Effect of multiple subpial transection on motor cortical excitability in cortical dysgenesis.
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We report here a 12-year-old patient with unilateral cortical dysgenesis and intractable simple partial seizure in his left arm, who underwent multiple subpial transection (MST) in the right cerebral cortex including the primary motor cortex. We investigated motor cortical excitability using multimodal transcranial magnetic stimulation (TMS) before and 1 month after MST, in which surgical cortical incisions were made with strokes 5 mm apart and 4 mm deep. Preoperative TMS studies showed hyperexcitability in the affected motor cortex as abnormally prolonged muscle responses to TMS with a wide cortical motor map, which were markedly reduced following the operation. The preoperative motor evoked potentials were large and polyphasic, and consisted of early and late components. The late component was completely abolished after MST, suggesting that this component might be due to activation of the corticospinal tract neurones by long recurrent axon branches of dysplastic excitatory pyramidal neurones, which were cut by MST, or by delayed, polysynaptic intracortical conduction with marked temporal dispersion. Intracortical inhibition in the affected motor cortex was also disrupted preoperatively and improved after MST. Postoperative recruitment order of muscle responses to TMS was bilaterally symmetrical, indicating that MST did not interfere with the function of the corticospinal tract neurones. The patient showed fair motor recovery and good seizure control after the operation. These results of TMS studies demonstrated the remarkable effectiveness of MST not only on intractable seizure but also on abnormal motor cortical organization and hyperexcitability in cortical dysgenesis. (+info)
Sham neurosurgery in patients with Parkinson's disease: is it morally acceptable?
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For a few decades, patients with Parkinson's disease (PD) have been treated with intracerebral transplantations of fetal mesencephalic tissue. The results of open trials have been variable. Double blind, placebo-controlled studies have recently been started in order to further investigate the efficacy of this new medical technique. In this paper we challenge the need for sham surgery in neurotransplantation research on PD patients. Considerations regarding the research subjects' informed consent, therapeutic misconception, the integrity of the human body, and the assessment of risks and benefits argue against sham surgery for patients with PD. Moreover, there is an alternative, less harmful mode of research that can provide the same or comparable scientific evidence. A plea is made for intrapatient research based on quantitative measurements of the patient's pre- and post-operative condition combined with similar research on a reference group of patients who have received the standard treatment. (+info)
A case of malignant proliferating trichilemmoma of the scalp with multiple metastases.
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We report a case of malignant proliferating trichilemmal tumor showing multiple distant metastases. The patient demonstrated a round mass in the right occipital area for 12 months and the lesion grew rapidly to assume 8 x 6.5 x 4 cm in diameter, with areas of superficial erosion and crusting within the recent 3 months. The entire lesion was removed with a wide surgical excision. It recurred on the neck area 4 months after excision and the lesion was removed with surgical resection again. There was evidence of multiple metastases on CNS and mediastinal lymph nodes after 6 months. The patient was treated with cisplatin and etoposide combination chemotherapy and a partial response was achieved. (+info)
The realities of postoperative disability and the carer's burden.
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Outcome after high-risk, complex neurosurgery for progressive skull base pathology, and its effect on carers, has been examined. Two different outcome measures were used. The Glasgow Outcome Score (GOS) assesses overall social capability and dependence of the patient, while the 36 item short-form health survey (SF-36), a generic quality of life measure, can be compared directly with the general population. Overall outcome using the GOS indicated a favourable outcome for 13 of the 17 patients studied. The SF-36 demonstrated that more than half the patients were functioning at a level below the accepted norm. The reasons for this discrepancy and the validity of outcome scales have been analysed. In addition, the effect upon carers, its relevance to assessment of outcome, and the need to involve potential carers in the process of informed consent was stated. Our conclusions are applicable throughout the surgical specialities, and especially to high-risk complex surgery. (+info)
Can evidence change the rate of back surgery? A randomized trial of community-based education.
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CONTEXT: Timely adoption of clinical practice guidelines is more likely to happen when the guidelines are used in combination with adjuvant educational strategies that address social as well as rational influences. OBJECTIVE: To implement the conservative, evidence-based approach to low-back pain recommended in national guidelines, with the anticipated effect of reducing population-based rates of surgery. DESIGN: A randomized, controlled trial. SETTING: Ten communities in western Washington State with annual rates of back surgery above the 1990 national average (158 operations per 100,000 adults). PARTICIPANTS: Spine surgeons, primary care physicians, patients who were surgical candidates, and hospital administrators. INTERVENTION: The five communities randomized to the intervention group received a package of six educational activities tailored to local needs by community planning groups. Surgeon study groups, primary care continuing medical education conferences, administrative consensus processes, videodisc-aided patient decision making, surgical outcomes management, and generalist academic detailing were serially implemented over a 30-month intervention period. OUTCOME MEASURE: Quarterly observations of surgical rates. RESULTS: After implementation of the intervention, surgery rates declined in the intervention communities but increased slightly in the control communities. The net effect of the intervention is estimated to be a decline of 20.9 operations per 100,000, a relative reduction of 8.9% (P = 0.01). CONCLUSION: We were able to use scientific evidence to engender voluntary change in back pain practice patterns across entire communities. (+info)
Nosocomial infections due to Acinetobacter baumannii in a neurosurgery ICU.
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Invasive infections caused by Acinetobacter baumannii in a post-operative neurosurgery ICU were studied. Sixty one patients admitted during a span of 11 months were culture positive for acinetobacter species from blood and/or CSF samples. They were followed up prospectively for evidence of infection and clinical outcome. 40 cases had clinical evidence of infection due to acinetobacter species while in 21 patients, the isolation of the organism was considered a contaminant. Acinetobacter baumannii was the most common organism associated with invasive infections. Respiratory tract was found to be the most common primary source of infection in patients with bacteraemia or meningitis. The age, sex and pre-operative hospital stay were not significantly different in the two groups (p>0.05), while post-operative hospital stay and mortality was significantly higher in patients with invasive infection (p<0.05). Acinetobacter baumannii was isolated from multiple sites (p<0.05) and repeatedly from the same site (p<0.001) in a significantly higher number of patients with invasive infections. Mortality was high in the patients infected with Acinetobacter baumannii. Even amongst the infected group, the patient shaving meningitis showed a higher mortality as compared to the patients having bacteraemia. (+info)
Surgeon's position for transsphenoidal surgery--technical note.
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Transsphenoidal resection of pituitary tumors is usually performed with the surgeon standing on the patient's right side. However, this configuration is awkward when the tumor extends to the right and access may be hindered if the patient has poor nuchal flexibility or a large chest due to giantism or acromegaly. The surgeon stood on the left side of the patient during transsphenoidal surgery in five selected cases. The position on the left provided good access to the tumors with minimal changes in technique. (+info)
Body morphology and the speed of cutaneous rewarming.
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BACKGROUND: Infants and children cool quickly because their surface area (and therefore heat loss) is large compared with their metabolic rate, which is mostly a function of body mass. Rewarming rate is a function of cutaneous heat transfer plus metabolic heat production divided by body mass. Therefore, the authors tested the hypothesis that the rate of forced-air rewarming is inversely related to body size. METHODS: Isoflurane, nitrous oxide, and fentanyl anesthesia were administered to infants, children, and adults scheduled to undergo hypothermic neurosurgery. All fluids were warmed to 37 degrees C and ambient temperature was maintained near 21 degrees C. Patients were covered with a full-body, forced-air cover of the appropriate size. The heater was set to low or ambient temperature to reduce core temperature to 34 degrees C in time for dural opening. Blower temperature was then adjusted to maintain core temperature at 34 degrees C for 1 h. Subsequently, the forced-air heater temperature was set to high (approximately 43 degrees C). Rewarming continued for the duration of surgery and postoperatively until core temperature exceeded 36.5 degrees C. The rewarming rate in individual patients was determined by linear regression. RESULTS: Rewarming rates were highly linear over time, with correlations coefficients (r2) averaging 0.98+/-0.02. There was a linear relation between rewarming rate (degrees C/h) and body surface area (BSA; m2): Rate (degrees C/h) = -0.59 x BSA (m2) + 1.9, r2 = 0.74. Halving BSA thus nearly doubled the rewarming rate. CONCLUSIONS: Infants and children rewarm two to three times faster than adults, thus rapidly recovering from accidental or therapeutic hypothermia. (+info)