Are head injury guidelines changing the outcome of head injured children? A regional investigation.

BACKGROUND: Secondary pathophysiological CPP insult is related to outcome after head injury, and improved management would be expected to reduce secondary brain insult. Paediatric head injury management guidelines have been published in recent years, by SIGN (2000), RCPCH (2001), NICE (June 2003), and jointly by Critical/Intensive Care Societies (C/ICS July 2003). We investigated whether outcome of children's head injury (and total burden of secondary CPP insult) has changed (1) annually; (2) before and after the introduction of any HI guidelines, and (3) following other service changes. METHODS: Seventy-six children (aged 1-14 years with severe HI) were admitted to the Edinburgh Regional Head Injury Service between 1989 and 2006, and dichotomised at various time points and compared in terms of: demographic factors, intracranial pressure (ICP), cerebral perfusion pressure (CPP) insults [e.g. age-banded pressure-time index (PTI)], and Glasgow Outcome Scale (GOS) score (assessed at 6 months post injury). FINDINGS: When dichotomised around the SIGN guidelines, there were no statistically significant differences between the two group's demography or in primary brain injury, but the outcomes were different (p = 0.03), with 6 vs 4 GOS1 (died), 2 vs 4 GOS3 (severely disabled), 5 vs 16 GOS4 (moderately disabled) and 23 vs 14 GOS5 (good recovery), when comparing before and after year 2000. GOS4 was significantly different (chi-square = 7.99, p < 0.007). There was a (non-significant) trend for the later years to have longer insult durations of ICP, hypertension, CPP, hypoxia, pyrexia, tachycardia and bradycardia, greater PTI for both CPP and ICP, and more CPP insults (p = 0.003). There was, however, significantly less CPP insult (p = 0.030) after the introduction of the more management-oriented C/ICS guidelines. CONCLUSIONS: The most recent paediatric HI guidelines appear to have reduced the burden of secondary insult, but more time is required to determine if this will be reflected in improved outcomes.

New proposals for training in neurosurgery.

The rapidly evolving changes in working patterns, career structure and the regulation of training of doctors have provided an ideal opportunity for proposals to improve the programme for the training of neurosurgeons. The Education and Training Committee of the Society of British Neurological Surgeons (D.G. Hardy, A. J. W. Steers, N. T. Gurusinghe, P. M. Foy, P. van Hille, R. A. Cowie, H. A. Crockard, O. Sparrow and S. Burn) has, in recent months, worked closely with the Specialist Advisory Committee (SAC) in neurosurgery, Department of Health (Modernizing Medical Careers Group, H. A. Crockard, A. Havers, T. Hobbs) and colleagues from the major neuroscience specialties to develop a new programme based on a 'Common Stem' approach. This article describes the principles of the programme. The proposals have received approval by the Council of the SBNS, the Presidents of the four Surgical Royal Colleges and the Senate of Surgery.

Cervical cord tethering due to split cord malformation at the cervico-dorsal junction presenting with self-mutilation of the fingers.

An unusual case of cervical spinal cord tethering with diplomyelia is described. A 12-month old female presented with self-mutilation of the fingers due to sensory loss in the hands, absent reflexes, poor muscle tone, and reduced distal upper-limb movements. There was a deep skin dimple overlying the T1 spinous process. Imaging showed angulation of the lower cervical cord and an operation revealed a low cervical meningocele and a split cord malformation with tethering of one half of the cord; the cord was untethered. In this report the literature is reviewed.