In-House Intraoperative Monitoring in Neurosurgery in England - Benefits and Challenges.

BACKGROUND: Intraoperative neurophysiological monitoring (IOM) is a valuable adjunct for neurosurgical operative techniques, and has been shown to improve clinical outcomes in cranial and spinal surgery. It is not necessarily provided by NHS hospitals so may be outsourced to private companies, which are expensive and at cost to the NHS trusts. We discuss the benefits and challenges of developing an in-house service. METHODS: We surveyed NHS neurosurgical departments across England regarding their expenditure on IOM over the period January 2018 - December 2022 on cranial neurosurgery and spinal surgery. Out of 24 units, all responded to our Freedom of Information requests and 21 provided data. The standard NHS England salary of NHS staff who would normally be involved in IOM, including physiologists and doctors, was also compiled for comparison. RESULTS: The total spend on outsourced IOM, across the units who responded, was over £8 million in total for the four years. The annual total increased, between 2018 and 2022, from £1.1 to £3.5 million. The highest single unit yearly spend was £568,462. This is in addition to salaries for staff in neurophysiology departments. The mean NHS salaries for staff is also presented. CONCLUSION: IOM is valuable in surgical decision-making, planning, and technique, having been shown to lead to fewer patient complications and shorter length of stay. Current demand for IOM outstrips the internal NHS provision in many trusts across England, leading to outsourcing to private companies. This is at significant cost to the NHS. Although there is a learning curve, there are many benefits to in-house provision, such as stable working relationships, consistent methods, training of the future IOM workforce, and reduced long-term costs, which planned expansion of NHS services may provide.

Patient selection and outcome of deep brain stimulation for multiple sclerosis-associated tremor.

INTRODUCTION: Tremor is a disabling symptom of multiple sclerosis (MS), with limited treatment modalities. Thalamic ventral-intermediate-nucleus (VIM) deep brain stimulation (DBS) is a method of neuromodulation. We describe the long-term outcomes of our carefully selected patients who underwent VIM DBS for their MS-associated tremor. METHODS: Patients were referred from the regional neurology units. Pre-operative assessments included suitability for anesthesia, tremor quantification by the Fahn-Tolosa-Marin scores, and quality-of-life (EQ5D) measures. Exclusion criteria included prominent cerebellar symptoms such as ataxia and dysmetria, intracranial pathology such as ventriculomegaly, cerebellar plaques and thalamic abnormality, and comorbid psychiatric symptoms. Seven patients (3M:4F) underwent DBS for MS-associated tremor between September 2013 and February 2019. Mean age was 42 years (±SD 8 years). DBS was performed at a mean of 13 years (±SD 9 years) after diagnosis of MS. RESULTS: There were no postoperative surgical complications. All patients showed improvement in FTM tremor scores, by up to 61% at 6 months postoperatively. There was an improvement of 30-175% in quality-of-life scores at 6 months. Improvement of tremor and quality of life, over baseline, was sustained over a long period of follow-up (mean 26.6 months ± SD 20.7 months), including our longest duration at 72 months. CONCLUSION: With careful selection, DBS is a safe, efficacious intervention for MS-tremor and can positively impact on tremor and quality of life, with effects over a long period. As patients live longer with MS and the advent of new therapies, DBS should be considered for selected patients.

Delayed presentation of bamboo foreign body in brainstem, with novel skull base foramen.

We describe the extremely unusual case of a childhood injury to the skull base presenting after many years, as a foreign body with chronic granulomatous infection of the brainstem, mimicking neoplasm. TB had an inconsequential penetrating injury to the left cheek, from a bamboo spike aged 15. After 4 years, he developed worsening left sided weakness, imaging at this time was normal. After a car accident aged 40, the weakness worsened further and imaging demonstrated a foreign body entering the skull base. At its tip, it had caused a chronic granulomatous reaction within the brainstem. Surgical removal of this bamboo splinter was via an infratemporal, transzygomatic craniotomy and TB made a good recovery postoperatively. This unusual case demonstrates the important of close inspection of imaging, and thorough history taking. It also questions the chronology of the ossification of the skull base.

Neurogenic Cough Associated with Hyperintensity in Dorsal Medulla: Case Report and Anatomical Discussion.

BACKGROUND: The nucleus tractus solitarius and paratrigeminal nucleus, which are implicated in the processing of airway-derived sensory information, are found in the dorsal medulla. The mechanism and localization of higher-order processing of urge to cough is poorly understood, and much of the existing anatomical localization is limited to animal studies. CASE DESCRIPTION: A 44-year-old Caucasian lady underwent elective foramen magnum decompression for symptomatic Chiari I malformation; postoperatively she had resolution of Chiari symptoms but developed an intractable neurogenic cough. She has no significant medical history or premorbid respiratory issues. Postoperative magnetic resonance imaging of her head demonstrated signal change in the left dorsal medulla, corresponding with the nucleus tractus solitarius and paratrigeminal nucleus. CONCLUSIONS: We suggest that this lesion explains her isolated new cough and localizes the pathway for "urge to cough" to this region of the medulla.

Percutaneous retrogasserian glycerol rhizotomy for trigeminal neuralgia: an alternative technique.

Background: One of the challenges faced by the modern-day NHS is workplace shortages, and experienced radiographers for intra-operative neurosurgical imaging is one such scenario. We describe our method for Percutaneous Retrogasserian Glycerol Rhizotomy (PRGR) using frameless neuronavigation which can be used effectively in such scenarios.Method: Stealth neuronavigation is used for needle placement within the foramen ovale and injection of glycerol, under sedation.Results: In our experience of ten procedures, it is accurate, safe and effective. Good results were obtained on all occasions. It can be repeated as often as necessary using the same Stealth® CT scan and reduces exposure for staff and patients, where repeated injections are required.Conclusion: This simple modification of PRGR technique is effective and safe provided the surgeon has previous experience in undertaking this procedure.