Nick Phillips

Diagnosis, medication, and surgical management for patients with trigeminal neuralgia: a qualitative study

BackgroundTrigeminal neuralgia (TN) is a serious health problem, causing brief, recurrent episodes of stabbing or burning facial pain, which patients describe as feeling like an electric shock. The consequences of living with the condition are severe. There is currently no cure for TN and management of the condition can be complex, often delayed by misdiagnosis. Patients’ qualitative experiential accounts of TN have not been reported in the literature. Capturing subjective experiences can be used to inform the impact of the condition on quality of life and may contribute to a better understanding of current clinical practice with the aim of improving patient care.MethodsParticipants with TN (n = 16; 11 female), including those who have and have not undergone surgical intervention(s), took part in one of four focus groups. We conducted a thematic analysis within an essentialist framework using transcripts.ResultsThe impact of TN and treatment on the lives of participants emerged as four predominant themes: (1) diagnosis and support with TN, (2) living in fear of TN pain, (3) isolation and social withdrawal, and (4) medication burden and looking for a cure. Each theme is discussed and illustrated with extracts from the transcripts.ConclusionsKey issues to address in the management of patients with TN include continued delays in diagnosis, persistent side effects from medication, and a lack of psychological support. Developing strategies to enhance the management of patients with TN, informed by a biopsychosocial approach and multidisciplinary team working, is essential to enhancing the provision of current care.

Evaluating the impact of trigeminal neuralgia.

Patients with idiopathic trigeminal neuralgia (TN) were categorised into 3 subtypes (n = 225). Group 1 (n = 155, 68.9%) had TN without concomitant pain, group 2 (n = 32, 14.2%) had TN with intermittent concomitant pain, and group 3 (n = 39, 16.9%) had TN with autonomic symptoms. We tested 2 hypotheses: (1) that different pain profiles would be associated with the different groups; (2) that the severe pain associated with TN would impact negatively on activities of daily living and thereby result in disability as defined by the World Health Organisation. A different pain profile was found across the groups. We obtained unequivocal evidence that TN causes disability with up to 45% of patients being absent from usual daily activities 15 days or more in the past 6 months. On the Hospital Anxiety and Depression Scale, 35.7% patients had mild-to-severe depression and over 50% were anxious. The Pain Catastrophizing Scale showed that 78% of patients had considerable negative thoughts with scores >20 and a mean score of 36.4. Prior to referral, only 54% had been prescribed carbamazepine while opioids had been prescribed in 14.6% of the patients. Prior to referral, over 80% had already been to 1 specialist centre which had not provided appropriate management. Patients with TN report varied characteristics but all result in some degree of psychosocial disability especially before adequate therapy is attained.

The volume in focus: hardware-assisted focus and context effects for volume visualization

In many volume visualization applications there is some region of specific interest where we wish to see fine detail - yet we do not want to lose an impression of the overall picture. In this research we apply the notion of focus and context to texture-based volume rendering. A framework has been developed that enables users to achieve fast volumetric distortion and other effects of practical use. The framework has been implemented through direct programming of the graphics processor and integrated into a volume rendering system. Our driving application is the effective visualization of aneurysms, an important issue in neurosurgery. We have developed and evaluated an easy-to-use system that allows a neurosurgical team to explore the nature of cerebral aneurysms, visualizing the aneurysm itself in fine detail while still retaining a view of the surrounding vasculature.

Public disclosure of surgeon's results – pituitary surgery

Abstract Objective. There are few agreed quantifiable outcome measures in pituitary surgery. The goal of this study is to present the measurement of resection volume after surgery for pituitary tumours as a surgeon-specific outcome measure that may have use in illustrating the performance of individual surgeons internally and externally, and contribute to quality improvement in pituitary surgery. Method. The authors used an existing validated method to measure the volume of pituitary tumours. This method was used to retrospectively assess the extent of resection (EOR) in all patients undergoing pituitary surgery for tumour volume reduction over a 3-year period in Leeds, UK. Three surgeons and two techniques (endonasal transsphenoidal surgery and conventional microscopic surgery) were compared. The results are summarised using Funnel plot methodology. Results. The overall mean EOR for the 3 years of study was 54%. There was no difference between endoscopic and microscopic techniques in terms of EOR. Significant differences were found between surgeons’ case mix (as estimated by preoperative tumour size) and EOR. One surgeon had smaller tumour cases at operation than the other two surgeons (p = 0.004). One surgeon achieved larger resections than the two other surgeons (p = 0.038 and 0.005). Conclusions. Measuring pituitary volumes manually using segmentation methods and existing software is possible for surgeons and provides valuable information on individual surgeon performance and departmental practice. A simple retrospective review of 3 years of practice has demonstrated that surgeons have different case-mix and their EOR can vary within safe limits. During a period of transition when we changed personnel and technique, the EOR was little affected and this was reassuring from a governance perspective. Performance assessment for low-volume conditions is possible .

Evolution of a UK endoscopic anterior skull base pituitary service – the first one hundred and twenty‐three patients: Our Experience

1 Jaquet Y., Monnier P., Van Melle G. et al. (2006) Complications of different ventilation strategies in endoscopic laryngeal surgery. Anesthesiology 104, 52–59 2 Hu A., Weissbrod P.A., Maronian N.C. et al. (2012) Hunsaker Mon-Jet tube ventilation: a 15-year experience. Laryngoscope 122, 2234–2239 3 BarakateM.,Maver E.,WotherspoonG. et al. (2010) Anaesthesia for microlaryngeal and laser laryngeal surgery: impact of subglottic jet ventilation. J. Laryngol. Otol. 124, 641–645 4 Taha S.K., Siddik-Sayyid M., EL-Khatib M.F. et al. (2006) Nasopharyngeal oxygen insufflation following pre-oxygenation using the four deep breath technique. Anaesthesia 61, 427–430 5 McGinley B., Halbower A., Schwartz A.R. et al. (2009) Effect of a high-flow open nasal cannula system on obstructive sleep apnea in children. Pediatrics 124, 179–188 6 Bobrow B.J., Ewy G.A., Clark L. et al. (2009) Passive oxygen insufflation is superior to bag-valve-mask ventilation for witnessed ventricular fibrillation out-of-hospital cardiac arrest. Ann. Emerg. Med. 54, 656–662 7 Gallagher T.Q., Setlur J., Maturo S. et al. (2012) Percutaneous transtracheal needle insufflation: a useful emergency airway adjunct simply constructed from common items found on your anesthesia cart. Laryngoscope 122, 1178–1180 8 Slutsky A.S., Watson J., Leith D.E. et al. (1985) Tracheal insufflation of O2 (TRIO) at low flow rates sustains life for several hours. Anesthesiology 63, 278–286 9 Holmdahl M. (1956) Pulmonary uptake of oxygen, acid-base metabolism, and circulation during prolonged apnoea. Apneic diffusion oxygenation. Acta Chir. Scand. Suppl. 212, S1–S128

Retrospective analysis of anterior skull base CSF leaks and endoscopic repairs at Leeds

Abstract Objectives: Over the past 10 years, endoscopic endonasal anterior skull base surgery has become established practice. Surgeons carrying out this surgery need to be able to endoscopically repair primary and secondary CSF leaks. A growing number of techniques have been adopted to date. This article highlights one UK institution’s experience in the management of anterior skull base leaks, and how surgeons there have identified leak defect types that are difficult to seal and how they have adopted a new way of repairing them, which uses a fat ring. Methods: Seventy-six patients requiring CSF leak repairs were identified form a prospective data base of 240 endoscopic anterior skull base procedures at the General Infirmary at Leeds performed between July 2009 and October 2015. Results: Fifty-one cases have undergone an endoscopic primary repair of a skull base defect following resection of a lesion and, of these, 10 (19%) cases required a secondary repair. This was particularly over the planum sphenoidale area. Twenty-five cases had undergone an endoscopic repair as the primary procedure. This was due to a spontaneous leak in 7 cases, trauma in 3 cases, following craniotomy in 3 cases and following pituitary surgery in 2 cases. The remaining 10 were the secondary repairs referred to above. Conclusions: A number of techniques are effective in CSF repair. Defects over the planum sphenoidale and clivus are associated with the highest recurrence, requiring specific repair techniques. Utilisation of a 5 “F” repair helps to prevent recurrence in high risk defect cases over the optic chiasm. The 5 “F” repair used takes the form of placing intradural Fat and Fascia; next a Fat sealing ring is used, followed by a nasoseptal Flap; finally a supporting fragmentable pack is applied.

How I do it - endoscopic endonasal approach for pituitary tumour

BackgroundEndoscopic endonasal surgery to access the anterior skull base has evolved in many centres worldwide and provides a minimally invasive alternative, with better patient experience, to open techniques.MethodWe present a basic approach to a midline lesion that is the fundamental starting point for wider access to the skull base.ConclusionThe nuances of this technique illustrated here have been developed in many centres to provide a safe procedure that has a low incidence of complications and excellent potential.

From above or from below? That is the question. Comparison of the supraorbital approach with the endonasal approach. A cadaveric study

Abstract Background: Nowadays the endoscopic endonasal approach is increasingly being used to remove craniopharyngiomas, tuberculum sellae meningiomas and other presellar and parasellar lesions and its value in anterior skull base surgery is undisputed. Herein, we assess the relative advantages, disadvantages and feasibility of the keyhole eyebrow approach and the endonasal endoscopic approach in four cadaveric heads for the removal of presellar and parasellar lesions. Methods: We used four cadaveric heads for 12 surgical dissections. The specimens were embalmed with two different techniques. Two bilateral supraorbital endoscopic assisted approaches and one transnasal expanded endonasal approach were performed for each head. We evaluated the feasibility, maneuverability and safety of each approach. We measured the operating room obtained with each approach and the distance from the main structures we reached. Results: The technical feasibility of the endoscopic endonasal transphenoidal approach and the supraorbital eyebrow approach was reproduced in all four cadaveric heads. The transnasal approach gave us a good operating field medial to the two optic nerves and the two carotid arteries anteriorly until the frontal sinus and, posteriorly, the basilar artery, the emergence of the superior cerebellar arteries and posterior cerebral arteries. After performing the supraorbital approach, we viewed a wider field of the anterior skull base and we were able to reach the ipsilateral carotid artery, the optico-carotid recess, the pituitary stalk, the lamina terminalis until the contra lateral optic nerve and carotid artery, keeping a wider angle of maneuverability. Conclusions: Although the endoscopic transnasal approach has developed in leaps and bounds in the last decade, other transcranial approaches maintain their value. The supraorbital endoscopic approach is a minimally invasive approach and seems to be optimal for those lesions wider than 2 cm in the lateral extension and for all the paramedian lesions.

Endoscopic repair of the anterior skull base -is there a learning curve?

Abstract Introduction: Endoscopic anterior skull base surgery is now established practice. For skull base teams to manage complex pathology a variety of good dural repair techniques are required. However repairing certain skull base defects can be challenging. We look to see if a learning curve is associated with different types of CSF leaks in the anterior skull base Methods: Analysis of a prospectively collected database, contain 383 cases, on all endoscopic anterior skull base operations at one UK institution looking at CSF repair. Chi squared statistical analysis was undertaken comparing results from 2009 to 2013 with the 2014 to 2017 results. CSF leaks were categorised as either low flow with defects less than 2cm in diameter or high flow with defects greater than 2cm in diameter associated with a CSF void. Results:137 cases requiring repair were identified. Overall 96% of cases underwent successful primary repair with low flow CSF defects. The primary repair rate was similar in the early and later years. Successful repair of large anterior skull base defects was statistically more likely in the 2014-2017 group 96% compare to the 2009–2013 group 65%. Conclusions: A learning curve for small defects was not seen. However a learning curve does exist in relation to large defects with high flow over the first 20 cases.

Recent-Onset Visual Field Loss and Raised Prolactin Level (Non-functioning Pituitary Tumour)

Non-functioning pituitary adenomas can exert their effects in a number of ways. They can lead to pressure on the optic chiasm, and this can produce visual field defects. More rarely the tumour extends laterally into the cavernous sinus and leads to cranial nerve palsies. Pituitary tumours may expand and therefore stretch the overlying dura and cause pressure effects around the pituitary fossa, leading to the development of headaches.