Stana Bojanic

Oxford craniotomy infections database: a cost analysis of craniotomy infection.

Abstract We describe the process of establishing a large database for the investigation of craniotomy infection and the preliminary results of this database. The initial results have been used to generate a cost analysis for craniotomy infection. The craniotomy infections database prospectively registers craniotomy cases taking place in the John Radcliffe Hospital. In order to achieve this, each patients details are registered at the time of operation and followed up to identify cases of infection. Infection was defined strictly according to Centre for Disease Control criteria and validated by at least two members of clinical staff. The first 10 months of data are presented here which identifies a total of 245 craniotomies and 20 verified craniotomy infections. An overall infection rate of 8% is identified, and the cost incurred by the neurosurgery department as a result of craniotomy infections is estimated at £1 85 660 for the 10-month period studied. This amounts to a cost per case of infection of £9283.

Yield and complications of frame-based and frameless stereotactic brain biopsy - The value of intra-operative histological analysis

Abstract Objectives. Image-guided brain biopsy is an established method to obtain histopathological diagnosis and guide management for cerebral lesions. The study aimed to establish negative biopsy and symptomatic haemorrhage rates at a single centre, and to assess the influence of factors such as lesion location, final pathology and the use of intra-operative smears. Methods. A retrospective analysis of all frame-based and frameless stereotactic biopsies carried out over 57 months from July 2006 to March 2011. Results. A total of 351 biopsies were undertaken, 256 frame-based (73%) and 95 frameless (27%). Mean age was 57 years (range 18–87). Negative biopsy rate was 5.1%. There was a significantly greater negative biopsy rate in deep brain biopsies (p = 0.011) and in the cerebellum (p < 0.001). Intra-operative smear significantly reduced negative biopsy rates from 11.1% to 3.7% (p = 0.011). If repeat smear was requested, yet not provided, then the negative biopsy rate was 57.1% (p = 0.0085). The overall symptomatic haemorrhage rate was 3.7%. There was a significant increase in haemorrhage rate in deep versus superficial biopsies (p = 0.023) and a significantly greater haemorrhage rate in lymphoma biopsies (p = 0.015). There was no significant increase in haemorrhage rate in high-grade- compared with low-grade tumour biopsies. Mortality rates at 7 and 30 days post-operatively were 0.6% and 1.7%, respectively, with mortality after 7 days unrelated to biopsy. Conclusion. We advocate intra-operative histopathological analysis to decrease negative biopsy rates and advise increased caution when undertaking biopsies of deep lesions or suspected lymphoma cases due to the potentially increased risk of haemorrhage.

Endoscopic fenestration of middle cranial fossa arachnoid cysts: Does size matter?

The middle cranial fossa (MCF) is the commonest location for intracranial arachnoid cysts and there has long been controversy regarding the optimal surgical management. Over the last 10 years there has been an increased interest in the potential of endoscopic techniques to treat these. In a review of the literature we identified 91 patients with MCF cysts treated with endoscopic techniques. Clinical improvement was seen in 95% of patients and radiological improvement was seen in 74%. The most common complications reported are subdural hygromas (9%) and subdural haematomas (5%). There does not appear to be an undue increased risk of complications compared to open surgical techniques. Reported methods of endoscopic fenestration advocate making as wide an opening as possible without damage to the surrounding neurovascular structures. We consider the possibility that smaller cystocisternostomy may be effective in achieving therapeutic goals while reducing potential risks to the patient.

Rapid development of glioblastoma at the site of atypical meningioma resection

The authors describe symptomatic presentation of glioblastoma within six months of resection of an atypical meningioma, at the same frontal parafalcine cerebral location. The patient had neither prior nor adjuvant radiotherapy nor known genetic risk factors. Possible links between invasive meningioma and transformation of adjacent glial cells or precursors to malignant glioma are discussed.

The Efficacy and Safety of Dorsal Root Ganglion Stimulation as a Treatment for Neuropathic Pain: A Literature Review

Dorsal root ganglion stimulation (DRGS) received its first regulatory approval (CE marking in Europe) in late 2011, and so its use is now almost six years old. Several thousand patients have already been treated, and a landmark trial in lower limb complex regional pain syndrome (CRPS) and causalgia has recently been published.

A Novel Approach to Chondrosarcoma of the Glenoid Fossa of the Temporomandibular Joint: A Case Report

Chondrosarcoma (CS) is a rare malignant tumor of cartilaginous tissue, with an incidence of 5% to 12% in the head and neck region. The maxilla and nasal and paranasal sinuses are most commonly affected. CS of the temporomandibular joint (TMJ) is extremely rare. Surgery remains the mainstay of treatment options. To our knowledge, this is the first report in the literature on CS arising from the glenoid fossa. We describe our surgical technique that allows immediate joint reconstruction and restoration of joint function.

Effective management of severe traumatic brain injury in a district hospital

Abstract The authors investigated how effectively adults with severe traumatic brain injury (TBI) can be managed in a district general hospital intensive care unit offering intracranial pressure monitoring (ICPM) receiving advice from a neurosurgical unit. A single-centre case series with retrospective review of prospectively collected information was undertaken of 44 consecutive patients presenting over seven years from January 2003 to January 2010 with severe traumatic brain injury to a single district general hospital intensive care unit serving a population of 500,000 adults. A prospectively entered clinical database was used to obtain information including patient demographics, Glasgow Coma Score (GCS) on admission, ICPM insertion, ICPM-related complications, inpatient mortality and neurosurgical advice. Case notes were used to ratify information and obtain neurorehabilitation clinic functional outcome scores. Forty-four patients were identified (40 male, age range 16–77 years). Mortality in intensive care was 30%. Twenty-eight patients received frontal twist drill ICPM following neurosurgical advice. ICPM had 2 (7%) device malfunctions but no other complications. Twelve additional patients were transferred to tertiary centres. Patients (23 of 31) who survived ICU stay (74%) were referred to neurorehabilitation. Mean clinic follow-up was 14 months. All patients had a Glasgow Outcome Score (GOS) of 3 or 4 at initial clinic assessment. Twenty-two improved to GOS to 4 or 5 at clinic discharge. One patient died prior to clinic discharge. Carefully selected patients with severe TBI can be managed safely and effectively in a district general hospital offering ICPM insertion if transfer to a neurosurgical centre is not possible. Neurosurgical advice regarding patient selection and on-going management is fundamental to provid a good service. Protocol driven therapies provide a useful systematic approach to doctors who do not deal with severe TBI on a routine basis.

Progressive dysphagia without dysarthria

A 50-year-old woman was referred with a 6-month history of progressive dysphagia. On examination, there was no dysarthria. Her voice was initially ‘wet’ but improved with coughing and throat clearing. Palatal movement, pharyngeal sensation and tongue appearance were normal. Laryngoscopy was normal. MRI of the brain showed a type 1 Chiari malformation with brainstem compression (figure 1). Following …

High-intensity focused ultrasonic ablation of sacral chordoma is feasible: a series of four cases and details of a national clinical trial.

Abstract High-intensity focused ultrasound describes the use of high-intensity focused ultrasound (HIFU) to ablate tumours without requiring an incision or other invasive procedure. This technique has been trialled on a range of tumours including uterine fibroids, prostate, liver and renal cancer. We describe our experience of using HIFU to ablate sacral chordoma in four patients with advanced tumours. Patients were treated under general anaesthetic or sedation using an ultrasound-guided HIFU device. HIFU therapy was associated with a reduction in tumour volume over time in three patients for whom follow up scans were available. Tumour necrosis was reliably demonstrated in two of the three patients. We have established a national trial to assess if HIFU may improve long-term outcome from sacral chordoma, details are given.

A young male patient with transient and temporally dissociated lower limb numbness and brachialgia

A 33-year-old male developed sudden numbness and paraesthesia below the waist. There were no motor symptoms, no pain and no bladder or bowel involvement. He fully recovered 2 days later, but described shock-like sensory episodes affecting his left arm, in a glove-like distribution, 10 years earlier (aged 23 years). These episodes, which were intermittent, lasting up to 5 minutes each and with full resolution in-between, abated after 2 months. There was no past medical history or any neurological family history of note. Examination revealed normal neurology. A further 7 years later (aged 40 years) he developed hiccups, bilateral brachialgia and mild arm weakness (4/5 in the Medical