Incidence and perioperative risk factors for surgical site infections in neurosurgery: prospective observational study

Background Surgical site infections (SSI) represent a burden on the health care system especially in developing countries with significant morbidity and mortality. In Egypt, especially in our institution, there is no registry for the SSI rate or the contributing factors with no clear guidelines regarding the regimen of perioperative antibiotic prophylaxis. Our study was conducted to assess the local practice and to calculate the rate and risk factors of SSI. Patients and methods A prospective registry was established at the Neurosurgery Department, Demerdash teaching hospital Ain Shams University, Cairo, Egypt. All patients who underwent elective neurosurgical procedures were included in this study. Trauma patients were excluded. Patients were followed-up for incident SSI for 1 month postoperatively. SSIs were identified based on CDC criteria and a standardized data collection form predictor variables including patient characteristics, preoperative, intraoperative, and postoperative factors along with the pattern of antimicrobial prophylaxis. Results The study included 248 patients with 1-month postoperative follow-up. An SSI rate of 19% was recorded being mainly in patients below 10 years of age. Postoperative CSF leak was noticed to be the most significant risk factor of SSI in our study (p value < 0.01). Sixty five percent of culture results showed infection with gram-negative bacilli with the predominance of Acinetobacter. Conclusion Prolonged use of perioperative antibiotics does not seem to have an added benefit in SSI prevention. Tailoring of the used antibiotic regimen is highly recommended according to the latest antimicrobial prophylaxis guidelines and the local culture and sensitivity results.

Examining the role of astrogliosis and JNK signaling in post-traumatic epilepsy

Objective Post-traumatic epilepsy is a devastating complication of traumatic brain injury that has no targeted pharmacological therapy. Previous literature has explored the role of the c-Jun N-terminal kinase (JNK) pathway in epilepsy and the creation of epileptogenic foci by reactive astrogliosis; however, the relationship between reactive astrogliosis and the c-Jun N-terminal kinase signaling pathway in the development of post-traumatic epilepsy has not been thoroughly examined. Methods Four experimental groups, consisting of c57/b16 male mice, were examined: (1) control, (2) traumatic brain injury of graded severity (mild, moderate, severe), (3) sub-convulsive kainic acid alone without traumatic brain injury (15 mg/kg i.p.), and (4) sub-convulsive kainic acid administered 72 h after moderate traumatic brain injury. Modified Racine scale from 1 to 72 h and total beam breaks at 72 h were used to assess seizure activity. Immunohistochemistry and western blot were utilized to examine astrogliosis (GFAP), microglia activation (IBA-1), and phosphorylated JNK in prefrontal cortex samples collected from the contracoup side at 72 h post-injury. Results Astrogliosis, measured by GFAP, was increased after traumatic brain injury and increased commensurately based on the degree of injury. Mice with traumatic brain injury demonstrated a four-fold increase in phosphorylated JNK: p < 0.001. Sub-convulsive kainic acid administration did not increase seizure activity nor phosphorylation of JNK in mice without traumatic brain injury; however, sub-convulsive kainic acid administration in mice with moderate traumatic brain injury did increase phosphorylated JNK. Seizure activity was worse in mice, with traumatic brain injury, administered kainic acid than mice administered kainic acid. Conclusions Reactive astrocytes may have dysfunctional glutamate regulation causing an increase in phosphorylated JNK after kainic acid administration. Future studies exploring the effects of JNK inhibition on post-traumatic epilepsy are recommended.

Spinal biopsies: a clinicopathologic review of 53 cases diagnosed between 2011 and 2018 at a tertiary hospital in Kampala, Uganda

Background Early diagnosis of spinal cord neoplasia serves patients from developing a number of complications and even death. Methods After obtaining ethical approval, retrospectively, a total of 53 tissue blocks of patients attended at the spinal ward were reviewed. Statistical analysis was done using SPSS version 20.0, and p value of less than 0.05 was applied to establish the existence of statistical significance between the compared categorical variables. Results The mean age of the patients was 30.7 ± 15.96 years. Most of the patients 32.1% (n = 17) were aged ≤ 19 years, and majority of the neoplasia 77.3% (n = 41) were extramedullary. Also, majority of the neoplasia 60.4% (n = 32) were benign and the malignant ones were 35.8% (n = 19). The mean duration of onset of symptoms for benign and malignant neoplasia in this study was 13.1 ± 16.4 and 3.4 ± 2.8 years, respectively, with statistical difference (95% CI 2.09–17.35, p = 0.014). Conclusion The patients with spinal cord neoplasia in the present study were of young age, and majority of them had benign neoplasia that were extramedullary located. The mean duration of onset of symptoms for patients with malignant neoplasia was significantly shorter than that of benign neoplasia.

Inclusion of the fractured level into the construct of short segment fixation in patients with thoracolumbar fractures: clinical and radiological outcome

Background Thoracolumbar fractures represent a widespread injuries that can cause significant disability and strain the healthcare system. Different surgical approaches are described in the literature. This study was conducted to evaluate the fractured level inclusion in short-segment fixation of thoracolumbar junction spine fractures. Results Preoperative neurological deficit was reported in seven patients ranging from ASIA grade C to D. All of these patients improved to grade E by the end of the follow-up period, except for one patient who improved from grade C to D. The mean Oswestry Disability Index was 19.87%. The mean postoperative Cobb angle was 11.77° which significantly improved compared to a preoperative value of 19.37°. There was a significant improvement in the postoperative anterior and posterior vertebral body height compared to the preoperative values. The vertebral body compression ratio significantly improved during the postoperative period to a mean of 84% compared to 76% preoperative. Conclusions There was significant improvement of the postoperative values of the mean Cobb angle, the anterior and the posterior vertebral body height as well as the vertebral body compression ratio compared to the preoperative values.

Fifth lumbar vertebrae solitary osteochondroma arising from the neural arch, a case report

Background Osteochondromas are a benign outgrowth of bone and cartilage and one of the most common bone tumors that usually occur in long bones, with only 1–4% being located in the spine, more frequently in the cervical and upper dorsal region, and rarely the lumbar spine. Here, we report a case of lumbar spine (L5) osteochondroma arising from the neural arch. Case presentation A 30-year-old man presenting with a solid painless mass at the lower lumbar region. No neurological symptoms. Radiological examinations revealed an exophytic lesion in the fifth lumbar articular process, and the spinous process appears to be a solitary osteochondroma. Lumbar spine magnetic resonance imaging showed a bony lesion covered by a 2-mm-thick cartilaginous cap. Surgical en bloc resection of the mass was performed, and the histopathological examination confirmed the diagnosis of osteochondroma. No evidence of recurrence at the end of 4-year follow-up. Conclusion Osteochondromas are benign tumors rarely present in the spine; diagnosis can be made by the typical appearance of the cartilaginous cap over the mass in the magnetic resonance imaging. Surgical excision is the best management option.

Functional outcome in operated patients of multilevel lumbar canal stenosis and use of HRQoL role in depicting the anxiety and its correlation with the pain

Background Lumbar canal stenosis (LCS) is a degenerative spinal disease of elderly people, and it not only impairs the mechanical activity but also alters the economic and mental status of the patients indirectly. This is single-center observational prospective study conducted for 2 years and included 30 consecutive operated patients of multilevel LCS patients and excluded the patients with single-level LCS, with primary LCS or with grade II subluxation. We analyzed the various measurement indices used for the surgical outcome assessment as ED-5D 5L and OLBPDI (Oswestry low back pain disability index). Statistical analysis was done using SPSS (Statistical Package for Social Sciences) Version 21.0 statistical Analysis Software. The independent t test, post hoc analysis, Wilcoxon signed rank statistic test and RM-ANOVA test were also applied. Result Most patients have improvement in pain and all the components of HRQoL (health-related quality of life) after surgery, which was further improved in mean follow-up of 1 year. Our study also suggested that the patients with higher anxiety/depression have higher pain intensity and low HRQoL, which was persistent in postoperative period (p < .001). Conclusion ED-5D 5L and OLBPD are good indices to assess all the components of quality of life and give valuable information overall. Anxiety has shown important correlation with the pain component in both preoperative and postoperative phase.

Leptomeningeal metastasis from melanoma emulating chronic subdural hematoma: a case report

Background Melanoma is a disease in which the patient doesn’t know about the primary lesion, and it has a propensity to metastases to any organ in the human body. Amongst melanoma, leptomeningeal metastasis has the least incidence. Case presentation In this case, we report a 56-year-old lady presenting with headache, recurrent vomiting and slurring of speech which on imaging was suggestive of chronic subdural hematoma which had led to surgical preparation but upon further examination, and radioimaging was found to be leptomeningeal metastasis from melanoma for which systemic therapy was started. Conclusions The concern is vigilance that is much needed in any case presenting in emergency. When the diagnosis is chronic subdural hematoma, it is followed by surgical treatment which is not done for leptomeningeal metastasis.

Acute spinal cord compression due to spinal subdural hematoma after spinal anaesthesia in-patient under anticoagulant drug

Background Subdural spinal cord hematomas are very rare condition. They most often occur in patients with primary or secondary blood haemostasis disorders and following lumbar punctures. Early diagnosis and management preserve functional prognosis. Case description We report the case of a female 69-year-old patient on oral anticoagulant, Acenocoumarol 4 mg (SINTROM) for previous aortic prosthesis. The patient had undergone surgery for appendicitis under spinal anaesthesia 2 days before her admission in neurosurgery department. She was admitted in emergency for 1/5 central flaccid paraplegia with sensitive umbilical level. A spinal MRI performed showed a collection intradural in intermediate signal in T1 and hyposignal in T2 with echo gradient of 8 mm thickness extended from D8 to L2 compressing the marrow with anomalies of intramedullary signal extended from D8 to the conus medullaris. We retained indication to operate the patient early in emergency because of acute spinal cord compression. We performed T12-L2 laminectomy, durotomy and evacuated hematoma. Postoperative marked by an immediate recovery of sensitivity and an onset of motor recovery from 1/5 to 2/5 and 4/5 follow up at on year with physiotherapy. Conclusion Spinal cord compression due to subdural spinal hematomas not often described especially in patients with haemostasis blood disorders due to anticoagulants drugs. In addition, we should pay attention with lumbar puncture in these patients. Emergency surgery allows a good prognosis about recovery of neurological disorders.

Gamma knife radiosurgery in patients with Cushing's Disease: Is it a curative option?

Background The first line of treatment of Cushing’s disease (CD) is surgery. However, surgical resection is not amenable in all cases and the role of radiosurgical management of residual tumors or upfront treatment has been reported. Our study highlights the effectiveness and safety of Gamma Knife Radiosurgery for the treatment of Cushing’s disease. Methods This was an ambidirectional descriptive cohort study on 16 consecutive patients with a confirmed Cushing’s disease that underwent Gamma Knife Radiosurgery (GKR) before July 2014 and assessed for outcome during the study period between January 2014 and June 2016 (30 Months). We included patients with a minimum of two years follow up. The main outcomes were biochemical remission and tumor volume control. Secondary outcomes were visual field changes and morbidity. Results Sixteen cases with CD were included into the study. The Mean age ± SD was 34.81 ± 10.10 years. The male to female sex ratio was 1:3. Six cases (37.5%) were de novo. Normalization of hypersecretion at 2 years was achieved in 13 cases (81.3%).The median hormone normalization time was 23 months. Tumor volume control was achieved in all the cases, whereas tumor shrinkage was achieved in (10 cases) 62.5%. The median shrinkage time was 13 months. Of the 12 eyes with pre-Gamma Knife visual affection, 8 (75%) normalized, 4 (25%) improved, and none deteriorated. No patient developed new hypopituitarism after GK radiosurgery. One case developed diplopia at 24 months follow up from abducens palsy. No mortality occurred in our series. Conclusion Gamma Knife Stereotactic Radiosurgery is an effective and safe treatment option for Cushing’s disease. It can be used as a complementary therapeutic procedure to classic surgery or as a first line treatment in selected number of patients.