Search

Purpose: The degree of disability that is acceptable to patients following traumatic brain injury (TBI) continues to be debated. While the dichotomization of outcome on the Glasgow Outcome Score (GOSE) into 'favourable' and 'unfavourable' continues to guide clinical decisions, this may not reflect an individual's subjective experience. The aim of this study is to assess how patients' self-reported quality of life (QoL) relates to objective outcome assessments and how it compares to other debilitating neurosurgical pathologies, including subarachnoid haemorrhage (SAH) and cervical myelopathy. Method: A retrospective analysis of over 1300 patients seen in Addenbrooke's Hospital, Cambridge, UK with TBI, SAH and patients pre- and post- cervical surgery was performed. QoL was assessed using the SF-36 questionnaire. Kruskal-Wallis test was used to analyse the difference in SF-36 domain scores between the four unpaired patient groups. To determine how the point of dichotomization of GOSE into 'favourable' and 'unfavourable' outcome affected QOL, SF-36 scores were compared between GOSE and mRS. Results: There was a statistically significant difference in the median Physical Component Score (PCS) and Mental Component Score (MCS) of SF-36 between the three neurosurgical pathologies. Patients with TBI and SAH scored higher on most SF-36 domains when compared with cervical myelopathy patients in the severe category. While patients with Upper Severe Disability on GOSE showed significantly higher PC and MC scores compared to GOSE 3, there was a significant degree of variability in individual responses across the groups. Conclusion: A significant number of patients following TBI and SAH have better self-reported QOL than cervical spine patients and patients' subjective perception and expectations following injury do not always correspond to objective disability. These results can guide discussion of treatment and outcomes with patients and families. [ABSTRACT FROM AUTHOR]

Cervical Spondylotic Myelopathy (CSM) is a disabling condition arising from arthritic compression and consequent injury of the cervical spinal cord. Stratification of CSM severity has been useful to inform clinical practice and research analysis. In the UK the Myelopathy Disability Index (MDI) is a popular assessment tool and has been adopted by the British Spinal Registry. However, no categories of severity exist. Therefore, the aim of this study was to define categories of mild, moderate and severe. An anchor-based analysis was carried out on previously collected data from a prospective observational cohort (N = 404) of patients with CSM scheduled for surgery and assessed pre-operatively and at 3, 12, 24 and 60 months post-operatively. Outcomes collected included the SF-36 version-1 quality of life measure, visual analogue scales for neck/arm/hand pain, MDI and Neck Disability Index (NDI). A Receiver Operating Curve (ROC) analysis, using the NDI for an anchor-based approach, was performed to identify MDI thresholds. Complete data was available for 404 patients (219 Men, 185 Women). The majority of patients underwent anterior surgery (284, 70.3%). ROC curves plotted to identify the thresholds from mild to moderate to severe disease, selected optimal thresholds of 4–5 (AUC 0.83) and 8–9 (AUC 0.87). These MDI categories were validated against domains of the SF36 and VAS scores with expected positive linear correlations. Categories of mild, moderate and severe CSM according to the MDI of 4–5 and 8–9 were established based on the NDI. [ABSTRACT FROM AUTHOR]

Although mostly used in the management of spinal trauma, hard collar immobilisation is also used as an adjunct to recovery after elective cervical spine surgery. Many surgeons believe that bracing reduces the risk of non-union and pain and provides a subjective sense of security for patients. There is little if any, evidence for this practice and immobilisation can be a direct cause of adverse events. The primary aim of this study was to provide an updated assessment of post-operative bracing practice in UK spinal surgeons, including the indications, rationale and perspectives on compliance and complications. Neurosurgeons and spinal orthopaedic surgeons completed a web-based survey distributed by email to members of the Society of British Neurological Surgeons (SBNS) and the British Association of Spinal Surgeons (BASS). Professional information captured included level of experience and whether surgeons had a specialist interest in spinal surgery. Questions first focused on the frequency and duration of hard collar immobilisation for common decompressive procedures. Later questions captured surgeon rationale, perceptions of patient compliance, complications, and collar removal. A total of 86 surgeons completed the survey, of whom 83% were spinal specialists. In total, 33 (38%) surgeons recommend a hard collar following at least one of the elective procedures listed. Collars were most commonly recommended following cervical corpectomy (30%). The support of fusion and bone healing was the most common rationale (82%), with post-operative pain (45%) and limiting patient activity (39%) also considered. Most surgeons (69%) believed that their patients were compliant. All listed types of complications were reported, with impaired activities of daily living (41%) and impaired sleep (34%) the most frequently cited. Current post-operative use of hard collars is much lower in the United Kingdom than previously reported in the United States. Surgeon decision-making is inconsistent and may benefit from greater standardisation. Future work is needed to help develop guidelines as a move away from arbitrary to evidence-based practice. [ABSTRACT FROM AUTHOR]

Objectives:Severe traumatic brain injury (TBI) is a potentially devastating insult to the brain with high rates of fatality and neurological deficits. TBI can result in substantial costs to the centre providing care. We sought to present the experience of a Major Trauma Centre (MTC) and ascertain the financial implications of this healthcare provision, in particular detailed costs, reimbursement and the surplus or deficit accrued by the centre. Design:All cranial non-elective neurosurgical admissions with a TBI over 4.5 months (26 October 2014 to 15 March 2015) were analysed retrospectively, excluding cases of chronic subdural haematoma, at an MTC in England. Demographic data were collected alongside detailed cost and income data. Results:Ninety four patients were identified. The majority of patients presented with more than one diagnosis of cranial trauma. Average length of stay was 18.8 ± 21.6 days. Total deficits as a result of treating this cohort amounted to £558,034. There was a significant association between (i) more complex presentations and (ii) a longer length of stay and the deficit accrued by the centre. The major drivers of the financial outcome were costs associated with wards, medical staffing and overheads. Conclusion:There was a substantial deficit accrued as a result of the management of patients with TBI at an MTC. The more complex the presentation, extensive the intervention, and lengthy the stay, the greater the deficit accrued by the centre. The current tariff payment system is not effectively reflecting the severity of injury or intensity of management of patients with TBI. [ABSTRACT FROM PUBLISHER]

Summary of background data. Physical outcomes following surgery for degenerative spine disease have been well studied whereas the importance of psychological factors has only recently been acknowledged. Previous studies suggest that pre-operative psychological distress predicts poor outcome from spinal surgery. In the drive to identify patients who will not benefit, these patients risk being denied surgery. Study design. This is a prospective series from a spinal surgical register. Aim. The study examines the relationship between the physical symptoms, pre-operative psychological distress and outcome following surgery. Methods. The Short Form 36 (SF36) Health Survey Questionnaire and the Hospital Anxiety and Depression Scale (HADS) were administered to patients undergoing elective surgery for degenerative spine disease pre-operatively and at 3 and 12 months post-operatively. Levels of physical disability (SF-36 physical functioning (SF36PF) and bodily pain (SF36BP) scores) and psychological distress (HADS-anxiety and HADS-depression scores) before and after surgery were compared. Results. A total of 302 patients were included (169 men, 133 women, mean age 55 years). Pre-operatively patients had worse physical scores than age-matched controls (SF36PF normative mean (S.D.) 80.97 (12.69) vs. pre-op 33.31 (24.7) P < 0.05). Of the 302 patients, 117 (39%) had significant anxiety or depression. Increased levels of anxiety or depression pre-operatively correlated with worse physical (SF-36PF and SF-36BP) scores pre-operatively (Spearman's r P < 0.05). Levels of anxiety and depression were reduced post-operatively and physical outcomes improved post-operatively. Physical function remained worse in those groups who had high levels of anxiety and depression pre-operatively but when matched for pre-operative physical function, psychological distress did not have any additional effect on outcome. Conclusions. Poor physical function pre-operatively correlates with psychological distress. Both physical and psychological symptoms improve after surgery. Physical outcome after surgery is strongly influenced by pre-operative physical functioning but not independently by psychological distress. Anxious and depressed patients should continue to be offered surgery if clinically indicated. [ABSTRACT FROM AUTHOR]

Health-Related Quality of Life (HRQoL) assessments in spinal disease offer the potential of outcome measures that better represent patients' disability and response to treatment. The Short Form 36 Health Survey (SF-36) is a generic HRQoL questionnaire that has been extensively used in primary and secondary care, but before it can be routinely applied in patients with spinal disease must be validated against traditional specific measures of physical and mental morbidity. Patients with lumbar disc prolapse, lumbar canal stenosis, and cervical spondylotic radiculomyelopathy were identified from a prospectively maintained database. Visual Analogue Scales (VAS) and condition-specific questionnaires including the Roland Morris Disability Score (RMDS), Myelopathy Disability Index (MDI), and Hospital Anxiety and Depression Scales (HADS), were completed alongside the SF-36 survey at baseline and following surgery. Convergent, discriminant, and predictive validity were assessed by computing correlations between the specific and generic scores. In addition, responsiveness (Standardised Response Mean, SRM) and floor and ceiling effects were examined. Data from 1623 assessments of 620 patients were available. Convergent validity was shown by strong correlations between condition-specific physical scores (MDI or RMDS) and the Physical Function and Bodily Pain domains of SF-36 (ρ = -0.52 to -0.76, all p < 0.01). VAS for leg or arm pain were also strongly correlated with Bodily Pain domain scores (ρ = -0.54 to -0.77, all p < 0.01). Discriminant validity was confirmed by non-significant partial correlations between Physical Function and Mental Health SF-36 domains when controlled for HADS scores (r = -0.01 to 0.02, p > 0.05). Predictive validity was demonstrated by similar correlations between pre- and post-operative scores for specific and generic instruments. Physical Function, Bodily Pain, and Mental Health domains were all free of significant floor or ceiling effects and showed moderate to good responsiveness (SRM 0.54-1.72). SF-36 domain scores are valid for measuring morbidity and surgical outcomes in common spinal disorders. [ABSTRACT FROM AUTHOR]

Introduction.Spinal Dural Fistulas (SDAVF) are the most common Spinal Vascular Malformation. The management of SDAVFs involves diagnosis and localisation with MRI and spinal angiography and subsequent embolisation or surgical interruption. We report our experience in treating these fistulas in which we undertake endovascular treatment, if technically feasible, with recourse to surgery only if occlusion is not possible.Method.This retrospective study reviews the management of 38 patients treated for SDAVFs over a 13-year period (1997–2010). Patient demographics, procedure and follow-up over a 6–12-month period (mean of approximately 10 months) were analysed and a qualitative assessment of patient outcome was made.Results.Patient ages ranged from 20 to 86 (mean 63.5), with 27 male and 11 female patients. A total of 28 patients managed with a combination of embolisation and surgery report either with improved symptoms or a return to normal. The presence of bladder and bowel symptoms indicated more severe disability and their presence at presentation was associated with lack of improvement following treatment.Conclusions.We report a treatment strategy for SDAVF involving primary endovascular intervention and reserving surgery for those patients in whom endovascular treatment is not possible. [ABSTRACT FROM AUTHOR]

Abstract Bilateral upper limb paraesthesia and pain are common symptoms of degenerative cervical myelopathy (DCM). Such symptoms instigate investigation by cervical spine magnetic resonance imaging (MRI). This was the case for our patient, who was 72-years-in age and otherwise fit and well. During the scan he unfortunately developed sudden onset quadriplegia secondary to an intervertebral disc prolapse. This necessitated intubation due to respiratory failure and urgent transfer to the neurosciences critical care unit at a tertiary neurosciences centre. Despite prompt surgical decompression, he did not regain function. Extubation was unsuccessful on three occasions. Following discussion between the patient and his family, ventilation was withdrawn, and he died the following day. This case highlights the potentially devastating consequences of DCM and poses questions about the aetiology of DCM. [ABSTRACT FROM AUTHOR]