Spinal dural arteriovenous fistulas--presentation, management and outcome in a single neurosurgical institution.

OBJECTIVE: To compare the outcome, with respect to treatment modality, of patients treated with spinal dural arteriovenous fistulas (SDAVF). METHOD: Retrospective cohort study of patients with SDAVF assessed at a single tertiary referral centre, between 1999 and 2009. Intervention type, pre-/ post-intervention Aminoff-Logue disability score (ALDS) and recurrence rate were obtained from medical records. RESULTS: 26 patients were identified with 23 receiving intervention. All patients initially received super selective angiogram, with 13 undergoing endovascular embolization at this stage, after discussion between the surgeon and interventional radiologist. Six patients who underwent embolization had a recurrence. The remaining 10 patients had fistulas marked during angiography, and were then treated surgically, after discussion. One of these recurred. The difference in recurrence rate between the two intervention types was not statistically significant. Fistulas treated with the embolization material onyx were twice as likely to recur as those treated with the alternative material, histoacryl-lipiodol. There was a statistically significant difference between the modes of intervention in relation to clinical outcome. Surgeries lead to an improvement in neurology, whereas treatment via embolization did not. Neurological improvement was seen in non-recurring cases, however deterioration in neurological function occurred with fistula recurrence. CONCLUSION: Super selective angiography is effective in defining the relevant vascular anatomy and allows for precise fistula localization during any potential subsequent surgery. Onyx was associated with a higher recurrence rate, suggesting it is less suitable as an embolization material for SDAVF treatment. Surgery appeared to correlate to reversal of neurological impairment seen at presentation, possibly due to a lower recurrence rate. The study is limited by small patient numbers, emphasizing the need for further studies of SDAVF patients.

Spine Tango annual report 2012.

PURPOSE: Since the Spine Tango registry was founded over a decade ago it has become established internationally. An annual report has been produced using the same format as the SWEspine group to allow for first data comparisons between the two registries. METHODS: Data was captured with the latest generation of surgery and follow-up forms. Also, the Core Outcome Measures Index (COMI) from interventions performed in the year 2012 with follow-up to June 2013 was analyzed. Groups of patients with the most common degenerative lumbar spine diseases and a single group of patients with degenerative cervical spine diseases were created. The demographics, risk factors, previous treatments, current treatment, short-term outcomes, patient satisfaction and complications were analyzed. Pre- and postoperative pain and function scores were derived from the COMI. RESULTS: About 6,500 procedures were captured with Spine Tango in 2012. The definitions and composition of all the degenerative groups could not completely be matched between the two registries with the consequence that the age and sex distributions were partially different. Preoperative pain levels were similar. The short-term outcomes available did not allow for evaluation of the final result of surgical intervention. This will be possible with the longer term data in the next annual report. There was a distinct disparity in reported complication rates between surgeons and patients. CONCLUSIONS: This is a valuable first step in creating comparable reports for SWEspine and Spine Tango. The German spine registry may be able to collaborate in the future because of similar items and data structure as Spine Tango. There needs to be more work on understanding the harmonization of the different degenerative subgroups. The Spine Tango report is weakened by the short and incomplete follow-up. The visual presentation of data may be a useful model for aiding decision making for surgeons and patients in the future.

Temporal trends in head injury outcomes from 2003 to 2009 in England and Wales.

BACKGROUND: Case fatality rates after blunt head injury (HI) did not improve in England and Wales between 1994 and 2003. The United Kingdom National Institute of Clinical Excellence subsequently published HI management guidelines, including the recommendation that patients with severe head injuries (SHIs) should be treated in specialist neuroscience units (NSU). The aim of this study was to investigate trends in case fatality and location of care since the introduction of national HI clinical guidelines. METHODS: We conducted a retrospective cohort study using prospectively recorded data from the Trauma and Audit Research Network (TARN) database for patients presenting with blunt trauma between 2003 and 2009. Temporal trends in log odds of death adjusted for case mix were examined for patients with and without HI. Location of care for patients with SHI was also studied by examining trends in the proportion of patients treated in non-NSUs. RESULTS: Since 2003, there was an average 12% reduction in adjusted log odds of death per annum in patients with HI (n=15,173), with a similar but smaller trend in non-HI trauma mortality (n=48,681). During the study period, the proportion of patients with HI treated entirely in non-NSUs decreased from 31% to 19%, (p <0.01). INTERPRETATION: The reduction in odds of death following HI since 2003 is consistent with improved management following the introduction of national HI guidelines and increased treatment of SHI in NSUs.

Hindbrain decompression for Chiari-syringomyelia complex: an outcome analysis comparing surgical techniques.

The natural history of Chiari malformation and our ability to alter it is poorly understood, and reported results of hindbrain decompression show high recurrence rates. We report 11 years of experience of hindbrain decompression, to evaluate long-term outcome related to surgical technique. The results of patients who underwent hindbrain decompression between 1994 and 2005 were retrospectively analysed. We identified 96 patients from operative records and reviewed all clinical records for presenting symptomatology and examination findings. Decompression technique includes traditional decompression, duraplasty and bone--only decompression. Symptoms at the last available follow-up visit were defined by the assessing clinician as resolved, improved, unchanged or worse. There were 35 males and 61 females with a mean age of 33 years (range 6 - 62 years). The mean length of follow-up is 3.6 years with a range of 6 months to 9 years. Postoperative resolution or improvement in symptoms was seen in 75 patients (78%). Drop attacks and headaches were the most likely to respond to hindbrain decompression, showing improvement or resolution in 100 and 92% of cases. Dysaesthetic arm pain and weakness carried the worse prognosis with only 20% having symptom resolution. Sixteen patients had only bony decompression leaving the dura intact. In eight patients (66%) the headaches resolved following bony decompression alone. However the headaches were unchanged in 25% of cases. Dysaesthetic pain and weakness was unchanged in 60%. Restoration of CSF flow dynamics at the foramen magnum by surgical decompression does not consistently result in resolution of symptoms in all patients. Identification of predictors of successful outcome following decompression, coupled with early intervention and appropriate choice of procedure may result in improved outcomes. Although this is a retrospective study it suggests that bone only decompression should be reserved for patients with isolated headache.

Multiple schwannomas: report of two cases.

In this paper authors present two cases of multiple schwannomas without the features of neurofibromatosis (NF). The authors retrospectively reviewed the hospital charts, radiology films, operative notes and pathology slides of these two patients. There was no family history of neurofibromatosis. The two patients had contrast enhanced MRI, which was negative for vestibular schwannomas. Both underwent surgical excision of symptomatic lesions. Histopathology confirmed these lesions as schwannomas. Molecular genetic analysis in case 1 demonstrated two distinct mutations of the NF2 gene in two different schwannomas, with concomitant loss of heterozygosity in both tumours. In contrast peripheral blood lymphocytes did not reveal mutations of NF2. The authors recommend surgery for symptomatic lesions. Asymptomatic tumours can be monitored. Regular follow up is essential as they may develop fresh lesions at any time. The relevant literature is discussed.

Magnetic resonance image findings in the early post-operative period after anterior cervical discectomy.

If early neurological deterioration occurs following anterior cervical discectomy, the patient should be evaluated by urgent MRI scanning. In order to interpret such a scan it is essential to know what the normal post-operative MRI appearance is following an uncomplicated procedure. In the lumbar spine it is well recognized that early post-operative imaging following discectomy is difficult to interpret with a high rate of false positive scans. The normal appearance of MRI in the early post-operative period was evaluated prospectively in 15 patients undergoing anterior cervical discectomy without fusion for either cervical radiculopathy or myelopathy. MRI was performed on the first post-operative day, at 6 weeks and 6 months. The successful outcome of the procedure was validated by uniform improvement of Visual Analogue Scale measurement for neck and arm pain, the Neck Disability Index and European Myelopathy Score as appropriate. In contrast to the established findings following lumbar discectomy, only two cases showed a persistent epidural mass in the first post-operative scan and this had completely resolved at 6 months. All patients had foraminal narrowing and root or cord compression pre-operatively. Sixty six percent of cases showed persistent foraminal narrowing on sequential imaging up to 6 months despite showing good symptomatic improvement. All cases demonstrated high signal in the operated disc space on T2 weighted imaging on the first post-operative day and this finding persisted in 13 of 15 scans performed at 6 weeks. Post contrast imaging demonstrated no enhancement of operated disc space and adjacent vertebral body on the first post-operative day, whereas all scans at 6 weeks showed enhancement and such enhancement persisted at 6 months in 50%. Persistent epidural filling defects are uncommon following successful anterior cervical discectomy but persistence of foraminal narrowing is common despite successful outcome. Enhancement of the disc space is also common and does not in itself imply infection.

High quality acute care for the severely injured is not consistently available in England, Wales and Northern Ireland: report of a survey by the Trauma Committee, The Royal College of Surgeons of England.

INTRODUCTION: A survey was undertaken to determine the extent to which acute hospitals in England, Wales and Northern Ireland were meeting the acute trauma management standards published in 2000 by The Royal College of Surgeons of England and the British Orthopaedic Association. METHODS: A questionnaire comprising 72 questions in 16 categories of management was distributed in July 2003 to all eligible hospitals via the link network of the British Orthopaedic Association. Data were collected over a 3-month period. RESULTS: Of 213 eligible hospitals, 161 (76%) responded. In every category of acute care, failure to meet the standards was reported. Only 34 (21%) hospitals met all the 13 indicative standards that were considered pivotal to good trauma care, but all hospitals met at least 7 of these standards. Failures were usually in the organisation of services rather than a lack of resources, with the exception of the inadequate capacity for admission to specialist neurosurgery units. A minority of hospitals reported an inability to provide emergency airway control or insertion of chest tube. The data have not been verified and deficiencies in reporting cannot be excluded. CONCLUSIONS: The findings of this survey suggest that high quality care for the severely injured is not available consistently across England, Wales and Northern Ireland, and appear to justify concerns about the ability of the NHS to deal effectively with the current trauma workload and the consequences of a major incident.

Outcome predictors and complications in the management of intradural spinal tumours.

The results of the management of 115 patients with intradural spinal tumours are presented. Data was collected retrospectively from the case notes. Tumours were categorized as intramedullary or extramedullary for statistical analysis. Meningioma, schwannoma and ependymoma accounted for 70% of tumours. Complete macroscopic excision was achieved in 84% of extramedullary and 54% of intramedullary tumours. There were two post-operative deaths, one of which was secondary to methacillin-resistant staphylococcus aureus (MRSA) meningitis. Cerebrospinal fluid leak (10%) and meningitis (7%) were the commonest complications. Ninety-six percent of patients with extramedullary tumours improved or remained unchanged on the Frankel scale. In the intramedullary group, 82% remained unchanged or improved after treatment. Pre-operative functional status was a predictor of good post-operative function for intra- and extramedullary tumours and for intramedullary tumours a good post-operative Frankel score predicted long-term survival.

Acquisition of a chronic subdural haematoma during training for competitive race walking?

A 65 year old man, anticoagulated for cardiac problems, developed hemiparesis while training for race walking. A computed tomography scan showed a chronic subdural haematoma. This is the first report of a chronic subdural haematoma possibly caused by the jarring action of race walking.

The power of statistical tests in meta-analysis.

Calculations of the power of statistical tests are important in planning research studies (including meta-analyses) and in interpreting situations in which a result has not proven to be statistically significant. The authors describe procedures to compute statistical power of fixed- and random-effects tests of the mean effect size, tests for heterogeneity (or variation) of effect size parameters across studies, and tests for contrasts among effect sizes of different studies. Examples are given using 2 published meta-analyses. The examples illustrate that statistical power is not always high in meta-analysis.

Missing predictors in models of effect size.

Missing data occur frequently in meta-analysis. Reviewers inevitably face decisions about how to handle missing data, especially when predictors in a model of effect size are missing from some of the identified studies. Commonly used methods for missing data such as complete case analysis and mean substitution often yield biased estimates. This article briefly reviews the particular problems missing predictors cause in a meta-analysis, discusses the properties of commonly used missing data methods, and provides suggestions for ways to handle missing predictors when estimating effect size models. Maximum likelihood methods for multivariate normal data and multiple imputation hold the most promise for handling missing predictors in meta-analysis. These two model-based methods apply to a broad set of data situations, are based on sound statistical theory, and utilize all information available to obtain efficient estimators.

En bloc removal of the lower lumbar vertebral body for chordoma. Report of two cases.

En bloc removal of the lower lumbar vertebral bodies (VBs) is a major surgical challenge. The authors describe the surgical technique used in two patients who presented with chordoma confined to the L-5 and L-4 VB, respectively. These tumors were diagnosed using magnetic resonance (MR) imaging during investigation for back pain. Both patients underwent a combined (two-stage) anterior-posterior approach. In the first case the posterior stage of the procedure was followed by an anterior retroperitoneal approach, and in the second case a lateral retroperitoneal approach was used. Complete en bloc excision of the tumor was achieved in each case, even though in the second case the VB fractured when it was mobilized. The correlation between the MR imaging findings and surgical specimens was remarkable. The authors conclude that en bloc resection is feasible in these cases. Because mobilization of the VB is more difficult in the lateral approach, the authors favor the anterior retroperitoneal approach. The authors anticipate the need for such procedures to increase with the widespread use of MR imaging, which demonstrates the extent of these tumors with remarkable accuracy.

Fluvoxamine for children and adolescents with obsessive-compulsive disorder: a randomized, controlled, multicenter trial.

OBJECTIVE: To determine the safety and efficacy of fluvoxamine for the treatment of children and adolescents with obsessive-compulsive disorder (OCD) with a double-blind, placebo-controlled, multicenter study. METHOD: Subjects, aged 8 to 17 years, meeting DSM-III-R criteria for OCD were recruited from July 1991 to August 1994. After a 7- to 14-day single-blind, placebo washout/screening period, subjects were randomly assigned to fluvoxamine 50 to 200 mg/day or placebo for 10 weeks. Subjects who had not responded after 6 weeks could discontinue the double-blind phase of the study and enter a long-term, open-label trial of fluvoxamine. Analyses used an intent-to-treat sample with a last-observation-carried-forward method. RESULTS: Mean Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) scores with fluvoxamine were significantly (p < .05) different from those with placebo at weeks 1, 2, 3, 4, 6, and 10. Significant (p < .05) differences between fluvoxamine and placebo were observed for all secondary outcome measures at all visits. Based on a 25% reduction of CY-BOCS scores, 42% of subjects taking fluvoxamine were responders compared with 26% taking placebo. Forty-six (19 fluvoxamine, 27 placebo) of 120 randomized subjects discontinued early. Adverse events with a placebo-adjusted rate greater than 10% were insomnia and asthenia. CONCLUSIONS: Fluvoxamine has a rapid onset of action and is well tolerated and efficacious for the short-term treatment of pediatric OCD.

Gender differences in the epidemiology and treatment of anxiety disorders.

Women are more likely than men to develop anxiety disorders. Yet, relatively few studies have investigated whether women with anxiety disorders have characteristics that are distinct from those of men with the same disorders. The cause of the enhanced vulnerability to anxiety for women remains largely undetermined. Recent data suggest that female reproductive hormones and related cycles may play an important role. In addition to etiologic functions, reproductive hormones may substantially influence the clinical course of preexisting anxiety conditions in women. Psychotropic medications are more likely to be prescribed to women, and gender differences have been identified in the pharmacokinetics of psychotropic medication. Yet, relatively few systematic data are available concerning the potential clinical relevance or possible treatment implications of gender differences in the treatment of women with anxiety disorders. This article reviews the unique characteristics of primary anxiety disorders in women, summarizes the neurobiological effects associated with estrogen and progesterone, discusses gender differences in medication metabolism and the potential relevance of these differences in the pharmacologic management of women with anxiety disorders, and reviews issues specific to women (e.g., hormone therapy, oral contraceptives, menstrual cycle, pregnancy, lactation) that may impact treatment with psychotropic medication.

The value of MR imaging in differentiating between hard and soft cervical disc disease: a comparison with intraoperative findings.

The aim of this study is to assess the accuracy of MRI alone in the differentiation of soft cervical disc protrusion from osteophytic compression in cervical disc disease. In a retrospective study, the MRI scans of 41 patients with cervical disc disease, who had previously undergone surgery, were presented to three independent observers, randomly on two different occasions, to identify the accuracy of the diagnosis of the presence of hard or soft disc or both as a cause of compression. The observers (two neurosurgeons and one neuroradiologist) were not involved with the treatment of the cases at any stage and were unaware of the surgical findings. Their observations were compared with those of the surgeon recorded at operation. The intra-observer agreement was poor for diagnosis into three categories as hard or soft disc or both. In distinguishing between the presence or absence of hard disc, there was moderate to good (Kappa = 0.6) intra observer and fair to moderate (Kappa = 0.4) interobserver agreement. The sensitivity of diagnosis of a hard disc was high (87%) but specificity was low (44%), due to the overestimation of the presence of hard disc. There was a significantly higher incidence of hard disc in the elderly age group (76% over the fifth decade, P = 0.0073). It is concluded that MRI alone is not a very efficient diagnostic tool in distinguishing between hard and soft disc in the cervical disc disease.

Medication treatment for the severely and persistently mentally ill: the Texas Medication Algorithm Project.

This article provides an overview of the issues involved in developing, using, and evaluating specific medication guidelines for patients with psychiatric disorders. The potential advantages and disadvantages, as well as the essential elements in the structure of algorithms, are illustrated by experience to date with the Texas Medication Algorithm Project, a public-academic collaboration. Phase 1 entailed assembling research findings on the efficacy of medications for schizophrenic, bipolar, and major depressive disorders. This knowledge was evaluated for its quality and relevance, integrated with expert clinical judgment as well as input by practicing clinicians, family advocates, and patients. Phase 1 (the design and development of the algorithms) was followed by a feasibility test (Phase 2). Phase 3 is an ongoing evaluation comparing the clinical and economic effects of using specific medication guidelines (algorithms) versus treatment as usual in public sector patients with severe and persistent mental illnesses.

Normal CSF oxytocin and NPY levels in OCD.

BACKGROUND: Attention has recently been focused on central nervous system neuropeptides as potential mediators of the symptom profile of obsessive-compulsive disorder (OCD). Increased CSF levels of the anxiolytic neuropeptide oxytocin have been reported in OCD. CSF levels of NPY, another anxiolytic neuropeptide, have not been studied. METHODS: We measured CSF oxytocin and NPY in 14 OCD patients and 26 healthy normal volunteers. RESULTS: There were no significant differences between the OCD patients and control subjects in CSF oxytocin or NPY levels. In both the OCD and control groups, women had significantly higher CSF oxytocin levels than men. CONCLUSIONS: These results do not support a prior finding of elevated CSF oxytocin in OCD patients and do not provide any evidence for an abnormality of NPY regulation in OCD.

The Texas Medication Algorithm Project: report of the Texas Consensus Conference Panel on Medication Treatment of Major Depressive Disorder.

BACKGROUND: This article describes the development of consensus medication algorithms for the treatment of patients with major depressive disorder in the Texas public mental health system. To the best of our knowledge, the Texas Medication Algorithm Project (TMAP) is the first attempt to develop and prospectively evaluate consensus-based medication algorithms for the treatment of individuals with severe and persistent mental illnesses. The goals of the algorithm project are to increase the consistency of appropriate treatment of major depressive disorder and to improve clinical outcomes of patients with the disorder. METHOD: A consensus conference composed of academic clinicians and researchers, practicing clinicians, administrators, consumers, and families was convened to develop evidence-based consensus algorithms for the pharmacotherapy of major depressive disorder in the Texas mental health system. After a series of presentations and panel discussions, the consensus panel met and drafted the algorithms. RESULTS: The panel consensually agreed on algorithms developed for both nonpsychotic and psychotic depression. The algorithms consist of systematic strategies to define appropriate treatment interventions and tactics to assure optimal implementation of the strategies. Subsequent to the consensus process, the algorithms were further modified and expanded iteratively to facilitate implementation on a local basis. CONCLUSION: These algorithms serve as the initial foundation for the development and implementation of medication treatment algorithms for patients treated in public mental health systems. Specific issues related to adaptation, implementation, feasibility testing, and evaluation of outcomes with the pharmacotherapeutic algorithms will be described in future articles.

A review of the efficacy of selective serotonin reuptake inhibitors in obsessive-compulsive disorder.

BACKGROUND: Obsessive-compulsive disorder (OCD) is a chronic illness associated with substantial morbidity; it often requires long-term medication. The best-studied therapeutic agent in the treatment of this disorder is the tricyclic antidepressant clomipramine. Since other tricyclic antidepressants appear to lack efficacy in OCD, that of clomipramine has been linked to its potent effects on serotonin. Consequently, agents that selectively inhibit serotonin reuptake have been the focus of several large-scale, placebo-controlled studies of OCD. Their efficacy in OCD is the focus of our review. DATA SOURCES: MEDLINE search (1966 to present) of OCD treatment with clomipramine or SSRI antidepressant medication using the key words obsessive-compulsive disorder, serotonin reuptake inhibitors, clomipramine, and pharmacology. STUDY FINDINGS: The selective serotonin reuptake inhibitors fluoxetine, sertraline, fluvoxamine, and paroxetine have, in separate multicenter trials, demonstrated efficacy and tolerability in the treatment of OCD. In contrast, clomipramine, though efficacious, is often associated with substantial adverse events, particularly anticholinergic side effects. While 2 recent meta-analyses support the superior efficacy of clomipramine over selective serotonin reuptake inhibitors in the treatment of OCD, 5 of 6 head-to-head comparisons of either fluoxetine or fluvoxamine versus clomipramine have found similar efficacy but a lower incidence of side effects with the selective serotonin reuptake inhibitor. A recently completed multicenter, 12-week, double-blind trial of paroxetine versus clomipramine versus placebo showed paroxetine to be as effective as clomipramine. With significantly fewer dropouts due to adverse effects than clomipramine, paroxetine was also associated with superior tolerability. CONCLUSION: The suggestion that selective serotonin reuptake inhibitors possess efficacy similar to that of clomipramine, but have a superior side effect profile, may have important implications for patients with OCD who require long-term treatment.

Obsessive-compulsive disorder: symptom overview and epidemiology.

Obsessive-compulsive disorder (OCD) is associated with substantial psychosocial impairment. Although large-scale population surveys suggest that OCD is fairly common, relatively few individuals receive adequate treatment. OCD symptoms characterized by "altered risk appraisal" versus a "need for completeness/symmetry" may differentiate distinct subgroups within OCD. Although females are more likely to develop OCD, males have an earlier age of onset. Full remission of OCD symptoms is rare, but episodic improvement in OCD symptoms is not uncommon. Reproductive hormone cycles may have a substantial impact on the course of OCD in women. Many OCD patients will have coexisting mood or anxiety disorders. Personality disorders are frequently diagnosed in OCD, but may remit with effective antiobsessional treatment(s). The differential diagnosis of OCD is extensive and includes neurological disorders, substance-induced conditions, and other primary psychiatric illnesses.