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Given the differing mechanisms thought to underlie therapeutic sub- and supra-perception-based neurostimulative modalities, Spinal Cord Stimulation (SCS) systems designed for combined delivery of these approaches may help improve analgesic outcomes and quality of life, and reduce treatment failures. This multicenter, observational case-series evaluated 188 patients with chronic back and/or leg pain implanted with an SCS device capable of sequential or simultaneous delivery of sub-perception and supra-perception stimulation programming (i.e., combination therapy) at 16 in Europe. Following implantation, patients were provided with an array of advanced supra-perception programs (e.g., paresthesia-based SCS using multiple independent current sources), and a custom set of sub-perception programs optimized with specific waveforms and/or field shapes. A mean overall pain score of 7.9 ± 1.7 (Standard Deviation (SD)) was reported pre-trial (Baseline). Overall pain was reduced by 4.4 ± 2.8 points (NRS) at 3-months (n = 117) and at 12 months post-implant (n = 90), respectively (p &lt, 0.0001). Substantial quality-of-life (EQ-5D-5L) improvement as assessed at last follow-up was also observed (n = 60). These results suggest that an implanted SCS device capable of combination therapy, while also enabled with patient-specific waveform optimization and stimulation field targeting capabilities, can enable highly effective pain relief and improve quality of life in patients suffering with chronic pain.

Consistent terminology is necessary to facilitate communication, but limited efforts have addressed this need in the neurostimulation community. We set out to provide a useful and updated glossary for our colleagues and prospective patients.This collaborative effort of the Neuromodulation Foundation (NF), the Institute of Neuromodulation (IoN), and the International Neuromodulation Society (INS) expands a glossary first published in 2007 for spinal cord stimulation. Peripheral nerve, dorsal root ganglion, deep brain, and motor cortex stimulation have been added to our scope. Volunteers from the collaborating entities used a nominal group process, consensus development panels, and the Delphi technique to reach consensus on inclusion and definition of terms. We created a glossary suitable for print and for expansion on the websites of the collaborating entities, which will offer the possibility of explaining definitions for a general audience. We excluded proprietary and brand names but included terms that have attracted proprietary interest without becoming brands or trademarks. We made an effort to be inclusive while also being concise and economical with space.We identified and defined 91 terms for this print edition and created an accompanying list of acronyms. As appropriate, we provided figures to illustrate the definitions.Although we refer to the glossary presented herein as the print edition, it can of course be viewed and searched electronically. NF, IoN, and INS will continue to collaborate on expanded web editions that can include hyperlinks for internal and external navigation. We believe this glossary will benefit our growing field by facilitating communication and mitigating inappropriate use of neurostimulation terms.

Failed back surgery syndrome (FBSS) is a stigmatizing and misleading term, and in many cases surgery is not relevant to the development, persistence, worsening or recurrence of the symptoms. An international panel recently proposed the notion of Persistent spinal pain syndrome (PSPS) as the preferred option to replace FBSS. The new label avoids ambiguity and inappropriately-implied causation. PSPS type 1 applies when there was no spinal surgery; type 2 applies when surgery had occurred. PSPS is therefore broader than FBSS but more accurate.

Objectives Currently little objective evidence exists regarding the phenotype or somato-sensory profile of patients with Failed Back Surgery Syndrome (FBSS). The aim of this study is to characterize the somato-sensory profile of the patients with FBSS undergoing spinal cord stimulation (SCS). Methods A combined quantitative sensory test and questionnaire approach was used to characterize the somatosensory profiles of patients undergoing SCS. Results Baseline somatosensory profiles were obtained from 23 patients and full three-month data was obtained from 19 patients. At baseline, there was a high prevalence (>50% prevalence of moderate to severe sensation) of burning, tingling, electric shock, numbness, and pressure pain sensitivity. None of the sensory symptoms were present at significant levels at three months following SCS. At baseline, 65% of patients had an inefficient conditioned pain modulation (CPM). Three months post-SCS, 95% of patients had an efficient CPM. All the patients who had an inefficient CPM at baseline had a successful implant at three months and their CPM became efficient in all but one patient. Only 50% of the patients with an efficient CPM at baseline, had a successful implant at three months post-SCS. Conclusion Although very low numbers, we could demonstrate the somatosensory profiles of patients with FBSS undergoing SCS. Early indication may associate an efficient CPM profile having a higher chance of an unsuccessful implant at three months.

This chapter has eleven sections: 1. Bibliography; 2. Manuscript Studies, Palaeography, and Facsimiles; 3. Cultural and Intellectual Contexts; 4. Literature: General; 5. The Poems of the Exeter Book; 6. The Poems of the Vercelli Book; 7. The Poems of the Junius Manuscript; 8. Beowulf and the Beowulf Manuscript; 9. Other Poems; 10. Prose; 11. Reception. Sections 1, 5, and 9 are by Simon Thomson and Eric Lacey; sections 2, 6, 7, and 8 are by Simon Thomson; sections 3, 4, 10, and 11 are by Eric Lacey.

Breast augmentation has been gaining popularity over the last two decades to correct congenital breast asymmetry or increase breast size and projection. Augmentation options started with saline implants, then silicone implants, and, recently, autologous fat transfer. Unfortunately, breast implants are not without complications, some of which are common, like capsular contracture, implant failure and infection. Others are quite rare, such as Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). Most of these complications will eventually require explantation in most cases, as the patients’ and implants' age and risk of complications increase. We present a 79-year-old patient who presented to our breast unit with a left breast lump with 50-year-old saline implants. A triple assessment revealed incidental right breast cancer treated with radiofrequency identification (RFID) tag-guided wide local excision, sentinel lymph node biopsy and bilateral explantation.

ObjectiveFor many medical professionals dealing with patients with persistent pain following spine surgery, the term Failed back surgery syndrome (FBSS) as a diagnostic label is inadequate, misleading, and potentially troublesome. It misrepresents causation. Alternative terms have been suggested, but none has replaced FBSS. The International Association for the Study of Pain (IASP) published a revised classification of chronic pain, as part of the new International Classification of Diseases (ICD-11), which has been accepted by the World Health Organization (WHO). This includes the term Chronic pain after spinal surgery (CPSS), which is suggested as a replacement for FBSS.MethodsThis article provides arguments and rationale for a replacement definition. In order to propose a broadly applicable yet more precise and clinically informative term, an international group of experts was established.Results14 candidate replacement terms were considered and ranked. The application of agreed criteria reduced this to a shortlist of four. A preferred option—Persistent spinal pain syndrome—was selected by a structured workshop and Delphi process. We provide rationale for using Persistent spinal pain syndrome and a schema for its incorporation into ICD-11. We propose the adoption of this term would strengthen the new ICD-11 classification.ConclusionsThis project is important to those in the fields of pain management, spine surgery, and neuromodulation, as well as patients labeled with FBSS. Through a shift in perspective, it could facilitate the application of the new ICD-11 classification and allow clearer discussion among medical professionals, industry, funding organizations, academia, and the legal profession.

Background: Treating chronic pain using sub-perception Spinal Cord Stimulation (SCS) does not elicit paresthesia but is associated with long analgesic "wash-in" (i.e., duration until maximum pain relief) and prolonged assessment of therapy. We describe attainment of clinically meaningful and rapid-onset analgesic outcomes using a novel sub-perception SCS approach.Methods: This observational case-series evaluated patients implanted with an SCS device for chronic pain, who underwent re-programming utilizing a new methodology in which paresthesia was used to guide sub-perception stimulation field targeting at specific parameters including charge-balanced symmetrical pulses at 90Hz (termed Fast-Acting Sub-Perception Therapy, FAST). Pain scores (NRS) were collected as reported per standard-of-care from patient charts. Energy usage was quantified as charge delivered-per-second (mC/s).Results: Mean overall pain score at baseline was 8.4±0.2 (n=41). After activation of FAST, a 7.1-point reduction in overall pain score was (1.3±0.2, p < 0.0001) reported within 11.2±1.9 minutes (n=34). This decrease in pain score was sustained out to 3-month (1.6±0.3, n=26) and 6-month follow-up (1.7±0.4, n=18). At last follow up (mean = 223±132 days), a pain score of 1.6±0.3, n=30 was determined. Mean charge-per-second using FAST was 6-18 times lower than conventional sub-perception approaches (1-10 kHz).Conclusions: After FAST implementation, a profound analgesic response, requiring substantially less energy than conventional sub-perception methodologies, was observed. This rapid analgesic onset achieved with the novel FAST technique suggests the potential for an alternative mechanism of action(s) of sub-perception SCS.

Purpose Glioblastoma prognosis is poor. Treatment options are limited at progression. Surgery may benefit, but no quality guidelines exist to inform patient selection. We sought to describe variations in surgical management at progression, highlight where further evidence is needed, and build towards a consensus strategy. Methods Current practice in selection of patients with progressive GBM for second surgery was surveyed online amongst specialists in the UK and Europe. We complemented this with an assessment of practice in a retrospective cohort study from six United Kingdom neurosurgical units. We used descriptive statistics to analyse the data. Results 234 questionnaire responses were received. Maintaining or improving patient quality of life was key to decision making, with variation as to whether patient age, performance status or intended extent of resection was relevant. MGMT methylation status was not important. Half considered no minimum time after first surgery. 288 patients were reported in the cohort analysis. Median time to second surgery from first surgery 390 days. Median overall survival 815 days, with no association between time to second surgery and time to death (p = 0.874). Conclusions This is the most wide-ranging examination of contemporaneous practice in management of GBM progression. Without evidence-based guidelines, the variation is unsurprising. We propose consensus guidelines for consideration, to reduce heterogeneity in decision making, support data collection and analysis of factors influencing outcomes, and to inform clinical trials to establish whether second surgery improves patient outcomes, or simply selects to patients already performing well.

BACKGROUNDChronic subdural hematoma is a common neurologic disorder that is especially prevalent among older people. The effect of dexamethasone on outcomes in patients with chronic subdural hematoma has not been well studied.METHODSWe conducted a multicenter, randomized trial in the United Kingdom that enrolled adult patients with symptomatic chronic subdural hematoma. The patients were assigned in a 1:1 ratio to receive a 2-week tapering course of oral dexamethasone, starting at 8 mg twice daily, or placebo. The decision to surgically evacuate the hematoma was made by the treating clinician. The primary outcome was a score of 0 to 3, representing a favorable outcome, on the modified Rankin scale at 6 months after randomization; scores range from 0 (no symptoms) to 6 (death).RESULTSFrom August 2015 through November 2019, a total of 748 patients were included in the trial after randomization — 375 were assigned to the dexamethasone group and 373 to the placebo group. The mean age of the patients was 74 years, and 94% underwent surgery to evacuate their hematomas during the index admission; 60% in both groups had a score of 1 to 3 on the modified Rankin scale at admission. In a modified intention-to-treat analysis that excluded the patients who withdrew consent for participation in the trial or who were lost to follow-up, leaving a total of 680 patients, a favorable outcome was reported in 286 of 341 patients (83.9%) in the dexamethasone group and in 306 of 339 patients (90.3%) in the placebo group (difference, −6.4 percentage points [95% confidence interval, −11.4 to −1.4] in favor of the placebo group; P=0.01). Among the patients with available data, repeat surgery for recurrence of the hematoma was performed in 6 of 349 patients (1.7%) in the dexamethasone group and in 25 of 350 patients (7.1%) in the placebo group. More adverse events occurred in the dexamethasone group than in the placebo group.CONCLUSIONSAmong adults with symptomatic chronic subdural hematoma, most of whom had undergone surgery to remove their hematomas during the index admission, treatment with dexamethasone resulted in fewer favorable outcomes and more adverse events than placebo at 6 months, but fewer repeat operations were performed in the dexamethasone group. (Funded by the National Institute for Health Research Health Technology Assessment Programme; Dex-CSDH ISRCTN number, ISRCTN80782810. opens in new tab.)

Introduction Small bowel lipomas are rarely encountered benign adipose growths found within the small intestine wall or mesentery. Limited up-to-date evidence exists regarding such lipomas. We aim to aid clinical decision-making and improve patient outcomes through this comprehensive review. Methodology The terms ‘small bowel,’ ‘small intestine,’ ‘jejunum’ and ‘ileum’ were combined with ‘lipoma.’ EMBASE, Medline and PubMed database searches were performed. All papers published in English from 01/01/2000-31/12/2019 were included. Simple statistical analysis (t-test, Anova) was performed. Results 142 papers yielded 147 cases (adults = 138, pediatric = 9). Male = 88, female = 59 (average age = 49.9 years). Presenting symptoms: abdominal pain = 68.7%; nausea/vomiting = 35.3%, hematochezia/GI bleeding = 33.3%; anaemia = 10.9%; abdominal distension = 12.2%; constipation = 8.9%; weight loss = 7.5%. Mean preceding symptom length = 58.1 days (symptoms >1 year excluded (n = 9)). Diagnostic imaging utilised: abdominal X-Ray = 33.3%; endoscopy = 46.3%; CT = 78.2%; ultrasound = 23.8%. 124/137 (90.5%) required definitive surgical management (laparotomy = 89, laparoscopcic = 35). 9 patients were successfully managed endoscopically. Lipoma location: ileum = 59.9%, jejunum = 32%, mesentery = 4.8%. Maximal recorded lipoma size ranged 1.2–22 cm. Mean maximum lipoma diameter and management strategy comparison: laparotomy 5.6 cm, laparoscopic = 4.4 cm, endoscopic = 3.7 cm, conservative = 4.5 cm. One-way Anova test, p value = 0.21. Average length of stay (LOS) was 7.4 days (range = 2–30). T-test p value = 0.13 when comparing management modalities and LOS. 4 complications, 0 mortality. Conclusions Important previously undocumented points are illustrated; a clearer symptom profile, diagnostic investigations utilised, size and site of lipomas, types and effectiveness of management modalities, associated morbidity and mortality. Open surgery remains the primary management. No statistically significant difference in LOS and lipoma size is demonstrated between management strategies. Endoscopic and laparoscopic techniques may reduce utilising invasive surgery in the future as skillset and availability improve., Highlights • Up to date overview of symptomatic lipomas of the jejunum and ileum which no other paper has previously covered. • Highlights associated symptom profile, investigations, site and size of symptomatic lipomas, morbidity and mortality. • Evaluates the effectiveness of management strategies. • Offers a practical summary that may help guide other clinicians faced with similar presentations in the future.

The study design of this paper is systematic review. The purpose of this review is to evaluate the existing radiological grading systems that are used to assess cervical foraminal stenosis. The importance of imaging the cervical spine using CT or MRI in evaluating cervical foraminal stenosis is widely accepted; however, there is no consensus for standardized methodology to assess the compression of the cervical nerve roots. A systematic search of Ovid Medline databases, Embase 1947 to present, Cinahl, Web of Science, Cochrane Library, ISRCTN and WHO international clinical trials was performed for reports of cervical foraminal stenosis published before 01 February 2020. In collaboration with the University of Leeds, a search strategy was developed. A total of 6952 articles were identified with 59 included. Most of the reports involved multiple imaging modalities with standard axial and sagittal imaging used most. The grading themes that came from this systematic review show that the most mature for cervical foraminal stenosis is described by (Kim et al. Korean J Radiol 16:1294, 2015) and (Park et al. Br J Radiol 86:20120515, 2013). Imaging of the cervical nerve root canals is mostly performed using MRI and is reported using subjective terminology. The Park, Kim and Modified Kim systems for classifying the degree of stenosis of the nerve root canal have been described. Clinical application of these scoring systems is limited by their reliance on nonstandard imaging (Park), limited validation against clinical symptoms and surgical outcome data. Oblique fine cut images derived from three dimensional MRI datasets may yield more consistency, better clinical correlation, enhanced surgical decision-making and outcomes.

Chyle leak following axillary lymph node clearance is a rarely reported complication. We present a case of chylous leakage following axillary lymph node clearance, which was diagnosed on clinical grounds. Surgical re-exploration was undertaken due to ongoing high output. However, the chylous leak recurred post-operatively, if at a lower rate. The patient was subsequently managed successfully with conservative measures, primarily utilizing regular aspiration and compression bandaging to the axilla.

Giuliano Lo Bianco, 1–3 Simon Thomson, 3 Simone Vigneri, 4 Hannah Shapiro, 5 Michael E Schatman 6, 7 1Università di Catania, Dipartimento di Scienze Biomediche e Biotecnologiche (BIOMETEC), Catania, Italy; 2I.R.C.C.S. CROB Centro di Riferimento Oncologico Basilicata, Rionero in Vulture, Potenza, Italy; 3Basildon and Thurrock University Hospitals NHSFT, Orsett Hospital, Pain Management and Neuromodulation, London, Essex, UK; 4Pain Medicine Department, Santa Maria Maddalena Hospital, Occhiobello, Rovigo, Italy; 5Department of Biopsychology, Tufts University, Medford, MA, USA; 6Department of Diagnostic Sciences, Tufts University School of Dental Medicine, Boston, MA, USA; 7Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USACorrespondence: Michael E Schatman Tel +1425647-4880Email Michael.Schatman@tufts.edu Abdominal pain is a nonspecific symptom which can be caused by myriad pathologies,resulting in frequent misdiagnosis. 1 Some pathological conditions can causeparoxysmal gastrointestinal symptoms, such as porphyria, cyclical vomiting, intestinalmalrotation, peritoneal bands, and abdominal migraine. 2 Furthermore, emotionaland psychological factors may also play an important role in the presentationof certain patients with gastrointestinal disorders, and accurate diagnosis can beconfounded by these. An accurate diagnosis may be delayed or even abandoned dueto the attribution of “functional” or “psychogenic” causality. 3 Physicians in numerousfields of practice too often respond in such a fashion when the more commoncauses of pain conditions are ruled out, 4 which potentially puts patients with rarepain disorders that are challenging to diagnose at considerable risk for needless,prolonged suffering. Further, the stigma associated with being diagnosed witha Somatoform Disorder or a Medically Unexplained Symptom (MUS) should notbe understated. 5

Cerebral abscess due to pigmented molds is a rare but usually fatal infection occasionally seen in transplant recipients. A 67‐year‐old man of Iraqi origin underwent a deceased donation renal transplant for renal failure and 2 months later was diagnosed with an abscess in the left posterior frontal lobe of his brain. Subsequent biopsy proved this to be due to the mold Rhinocladiella mackenziei. Further interventions included two operations to aspirate the lesion, voriconazole, then liposomal amphotericin B, then a combination of posaconazole and flucytosine which he continued for over 4 years. He also suffered from right ankle pain and was diagnosed with septic arthritis; R mackenziei was isolated from pus aspirated from the ankle joint. He responded well to the treatment and has had little loss of function, and on CT, the cerebral lesion has stabilized. Beta‐D‐glucan, initially at very high levels proved useful to monitor response over the 5 years and the latest sample was negative (38 pg/mL). This case is notable for the first disseminated case of this infection, its favorable outcome on a novel antifungal combination and a new approach to monitoring the course of disease.

Therapeutic mammaplasty (TM) may be an alternative to mastectomy, but few well designed studies have evaluated the success of this approach or compared the short-term outcomes of TM with mastectomy with or without immediate breast reconstruction (IBR). Data from the national iBRA-2 and TeaM studies were combined to compare the safety and short-term outcomes of TM and mastectomy with or without IBR.The subgroup of patients in the TeaM study who underwent TM to avoid mastectomy were identified, and data on demographics, complications, oncology and adjuvant treatment were compared with those of patients undergoing mastectomy with or without IBR in the iBRA-2 study. The primary outcome was the percentage of successful breast-conserving procedures in the TM group. Secondary outcomes included postoperative complications and time to adjuvant therapy.A total of 2916 patients (TM 376; mastectomy 1532; mastectomy and IBR 1008) were included in the analysis. Patients undergoing TM were more likely to be obese and to have undergone bilateral surgery than those having IBR. However, patients undergoing mastectomy with or without IBR were more likely to experience complications than the TM group (TM: 79, 21·0 per cent; mastectomy: 570, 37·2 per cent; mastectomy and IBR: 359, 35·6 per cent; P 0·001). Breast conservation was possible in 87·0 per cent of patients who had TM, and TM did not delay adjuvant treatment.TM may allow high-risk patients who would not be candidates for IBR to avoid mastectomy safely. Further work is needed to explore the comparative patient-reported and cosmetic outcomes of the different approaches, and to establish long-term oncological safety.La mamoplastia terapéutica (therapeutic mammaplasty, TM) puede ser una alternativa a la mastectomía, pero hay pocos estudios bien diseñados que hayan evaluado el éxito de esta estrategia o hayan comparado los resultados a corto plazo de la TM con la mastectomía con o sin (+/-) reconstrucción mamaria inmediata (immediate breast reconstruction, IBR). Para comparar la seguridad y los resultados a corto plazo de la TM y la mastectomía +/- IBR se combinaron los datos de los estudios nacionales iBRA-2 y TeaM. MÉTODOS: En el estudio TeaM se identificó el subgrupo de pacientes al que se realizó una TM para evitar la mastectomía y se compararon los datos demográficos, las complicaciones, los resultados oncológicos y el tratamiento adyuvante con las pacientes sometidas a mastectomía +/- IBR del estudio iBRA-2. La variable principal fue el porcentaje de éxito de la cirugía conservadora de mama en el grupo TM. Las variables secundarias fueron las complicaciones postoperatorias y el intervalo de tiempo hasta el inicio del tratamiento adyuvante.Se incluyeron en el análisis 2.916 pacientes (TM n = 376; mastectomía n = 1.532; IBR n = 1.008). La TM era más frecuente en pacientes obesas o en las sometidas a cirugía bilateral en comparación con las pacientes con IBR. Sin embargo, las pacientes sometidas a una mastectomía +/- IBR tenían más probabilidades de desarrollar complicaciones que las del grupo TM (TM n = 79, 21,0%; mastectomía n = 570, 37,2%; mastectomía y IBR n = 359, 35,6%; P 0,001). La conservación de la mama fue posible en el 87% de las pacientes con TM y el procedimiento no retrasó el inicio del tratamiento adyuvante. CONCLUSIÓN: La TM puede permitir que pacientes de alto riesgo que no serían candidatas a IBR eviten la mastectomía de una forma segura. Se necesitan más trabajos para comparar los resultados percibidos por las pacientes y los estéticos de las diferentes estrategias terapéuticas y establecer la seguridad oncológica a largo plazo.

The study of phloem transport and its vital roles in long-distance communication and carbon allocation have been hampered by a lack of suitable tools that allow high-throughput, real-time studies. Esculin, a fluorescent coumarin glucoside, is recognized by Suc transporters, including AtSUC2, which loads it into the phloem for translocation to sink tissues. These properties make it an ideal tool for use in live-imaging experiments, where it acts as a surrogate for Suc. Here, we show that esculin is translocated with a similar efficiency to Suc and, because of its ease of application and detection, demonstrate that it is an ideal tool for in vivo studies of phloem transport. We used esculin to determine the effect of different environmental cues on the velocity of phloem transport. We provide evidence that fluctuations in cotyledon Suc levels influence phloem velocity rapidly, supporting the pressure-flow model of phloem transport. Under acute changes in light levels, the phloem velocity mirrored changes in the expression of AtSUC2 This observation suggests that under certain environmental conditions, transcriptional regulation may affect the abundance of AtSUC2 and thus regulate the phloem transport velocity.

Objective The PROCO RCT is a multicenter, double-blind, crossover, randomized controlled trial (RCT) that investigated the effects of rate on analgesia in kilohertz frequency (1–10 kHz) spinal cord stimulation (SCS). Materials and Methods Patients were implanted with SCS systems and underwent an eight-week search to identify the best location (“sweet spot”) of stimulation at 10 kHz within the searched region (T8–T11). An electronic diary (e-diary) prompted patients for pain scores three times per day. Patients who responded to 10 kHz per e-diary numeric rating scale (ED-NRS) pain scores proceeded to double-blind rate randomization. Patients received 1, 4, 7, and 10 kHz SCS at the same sweet spot found for 10 kHz in randomized order (four weeks at each frequency). For each frequency, pulse width and amplitude were titrated to optimize therapy. Results All frequencies provided equivalent pain relief as measured by ED-NRS (p ≤ 0.002). However, mean charge per second differed across frequencies, with 1 kHz SCS requiring 60–70% less charge than higher frequencies (p ≤ 0.0002). Conclusions The PROCO RCT provides Level I evidence for equivalent pain relief from 1 to 10 kHz with appropriate titration of pulse width and amplitude. 1 kHz required significantly less charge than higher frequencies.

Sir,Flawed nomenclature and classification inevitably hamper diagnosis, clinical communication and research, and may impede access to appropriate treatment. This is clearly illustrated by the term ...

Background Spinal cord stimulation (SCS) is a recognized management option for patients with refractory neuropathic pain. Despite randomized controlled trials reporting the effectiveness of SCS, there is a lack of long-term data reflecting usual SCS practice. The aim of this study is to present the long-term outcomes of a cohort of patients from a single centre undertaking SCS with devices from a single manufacturer. Methods Data were collected between January 2008 and July 2015 on 321 patients who had an SCS trial. Outcome measures included numerical rating scale of pain intensity (NRSPI), brief pain inventory (BPI), EQ5D and quality-adjusted life-years (QALYs). Adverse effects also were recorded. Results Statistically significant reductions in NRSPI and BPI and increases in health utility using the EQ5d were observed. SCS over a 15-year time period resulted in a mean projected gain of 6.2 QALY. The rates of implant infection and device explantation were 2.3% (2.4% not including legacy patients) and 6.7% (7.6% not including legacy patients) respectively but only 3.4% (4% excluding legacy patients) explanted due to late failure to relieve pain. Satisfaction with SCS was high with 92% of patients stating that they would have it all done again for the same result. 96.4% would have wanted SCS as a treatment option earlier. Conclusions Patients with neuropathic pain undertaking SCS experience long-term reductions in pain intensity and increases in health utility and associated QALY gains. The findings from this study associated with the increased longevity of rechargeable SCS devices suggest that the cost-effectiveness of SCS may become increasingly favourable when compared with conventional medical management.

BACKGROUND The COVID-19 pandemic has profoundly affected cancer services. Our objective was to determine the effect of the COVID-19 pandemic on decision making and the resulting outcomes for patients with newly diagnosed or recurrent intracranial tumors. METHODS We performed a multi-centre prospective study of all adult patients discussed in weekly neuro-oncology and skull base MDTs who had a newly diagnosed or recurrent intracranial (excluding pituitary) tumor between 01 April and 31 May 2020. All patients had follow-up data at least 30-days after the index MDT date. Descriptive statistical reporting was used. RESULTS There were 1357 referrals for newly diagnosed or recurrent intracranial tumors across fifteen neuro-oncology centres. Of centres with all intracranial tumors, a change in initial MDT management was reported in 8.6% of cases (n=104/1210). Decisions to change the MDT management plan reduced over time from a peak of 19% referrals at the start of the study to 0% by the end of the study period. Changes in management were reported in 16% (n=75/466) of cases previously recommended for surgery and 28% of cases previously recommended for chemotherapy (n=20/72). The reported SARS-CoV-2 infection rate was similar in surgical and non-surgical patients (2.6% vs. 2.4%, p >0.9). CONCLUSIONS Disruption to neuro-oncology services in the UK caused by the COVID-19 pandemic was most marked in the first month, affecting all diagnoses. Patients considered for chemotherapy were most affected. In those recommended surgical treatment this was successfully completed. Longer-term outcome data will evaluate oncological treatments received by these patients and overall survival.

Nasogastric tubes (NGTs) have long been used for various indications, most commonly to decompress the stomach of its contents in intestinal obstruction or after abdominal surgery, to provide enteral feeding or to allow enteral liquid medication administration. Recently greater importance has been given to the correct placement NGTs to avoid serious complications. We present a case of a spontaneously knotted NGT that was identified and safely removed without complications, but which may have resulted from suboptimal placement. We discuss this case to raise awareness of this complication and how to minimize the likelihood of it happening and improve patient outcome.

This chapter is an introduction to spinal surgery, specific surgical techniques will be covered in other chapters. Preoperative considerations include the need for effective preoperative patient selection and careful consent. The optimal management of antiplatelet drugs and low molecular weight heparins in patients having spinal surgery is discussed but remains unclear. Perioperative considerations include careful patient positioning to protect the eyes and other pressure areas as well as the accurate marking of levels using X-ray. The use of microscopes and neurophysiology in spinal surgery is also discussed. The importance of fusion and the techniques used to promote it are covered in this chapter. Screw, rod, and plate design is explained. The principles of minimal access surgery down tubes or with dedicated implant kits is also considered. Postoperative considerations include the place of physiotherapy and venous thromboembolism avoidance.

Gallstone ileus is an uncommon complication of cholelithiasis but an established cause of mechanical bowel obstruction in the elderly. Perforation of the small intestine proximal to the obstructing gallstone is rare, only a handful of cases having been reported. Management is mainly surgical, but conservative treatment is occasionally appropriate. We report the case of an 86-year-old female who presented with a clinical picture of bowel obstruction, proven to be related to gallstone ileus which resolved spontaneously. We discuss the role of conservative management for this condition.

A case of a newly diagnosed calcified gallbladder cancer is presented, who had pre-existing porcelain gallbladder. Due to the advanced stage of the disease at presentation, the patient had a poor outcome. The investigation and management of gallbladder carcinoma is discussed as well as the relationship with porcelain gallbladder. We conclude that there is only a weak association between porcelain gallbladder and gallbladder cancer, but because gallbladder cancer typically presents late, a stratified approach to offering cholecystectomy to asymptomatic porcelain gallbladder is reasonable.

To the Editor, Their retrospective case series is of a population of patients with mixed diagnoses who had not responded sufficiently to paresthesia-based spinal cord stimulation. They have gone on to show that with their short-term effort to convert to 1–1.2 kHz spinal cord stimulation (SCS)

OBJECTIVES: Day-case brain tumour biopsy is an established practice in only a limited number of UK neurosurgical centres. The reluctance to adopt this protocol may be due to the lack of published evidence on its safety. We present our experience following 8 years practice. METHODS: All patients undergoing brain tumour biopsy between November 2009–2017 were included. Subjects were identified through hospital operations database and their electronic case notes. RESULTS: 447 biopsies were performed over 8 years with 160 intended as day-case and 135 actual day-case procedures, revealing a failure rate of 15.6% (25). Mean age was 58 years. Pathology included low grade tumours (26), high grade tumours (95), lymphoma (21), metastases (6) and non-tumours (12). Locations were broadly categorised as frontal (69), parietal (40), temporal (35), occipital (3) or posterior fossa (13). Causes for failed day-cases included post-operative haematoma, delayed imaging and new neurological deficit. Mortality rate was 0%. Re-admission rate was 3% due to seizures (3) and wound infection (1). CONCLUSION: Close surveillance post-operatively permits for prompt delivery of care together with an enhanced patient experience. As demonstrated and consistent with other centres’ experience, this is a safe and effective technique. Day-case surgery helps meet the modern demands of the NHS by improving patient flow and relieving bed pressures provided a bespoke day-case pathway exists.

Formative assessment is a key component in medical education and that it is a helpful process for all involved. Until recently there was no national formative examination for neurosurgical trainees. The Neurosurgery Annual in Training Examination (NAiTE) is an annual online, formative assessment that was introduced in 2014. In this paper, we seek to discuss how well NAiTE relates to established educational practice and principles and its fitness for purpose by discussing its rationale, structure and utility.A national online examination was introduced in 2014. The NAiTE consists of 100 single best answer multiple choice questions. The examination and questions with were reviewed and the global results presented. The existing literature and educational theory are used to guide subjective assessment of the process.In 2016, 191 candidates participated in the NAiTE, of whom 154 were trainees working in UK neurosurgical units. The mean score for early stage UK trainees (years 1-3) was 52.4%, intermediate (years 4-5) 58.5% and senior (years 6-8) 65.4%. The NAiTE was found to be a reliable (Cronbach-Alpha of 0.89) and valid assessment of trainees with scores approximating those attained in the Intercollegiate Specialty Examination itself.Potential areas for improvement are highlighted, including reference to some that have already been implemented.Overall, the examination is a cheap, viable and reliable means of testing trainees and encouraging their onward development and learning as they work towards the Intercollegiate Specialty Examination.

Immune checkpoint inhibitors, including those targeting programmed cell death protein 1 (PD-1), are reshaping cancer therapeutic strategies. Evidence suggests, however, that tumor response and patient survival are determined by tumor programmed death-ligand 1 (PD-L1) expression. We hypothesized that preconditioning of the tumor immune microenvironment using targeted, virus-mediated interferon (IFN) stimulation, would upregulate tumor PD-L1 protein expression and increase cytotoxic T cell infiltration, improving the efficacy of subsequent checkpoint blockade. Oncolytic viruses (OVs) represent a promising form of cancer immunotherapy. For brain tumors, almost all studies to date have used direct intralesional injection of OV, because of the largely untested belief that intravenous (i.v.) administration will not deliver virus to this site. Here we show, in a window-of-opportunity clinical study, that i.v. infusion of oncolytic human Orthoreovirus (referred to herein as reovirus), leads to infection of tumor cells subsequently resected as part of standard clinical care, both in high-grade glioma (HGG) and in brain metastases, and increases cytotoxic T cell tumor infiltration relative to patients not treated with virus. We further show that reovirus upregulates IFN-regulated gene expression, as well as the PD-1/PD-L1 axis in tumors, via an IFN-mediated mechanism. Finally, we show that addition of PD-1 blockade to reovirus enhances systemic therapy in a preclinical glioma model. These results support the development of combined systemic immunovirotherapy strategies for the treatment of both primary and secondary tumors in the brain.

Reimbursement strategies for health care interventions vary across the world. In the case of neuromodulation interventions, the differences, not only concern reimbursement, but also which conditions neuromodulation interventions are eligible for reimbursement. The decision-making process of which interventions to reimburse is mostly based on the health care system of the country, which varies widely across the globe, and the effectiveness and cost-effectiveness of interventions, although in some cases where robust evidence is not available, treatments may be reimbursed under certain restrictions. The current chapter provides an overview of reimbursement strategies in the United States, the United Kingdom, and some countries in Europe and South America with a focus on the process employed to reimburse neuromodulation. The decisions made in various countries concerning neuromodulation procedures for a range of indications are presented.

The surgical management of cervical brachialgia utilising anterior cervical discectomy and fusion (ACDF) or posterior cervical foraminotomy (PCF) is a controversial area in spinal surgery. Previous studies are limited by utilisation of non-validated outcome measures and, importantly, absence of pre-operative analysis to ensure both groups are matched. The authors aimed to compare the effectiveness of ACDF and PCF using validated outcome measures. To our knowledge, it is the first study in the literature to do this. The authors conducted a 5-year retrospective review (2008–2013) of outcomes following both the above procedures and also compared the effectiveness of both techniques. Patients with myelopathy and large central discs were excluded. The main outcome variables measured were the neck disability index (NDI) and visual analogue scores (VAS) for neck and arm pain pre-operatively and again at 2-year follow-up. The Wilcoxon signed-rank test and Student t-tests were used to test differences. A total of 150 ACDFs and 51 PCFs were performed for brachialgia. There was no differences in the pre-operative NDI, VAS neck and arm scores between both groups (p > 0.05). As expected, both ACDF and PCF delivered statistically significant improvement in NDI, VAS-neck and VAS-arm scores. The degree of improvement of NDI, VAS-neck and VAS-arm were the same between both groups of patients (p > 0.05) with a trend favouring the PCF group. In the ACDF group, two (1.3 %) patients needed repeat ACDF due to adjacent segment disease. One patient (0.7 %) needed further decompression via a foraminotomy. In the PCF group one (2.0 %) patient needed ACDF due to persistent brachialgia. We found both interventions delivered similar improvements in the VAS and NDI scores in patients. Both techniques may be appropriately utilised when treating a patient with cervical brachialgia.

BACKGROUND: Brain tumours account for

Objective: In an increasingly complex and competitive professional environment, improving methods to educate neurosurgical residents is key to ensure high quality patient care. Electronic (e)Learning resources promise interactive knowledge acquisition. We set out to give a comprehensive overview on [for full text, please go to the a.m. URL], 68. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie (DGNC), 7. Joint Meeting mit der Society of British Neurological Surgeons (SBNS)

Introduction Spinal cord stimulation (SCS) is well accepted for the treatment of chronic pain since its beginning in 1967. As its use continues to enter into the chronic pain treatment algorithm earlier, conscience patient selection and durability of the therapy are clearly clinically relevant. To improve treatment efficacy, consensus statements and guidelines were developed. Objective The purpose of this work is to review the relevant guideline statements for implantable neurostimulation therapies to treat chronic pain and to identify guideline gaps and future directions for recommendation platforms. Materials and Methods A systematic literature search through EMBASE, Medline, Cochrane data base, as well as peer-reviewed, nonindexed journals and materials presented at national and international meetings was performed to chronologically identify consensus statements or guideline statements for use of neurostimulation therapies to treat chronic neuropathic pain limited to the English language. Results From 1998 to 2013, 22 guideline statements were identified. Thirteen of the 22 guidelines were society-sponsored guideline statements from ten societies. Two guideline statements were from research foundations, two were government supported, and one statement was published as a position statement. Conclusions The current available guideline statements have clear deficiencies in either scope of coverage, evidence synthesis, or lack of transparency of funding. Improved evidence and best practice/guideline assessment may improve patient outcomes and accessibility to these important modalities. Further prospective comparator randomized data are required to not only provide data of clinical and cost-effectiveness in other indications but also to better describe the position of neurostimulation application within the disease management pathway. Therein cases where there appears to be sufficient evidence and consensus, every effort should be made to secure access to these effective therapies. Importantly, each guideline only has a useful clinical half-life, if not updated. This should be acknowledged by both clinicians and third-party payers. Based on these deficiencies, the International Neuromodulation Society recommended the creation of a consensus conference to examine the appropriate use of neurostimulation for pain and ischemic disease.

Introduction The International Neuromodulation Society (INS) has determined that there is a need for guidance regarding safety and risk reduction for implantable neurostimulation devices. The INS convened an international committee of experts in the field to explore the evidence and clinical experience regarding safety, risks, and steps to risk reduction to improve outcomes. Methods The Neuromodulation Appropriateness Consensus Committee (NACC) reviewed the world literature in English by searching MEDLINE, PubMed, and Google Scholar to evaluate the evidence for ways to reduce risks of neurostimulation therapies. This evidence, obtained from the relevant literature, and clinical experience obtained from the convened consensus panel were used to make final recommendations on improving safety and reducing risks. Results The NACC determined that the ability to reduce risk associated with the use of neurostimulation devices is a valuable goal and possible with best practice. The NACC has recommended several practice modifications that will lead to improved care. The NACC also sets out the minimum training standards necessary to become an implanting physician. Conclusions The NACC has identified the possibility of improving patient care and safety through practice modification. We recommend that all implanting physicians review this guidance and consider adapting their practice accordingly.

ObjectivesTo investigate if there is a significant difference between the LOS for patients admitted as waiting list initiative patients to a private hospital versus standard care in an NHS hospital.DesignRetrospective analysis between 2015 and 2017 of all ACD procedures at the two hospitals.Subjects674 elective NHS patients were included, 340 were admitted to the NHS hospital and 334 as waiting list initiative patients to the private hospital. Acute patients were excluded.MethodsRetrospective database search of electronic hospital records for all ACD procedures carried out between 2015 and 2017. The student standard t test analysis was used to compare the difference in LOS.ResultsIn both groups 100% were admitted on the day of surgery. The mean NHS LOS was 3.3 (SD=6.34) days and the private hospital was 1.1 (SD=0.97) days. (pConclusionsWe found that length of stay is significantly shorter in the private hospital than in the NHS hospital. This could be due to patient selection, a swifter patient pathway or a combination of the two and these factors will be explored.