain the benefits of PPN DBS in axial motor function.

Pelvic occupation: the challenges of treating a symptomatic tarlov cyst.

Tarlov (perineural) cysts are meningeal dilations of the posterior spinal nerve root sheath located in between the peri- and endoneurium. We present a patient with a symptomatic sacral Tarlov cyst and the technical challenges faced by surgically treating the lesion by disconnection of the cyst from the subarachnoid space.

Nurturing the Next Generation of Neurosurgeons: How Important Are Nontechnical Skills?

BACKGROUND: A recent trend has occurred of increased awareness and an emphasis for teaching nontechnical skills (NTSs) in the world of surgery. Although neurosurgery has incorporated simulation-based training as a part of the training curriculum in the United Kingdom, it has yet to formally introduce NTS training. The present study, therefore, queried both neurosurgical trainees and tutors regarding how much they valued NTSs and their development. METHODS: We performed a questionnaire-based, mixed-methods study to determine the knowledge, attitudes, and practices of both neurosurgical trainees and tutors regarding NTSs across neurosurgical centers in the United Kingdom in 2015. RESULTS: The trainees valued NTSs and their development more than did their tutor counterparts (P < 0.05, z-testing). This was evident from both the quantitative results and the qualitative data gained from the questionnaire. Various areas for potential improvement of the curriculum were also identified. CONCLUSION: The results of the present study highlight the importance of NTS development in neurosurgery. These results could act as a good starting point for further larger scale similar studies and discussion on curriculum committees.

Caecal perforation from TB and the Law of Laplace.

A 43-year-old man presented to the hospital with haemoptysis. When worked up, his history and examination were highly suggestive of pulmonary tuberculosis (TB). He subsequently developed a massive upper gastrointestinal bleed and underwent an emergency laparotomy, which revealed a massively dilated caecum measuring ∼20 cm in diameter. The caecum had perforated due to acute decompensation of intestinal TB. Though common in developing countries, TB is rare in the UK, especially the intestinal kind. The most striking feature of this case is, however, the size of the caecal distension caused by the tubercular inflammation and subsequent perforation-something unheard of in the literature. This massive caecal distention would be explained by the Law of Laplace. In conclusion, massive distension and caecal perforation are possible consequences of intestinal TB, especially in the 48-72 h immediately after starting anti-tubercular therapy.

Bowel hath no fury like a gallbladder inflamed.

Gallstone ileus is a well-established phenomenon in which a large gallstone leads to mechanical small bowel obstruction. This case, however, reports the novel finding of a patient presenting with suprapubic pain and guarding caused by paralytic ileus of the small bowel and a duodenal perforation secondary to a necrotic gallbladder. It highlights the importance of distinguishing between gallstone ileus and paralytic ileus and how the management of the two conditions differs. Furthermore, this article discusses how paralytic ileus caused by intra-abdominal inflammatory conditions such as cholecystitis can mask the typical clinical findings making the diagnosis difficult.

Improvement of patient satisfaction with the neurosurgery service at a large tertiary care, London-based hospital.

Patient satisfaction is central to healthcare provision and the effective running of any surgical unit. Following on from both formal and informal feedback, we decided to look objectively at patient satisfaction with the neurosurgery service at a large tertiary care hospital in London and identify areas that needed improvement within the unit. Patient satisfaction was looked at with respect to four different aspects of the neurosurgery service: the surgeons, ward doctors, nurses, and hospital services. A questionnaire-based cross-sectional study was conducted and once the data were collected a plan of action to improve service provision was put into place. Data were collected from 150 patients over a 3 month period from September to November 2012. Interventions were made and data re-collected from 150 patients from January to March 2013. With regards to satisfaction with the neurosurgery service, 76.7% (n=115) were satisfied; following implementation of our measures for improvement, which included staff education, meetings and posters, this figure increased to 90.6% (n=136, p<0.001 on Chi-square testing). In conclusion, patient satisfaction should be at the crux of patient care, with a strong focus on effective communication skills, and can be improved by identification of issues by direct patient feedback and subsequent action based on this.

Weight a minute - iatrogenic paracetamol toxicity is preventable by utilisation of well-designed drug charts.

Iatrogenic Paracetamol toxicity is a potentially life-threatening yet avoidable cause of acute liver failure. Unfortunately, several cases have recently been reported nationally (1,2). The impetus behind our project was a recent case of iatrogenic Paracetamol induced hepatotoxicity within our trust, a London-based District General Hospital. According to the British National Formulary, for adults weighing 10-50kg the intravenous (IV) dose is 15mg/kg every 4-6hours (max. 60mg/kg daily), not the usual 1 gram QDS oral dose which is applied irrespective of weight (3). We audited 100 adult patients in April 2013 and re-audited in July 2013. Both of the randomly selected samples consisted of an equal number of surgical and medical patients, with an equal gender ratio. Data of interest included whether patients were on IV Paracetamol, appropriately dosed; if and when patients had been weighed during admission; and whether the WHO pain ladder of analgesia was followed. Identified shortcomings included patient weight on admission not being recorded, and IV Paracetamol dose adjustment not being made in patients <50kg. 3 months were spent raising awareness of the importance to record patient weights and to dose-adjust IV Paracetamol when indicated. Patients weighed on admission improved from 37% to 68% (p<0.0001) and those on the inappropriate dose of Paracetamol fell from 18 (25% of the patients on Paracetamol) to 5 (5.75% of the patients on Paracetamol) p=0.0013. There was a marked improvement in the number of patients with the weight written on their drug chart from 27% to 53% post-intervention. (p=0.0003) In conclusion, every patient should be weighed on admission. In order to prevent potential hepatotoxicity, staff should document patient weights on the drug charts and be aware of the fact that patients who weigh <50 kg should be on a 15 mg/kg/dose of IV Paracetamol, not 1 gram QDS.

An eye-tracking version of the trail-making test.

The neurodegenerative disorder amyotrophic lateral sclerosis may render patients unable to speak or write, so that objective assessment of cognitive impairment, which is commonly of a dysexecutive nature, is challenging. There is therefore a need to develop other methods of assessment that utilize other relatively unaffected motor systems. In this proof-of-principle study a novel eye-tracking version of the trail-making test was compared with performance on the standard written version in a group of healthy volunteers. There was good correlation for speed between both versions of Part B (R(2)=0.73), suggesting that this is a viable method to objectively assess cognitive impairment in disorders where patients are unable to speak or write.

Erratum: Intradiploic epidermoid cyst overlying the torcula: a surgical challenge.

[This corrects the article DOI: 10.1136/bcr.08.2010.3245.].

Impact of today's media on university student's body image in Pakistan: a conservative, developing country's perspective.

BACKGROUND: Living in a world greatly controlled by mass media makes it impossible to escape its pervading influence. As media in Pakistan has been free in the true sense of the word for only a few years, its impact on individuals is yet to be assessed. Our study aims to be the first to look at the effect media has on the body image of university students in a conservative, developing country like Pakistan. Also, we introduced the novel concept of body image dissatisfaction as being both negative and positive. METHODS: A cross-sectional study was conducted among 7 private universities over a period of two weeks in the city of Karachi, Pakistan's largest and most populous city. Convenience sampling was used to select both male and female undergraduate students aged between 18 and 25 and a sample size of 783 was calculated. RESULTS: Of the 784 final respondents, 376 (48%) were males and 408 (52%) females. The mean age of males was 20.77 (+/- 1.85) years and females was 20.38 (+/- 1.63) years. Out of these, 358 (45.6%) respondents had a positive BID (body image dissatisfaction) score while 426 (54.4%) had a negative BID score. Of the respondents who had positive BID scores, 93 (24.7%) were male and 265 (65.0%) were female. Of the respondents with a negative BID score, 283 (75.3%) were male and 143 (35.0%) were female. The results for BID vs. media exposure were similar in both high and low peer pressure groups. Low media exposure meant positive BID scores and vice versa in both groups (p < 0.0001) showing a statistically significant association between high media exposure and negative body image dissatisfaction. Finally, we looked at the association between gender and image dissatisfaction. Again a statistically significant association was found between positive body image dissatisfaction and female gender and negative body image dissatisfaction and male gender (p < 0.0001). CONCLUSIONS: Our study confirmed the tendency of the media to have an overall negative effect on individuals' body image. A striking feature of our study, however, was the finding that negative body image dissatisfaction was found to be more prevalent in males as compared to females. Likewise, positive BID scores were more prevalent amongst females.

Intradiploic epidermoid cyst overlying the torcula: a surgical challenge.

Intradiploic tumours are rare, slow growing tumours that can present in many different ways, including a painless lump, tenderness, headache and rarely with focal neurological signs. The authors present the case of a gentleman in whom the tumour presented in an unusual location and presented a surgical challenge. The major take home message from this case report is that an epidermoid cyst overlying the torcula is to be approached with great caution and care and is without doubt a surgical challenge.

Palinopsia from a posteriorly placed glioma--an insight into its possible causes.

Palinopsia is a distortion of processing in the visual system in which images persist or recur after the visual stimulus has been removed. It is a dysfunction of the association areas at the junction of temporal, occipital and parietal lobes and can be triggered by any lesion or dysfunction in this region. Here, the authors report the case of a patient with a glioma involving this region of the brain, who presented with palinopsia that subsequently disappeared once the tumour was surgically debulked. In the few cases of palinopsia that have been published so far, no such case has ever been reported. Furthermore, we took an insight into this rare and elusive phenomenon's causes and suggested Bayesian inference as a possible cause. The authors also mentioned visual evoked potentials as a useful test to be considered in future palinoptic patients.