A case of conservatively managed idiopathic spinal cord herniation presenting with low-pressure headache.

Idiopathic spinal cord herniation presenting with low-pressure headache is extremely rare. We present a case of thoracic ventral spinal cord herniation in a 35-year-old lady who presented with low-pressure headaches. To our knowledge, this is only the fourth case described in the literature of spontaneous ventral cord herniation presenting in this way. The patient was managed conservatively with no manifestation of focal neurological symptoms at 12-month follow-up. The proposed aetiology of spontaneous ventral cord herniation is an initial CSF leak via a dural defect, through which the cord subsequently also enters blocking the CSF leak. We endorse a conservative approach for patients who present similarly, secondary to the above pathophysiology.

Intra-arterial lidocaine therapy via the middle meningeal artery for migraine headache: Theory, current practice and future directions.

Recent developments in neurointerventional research have seen the emergence of the middle meningeal artery (MMA) as an effective conduit for intra-arterial (IA) therapy for a number of pathologies. Here, we review the anatomical, pathophysiological and experimental basis for utilisation of the MMA for IA treatment of migraine headache. We explore the in-human case literature for the treatment of headaches with IA lidocaine and discuss considerations and challenges for future research.

Comparison of External Ventricular Drains with Ventricular Access Devices for the Emergency Management of Adult Hydrocephalus.

OBJECTIVE: We compared external ventricular drains (EVDs) with percutaneous continuous cerebrospinal fluid (CSF) drainage via ventricular access devices (VADs) for the acute management of hydrocephalus in adults. METHODS: This was a retrospective review of all ventricular drains inserted for a new diagnosis of hydrocephalus into noninfected CSF over four years. We compared infection rates, return to theatre, and patient outcome between EVDs and VADs. We explored the effect of duration of drainage, frequency of sampling, hydrocephalus aetiology, and catheter location on these outcomes using multivariable logistic regression modelling. RESULTS: We included 179 drains (76 EVDs and 103 VADs). EVDs were associated with a higher rate of unplanned return to theatre for replacement or revision (27/76, 36%, vs. 4/103, 4%, OR: 13.4 95%CI: 4.3-55.8). However, infection rates were higher in VADs (13/103, 13% vs. 5/76, 7%, OR: 2.0, 95%CI: 0.65-7.7). EVDs were 91% antibiotic impregnated whereas VADs were 98% nonimpregnated. In multivariable analysis, infection was associated with duration of drainage (median: 11 days prior to infection for infected drains vs. 7 days total for noninfected drains), but not drain type (VADs vs. EVDs OR: 1.6, 95%CI: 0.5-6). CONCLUSIONS: EVDs had a higher rate of unplanned revisions but a lower infection rate compared to VADs. However, in multivariable analysis choice of drain type was not associated with infection. We suggest a prospective comparison of antibiotic impregnated VADs and EVDs using similar sampling protocols to assess whether VADs or EVDs for acute hydrocephalus have a lower overall complication rate.

Promoting padawans: a survey examining the state of mentorship in neurosurgical training in the United Kingdom.

BACKGROUND: Mentorship has long since been acknowledged as an integral part of Neurosurgical training. The authors sought to evaluate the state of mentorship in Neurosurgical training in the United Kingdom (UK). METHODS: A 28-point questionnaire was sent to all neurosurgical trainees in the UK and Ireland via the British Neurosurgical Trainee's Association (BNTA), comprising 180 trainees. RESULTS: There were 75 responses (180 trainees on the mailing list, 42% response rate). Despite all respondents reporting it to be at least somewhat important to have a mentor, 16% felt they had no mentors. The mean number of mentors was 2.91 with 72% of respondents having more than 1 mentor. In terms of the content of mentorship relationships, 63% were comfortable discussing career related topics with their mentor to a high or very high degree but only 29% felt comfortable discussing their general wellbeing. With regards to allocated educational supervisors, 43% thought this person to be a 'low' or 'very low' source of mentorship. The three most important traits of the ideal mentor as reported by respondents were: someone chosen by them (48%), working in the same hospital (44%) and having received formal mentorship training (36%). CONCLUSIONS: The current perception of mentorship in Neurosurgery from the surveyed trainees is mixed. A healthy majority of trainees benefit from mentorship of some kind, whilst a significant minority feel underserved. The surveyed trainees feel mentorship is slanted more towards clinical and professional aspects of development than it is towards personal ones. Suggestions for future insight would be an evaluation of senior registrar and consultant sentiments towards mentorship, whilst exploration into more flexible models for establishing mentoring relationships may help to address the heavy importance of trainee choice which is voiced by this survey's results.

What is the quality of the information available on the internet for patients suffering with sciatica?

BACKGROUND: Sciatica is a common neurological condition with a wide variety of clinical specialists and allied health professionals involved, and a broad range of treatment options. We sought to assess the quality of information available on the internet. METHODS: An internet search for 'sciatica' was performed using 'Google'. The first fifty links were assessed using the DISCERN instrument, a validated questionnaire for health consumers and providers. RESULTS: After exclusions, 44 websites were assessed. Only 37% of sites had clear aims and objectives; 79% provided relevant information; 81% did not provide clear sources of their information; 67% had no indication of when the information was compiled or updated; 63% clarified that more than one treatment option was available; only 28% described in moderate to extensive detail how the various treatment modalities might work; only 14% informed patients of potential risks and complications for each treatment. The biased and/or unbalanced websites amounted to 40%, offering greater detail about one treatment modality over others. Overall, 93% of assessed websites did not inform patients of the consequences/natural history if no treatment were undertaken; and 91% did not describe the potential impact of treatment and how it could affect quality of life. CONCLUSIONS: Despite the role that the internet plays in everyday life, information on the common and debilitating condition of sciatica is mostly of low-to-moderate quality, and with serious shortcomings. Healthcare stakeholders ought to be aware of the risks of misinformation and ensure that health-related internet website design and upkeep is guided by instruments such as DISCERN.

Management of traumatic atlanto-occipital dislocation in a 10-year-old with noninvasive halo immobilization: A case report.

Background: Traumatic atlanto-occipital dislocation is an unstable injury of the craniocervical junction. For pediatric patients, surgical arthrodesis of the occipitocervical junction is the recommended management. While having a high success rate for stabilization, the fusion comes with obvious morbidity of limitation in cervical spine flexion, extension, and rotation. An alternative is external immobilization with a conventional halo. Case Description: We describe the case of a 10-year-old boy who was treated successfully for traumatic AOD with a noninvasive pinless halo. Following initial brain trauma management, we immobilized the craniocervical junction with a pinless halo after reducing the atlanto-occipital dislocation. The pinless halo was kept on at all times for the next 3 months. The craniocervical junction alignment was monitored with weekly cervical spine X-rays and CT craniocervical junction on day 15th, day 30th, and day 70th. A follow-up MRI C-spine 3 months from presentation confirmed resolution of the soft-tissue injury and the pinless halo was removed. Dynamic cervical spine X-rays revealed satisfactory alignment in both flexion and extension views. The patient has been followed up for 2 years postinjury and no issues were identified. Conclusion: Noninvasive pinless halo is a potential treatment option for traumatic pediatric atlanto-occipital dislocation. This should be considered bearing in mind multiple factors including age and weight of the patient, severity of the atlanto-occipital dislocation (Grade I vs. Grade II and incomplete vs. complete), concomitant skull and scalp injury, and patient's ability to tolerate the halo. It is vital to emphasize that this necessitates close clinicoradiological monitoring.

Adult WHO grade II ependymomas: is Ki67 a sex-specific proliferation marker?

Ki67 is a marker for proliferation of a given cell population. Low expression of Ki67 may be associated with a favourable outcome. We investigate how the proliferation index correlates with the location, morphology and behaviour of WHO grade II ependymomas with a single-centre cohort study of adult patients admitted for surgery of WHO grade II ependymomas between 2008 and 2018. Seventeen patients were included, seven had supratentorial and 10 had infratentorial tumours. Three patients died and eight had recurrent disease. Age, gender, location, extent of resection, chemotherapy, radiotherapy and histological markers were not associated with tumour progression. Both unadjusted and adjusted analysis confirmed a higher Ki67 index in male patients. Sensitivity analysis further supported the correlation between Ki67 and male gender. Ki67 may be sex specific but does not seem to correlate with survival and time to recurrence in this series.

Burnout amongst neurosurgical trainees in the UK and Ireland.

INTRODUCTION: Burnout is becoming an increasingly recognised phenomenon within the medical profession. This study aims to investigate the presence of burnout amongst neurosurgical trainees in the UK and Ireland as well as investigating potential exacerbating and protective factors. METHOD: An online survey was sent to all neurosurgical trainees in the UK and Ireland via the British Neurosurgical Trainees' Association (BNTA) mailing list. Responding participants anonymously completed the Copenhagen Burnout Inventory (CBI) and answered questions about known risk factors for burnout including workplace environment, workplace bullying, time spent on leisure activities and sleep and reported likelihood of leaving neurosurgery. We also collated data on responders' demographics. We compared CBI scores for participants with and without risk factors to determine correlation with CBI. RESULTS: There were 75 respondents (response rate 42%) from a range of ages and all training grades, 72% of whom were male. The median CBI score was 38.85 (IQR 17.76). Participants showed a higher degree of personal and workplace burnout (median CBIs of 47.02, IQR 25.00; and 49.14, IQR 19.64, respectively) compared with patient-related burnout (median CBI 18.67, IQR 25.00). Participants with the following self-reported risk factors were significantly more likely to have higher CBIs: workplace bullying (p = 0.01), getting on less well with colleagues (p < 0.05), working longer hours (p < 0.05) and insufficient sleep, exercise and leisure time (all p < 0.01). Those with higher CBI scores were more likely to consider leaving neurosurgical training (p = 0.01). CONCLUSION: We identified a high burnout incidence in a cohort representative of UK neurosurgical trainees, although our results may have been skewed somewhat by selection bias. We determined potential risk factors for burnout related to specific workplace stressors and time for non-work activities. In the future, changes to training curricula should address these issues, aiming to improve training, enhance patient care and reduce attrition rates.

Acute bilateral foot drop with or without cauda equina syndrome-a case series.

INTRODUCTION: Isolated acute bilateral foot drop due to degenerative spine disease is an extremely rare neurosurgical presentation, whilst the literature is rich with accounts of chronic bilateral foot drop occurring as a sequela of systemic illnesses. We present, to our knowledge, the largest case series of acute bilateral foot drop, with trauma and relevant systemic illness excluded. METHODS: Data from three different centres had been collected at the time of historic treatment, and records were subsequently reviewed retrospectively, documenting the clinical presentation, radiological level of compression, timing of surgery, and degree of neurological recovery. RESULTS: Seven patients are presented. The mean age at presentation was 52.1 years (range 41-66). All patients but one were male. All had a painful radiculopathic presentation. Relevant discopathy was observed from L2/3 to L5/S1, the commonest level being L3/4. Five were treated within 24 h of presentation, and two within 48 h. Three had concomitant cauda equina syndrome; of these, the first two made a full motor recovery, one by 6 weeks follow-up and the second on the same-day post-op evaluation. Overall, five out of seven cases had full resolution of their ankle dorsiflexion pareses. One patient with 1/5 power has not improved. Another with 1/5 weakness improved to normal on the one side and to 3/5 on the other. CONCLUSION: When bilateral foot drop occurs acutely, we encourage the consideration of degenerative spinal disease. Relevant discopathy was observed from L2/3 to L5/S1; aberrant innervation may be at play. Cauda equina syndrome is not necessarily associated with acute bilateral foot drop. The prognosis seems to be pretty good with respect to recovery of the foot drop, especially if partial at presentation and if treated within 48 h.