Bhadrakant Kavar

MANAGEMENT AND HOSPITAL OUTCOME OF THE SEVERELY HEAD INJURED ELDERLY PATIENT

Introduction:  Severe traumatic head injury in the elderly has been associated with poor outcomes. However, there is currently no consensus to direct management in these patients. This study outlines the demographics, injury characteristics, management and outcome of the elderly trauma patients with severe head injury across a defined population.

The efficacy of spinal cord stimulation for chronic pain

A prospective study was undertaken to evaluate the efficacy of spinal cord stimulation (SCS) in the management of chronic pain syndrome. The study included all patients who underwent this procedure at the Royal Melbourne Hospital and the Melbourne Private Hospital over a period of two years. A total of 29 patients were managed by the end of June 1996. These patients were carefully screened by a neurosurgeon (JVR) and a psychiatrist. Of these, 26 patients had a follow up evaluation at the end of August 1996. From the group of 29 patients, four patients failed to obtain any relief during the trial phase of the procedure and thus did not have the stimulator implanted permanently. From the 25 patients who proceeded to have the stimulator implanted, 11 patients had a variable beneficial response, three patients found it to be of marginal benefit, six had no benefit, three patients initially had a good response but subsequently gained no benefit whilst two patients were uncertain of its benefit. It thus appears that SCS was of benefit in 50% of our carefully selected patients with chronic pain syndromes.

Extensive spinal epidural abscess as a complication of Crohn’s disease

A spinal epidural abscess is a neurosurgical emergency. Successful treatment frequently requires decompression of the spinal canal in combination with intravenous antibiotics. We report a patient with Crohns disease who developed an extensive spinal epidural abscess communicating with an intra-abdominal collection.

Clinical presentation and outcome of patients with intradural spinal cord tumours.

We aimed to retrospectively investigate the clinical presentation and outcome of surgical intervention of patients with intradural spinal cord tumours (IDSCT), and to assess the predictors of surgical outcome. A total of 109 patients with IDSCT (57 males and 52 females) (130 admissions; mean age, 45.9 years; range, 14-89 years) underwent surgery between 1 January 1994 and 30 June 2009 at The Royal Melbourne Hospital. Ninety per cent of tumours were classified as low grade. Pain was the most common symptom at presentation (60%) and the mean duration of symptoms was 37.8 weeks (0-4 years). Total resection was achieved in 72.3% of patients with IDSCT. An extramedullary location was the strongest predictor of greater extent of tumour resection (odds ratio [OR]=4.367, 95% confidence interval [CI]=1.876-10.204, p=0.001), whereas a rostral location was also a significant predictor of greater resection (OR=1.393, 95% CI=1.014-1.908, p=0.040). The surgical mortality rate was 0.92%. A good pre-operative clinical grade was the strongest predictor of a positive post-operative neurological status at discharge for IDSCT (OR=7.382, 95% CI=4.575-11.912, p<0.001). The mean follow-up was 37.9 months (16 days-165 months). A good post-operative clinical grade was the most significant predictor of a positive neurological outcome at short-term follow-up (OR=9.953, 95% CI=4.941-20.051, p<0.001), while a good pre-morbid clinical grade was the most significant predictor of a positive outcome at long-term follow-up (OR=9.498, 95% CI=2.780-32.451, p<0.001). We concluded that surgical outcome was influenced by pre-morbid, pre-operative and post-operative clinical grades, the extent of resection, tumour grade and tumour location with respect to the spinal parenchyma. Surgical intervention has a high success rate for tumour control and we recommend total resection where possible.

Metastatic prostate adenocarcinoma invading an atypical meningioma.

Although prostate adenocarcinoma is the most commonly diagnosed cancer in men, intracranial metastases are rare. We describe a 72-year-old patient with known metastatic prostate cancer, presenting with a dural-based parafalcine lesion on radiological imaging, following a seizure. Total macroscopic excision of the lesion was achieved at surgery, with histopathology confirming prostate adenocarcinoma embedded in an atypical (World Health Organization Grade II) meningioma, fulfilling all the criteria for true tumour-to-tumour metastasis. To our knowledge, this is the first report of prostate cancer metastasising to an atypical meningioma.

Central nervous system lymphoma associated with natalizumab

Patients with primary central nervous system lymphoma (PCNSL) after treatment with natalizumab have been considered co-incidental. We report another case of PCNSL in a patient where the explosive onset suggests a causal link.

Early detection of spinal sepsis

Spinal sepsis (spinal epidural or subdural abscess) is a rare condition, which, if not diagnosed rapidly, can lead to paralysis or death. It is difficult to diagnose in its early stages as the symptoms are as yet non-specific. We aimed to identify predisposing factors and presenting symptoms that might aid in the early diagnosis of spinal sepsis. A case-control study was performed with non-pediatric patients who had been diagnosed with spinal sepsis from 1998 to 2007. Our control group comprised 80 randomly selected patients who had presented to the emergency department with back pain. We identified 72 patients with spinal sepsis. A multivariate analysis revealed that obesity (adjusted odds ratio [aOR] 21.4; 95% confidence interval [CI] 1.8-257.5) and alcoholism (aOR 6.5; 95% CI 1.3-32.8) were important predictive factors for spinal sepsis. To our knowledge, this is the first report that associates obesity and alcoholism with spinal sepsis.

Splenic angiosarcoma metastasis to the brain.

Angiosarcoma is a rare primary non-haematolymphoid malignant neoplasm of the spleen. This neoplastic process has a poor prognosis, with disease usually widespread by the time of presentation. In the literature there has been only six case reports of cerebral metastasis from splenic angiosarcomas. We report a 61-year-old woman who presented with a right occipital metastasis of a splenic angiosarcoma, 5 years after initial diagnosis, treated by stereotactic occipital craniotomy and resection of metastasis.

Progression and management of superficial siderosis

This report illustrates the progression and surgical management of a patient with superficial siderosis associated with a cervical pseudomeningocoele.

Intradural extramedullary spinal spread of oligoastrocytoma

Spinal involvement from supratentorial oligoastrocytoma is rare, with only five previous case reports. We report a patient with a past history of a frontal oligoastrocytoma who presented 26 months post-primary resection with posterior fossa disease and spinal extension, in the absence of local recurrence or malignant transformation. The case and relevant literature review are instructive to those following patients with previously treated central nervous system tumours possessing seeding potential.