Surgical management of spasticity

The management of patients with cerebral palsy and other causes of spasticity is a challenge to an entire rehabilitation team and to caregivers.InSouth Africa, neurosurgeons have had limited involvement in this field owing to a perceived lack of options, leaving the care of these patientslargely in the hands of paediatric neurologists and orthopaedic surgeons. A committed team-based approach, where a neurosurgeon is partof the decision-making process, can however significantly improve functional outcomes in patients with spasticity. Key to the evaluationand therapeutic decision-making is the focus on function – not only the range of movement or the presence of spasticity. Some techniquescan completely remove spasticity and contractures, but these mostly leave a patient with more functional impairment than they had beforethe surgery. With the careful combination of botulinum toxin injections and oral baclofen, these patients, who may benefit from furtherorthopaedic and neurosurgical procedures, can be identified and helped in reducing the function-limiting spasticity. With the emphasison function as an individualising factor, significant improvements may follow minor interventions, e.g. performing a surgical procedure toallow reduced hip adductor spasticity, thereby allowing improved hygiene and less pain in a child in whom it was previously not possibleto abduct the hips enough to change a nappy. Functional improvement does not necessarily equate to walking. We describe the process ofevaluating patients with spasticity and outline the surgical decision-making process that helps towards an individualised therapeutic strategyin managing this challenging group of patients

Surgical management of epilepsy

The fact that epilepsy can be cured or ameliorated with surgery is an often neglected and overlooked aspect of modern management.Epilepsy affects almost 50 million people worldwide. One-third of people who suffer from epilepsy are refractory to medication alone. Itis this group of patients who may benefit from epilepsy surgery, which can be divided into three main categories, i.e. resection procedures,disconnection procedures, and neuromodulation procedures. The goal of surgery in epilepsy is to remove the epileptogenic region from thebrain, or to disconnect it and thereby prevent spread to other parts of the brain. In cases where this is not possible owing to the location ofthe epileptic focus, certain neuromodulation techniques may benefit the patient. Successful outcomes of epilepsy surgery techniques varyfrom 50% to 80% in rendering patients free of their epilepsy; many more patients can expect improvement in the severity or frequency oftheir disabling seizures. The outcome depends on factors such as age, location of the epileptogenic zone, histology and cause of the seizures.Patients undergo a detailed and prolonged work-up to determine candidacy and to decide on the safest technique that will lead to the bestoutcomes. An experienced team should perform the surgery. This team should consist of multiple members who can attend to the medical,social, psychological and reintegration needs of the patient before and after surgery

Impressions of defensive medical practice and medical litigation among South African neurosurgeons

From a litigation perspective, neurosurgery is considered a ‘super high-risk’ field, and this has been associated with rapidly increasing malpractice cover costs. In 2013 the annual Medical Protection Society fee for cover was R250 900. We wished to determine whether high malpractice cover was influencing how neurosurgeons managed patients. A 40-question online survey asking questions on defensive medicine was distributed to determine perceptions around liability risk and whether these influenced how patients were managed. Eighty-four per cent of respondents agreed that a medicolegal crisis existed, and over half (53.8%) had been sued for malpractice during their career. Altering practice behaviour to minimise the risk of a lawsuit is common. The increasing number of legal claims against respondents in this survey has resulted in most neurosurgeons practising defensive medicine. Arguably this will result in increased healthcare costs, inferior patient care and decreased access to skilled surgeons.

Ventriculoperitoneal shunt insertion in human immunodeficiency virus infected adults:a systematic review and meta-analysis

Abstract Background Hydrocephalus is a common, life threatening complication of human immunodeficiency virus (HIV)-related central nervous system opportunistic infection which can be treated by insertion of a ventriculoperitoneal shunt (VPS). In HIV-infected patients there is concern that VPS might be associated with unacceptably high mortality. To identify prognostic indicators, we aimed to compare survival and clinical outcome following VPS placement between all studied causes of hydrocephalus in HIV infected patients. Methods The following electronic databases were searched: The Cochrane Central Register of Controlled Trials, MEDLINE (PubMed), EMBASE, CINAHL Plus, LILACS, Research Registry, the metaRegister of Controlled Trials, ClinicalTrials.gov, African Journals Online, and the OpenGrey database. We included observational studies of HIV-infected patients treated with VPS which reported of survival or clinical outcome. Data was extracted using standardised proformas. Risk of bias was assessed using validated domain-based tools. Results Seven Hunderd twenty-three unique study records were screened. Nine observational studies were included. Three included a total of 75 patients with tuberculous meningitis (TBM) and six included a total of 49 patients with cryptococcal meningitis (CM). All of the CM and two of the TBM studies were of weak quality. One of the TBM studies was of moderate quality. One-month mortality ranged from 62.5–100% for CM and 33.3–61.9% for TBM. These pooled data were of low to very-low quality and was inadequate to support meta-analysis between aetiologies. Pooling of results from two studies with a total of 77 participants indicated that HIV-infected patients with TBM had higher risk of one-month mortality compared with HIV non-infected controls (odds ratio 3.03; 95% confidence-interval 1.13–8.12; p = 0.03). Conclusions The evidence base is currently inadequate to inform prognostication in VPS insertion in HIV-infected patients. A population-based prospective cohort study is required to address this, in the first instance

Spina bifida: A multidisciplinary perspective on a many-faceted condition

Open spina bifida or myelomeningocele (SBM) is the most common birth defect involving the central nervous system, second only in incidence to congenital cardiac disease. Outcomes in this disorder were poor until the mid-20th century, when modern neurosurgical techniques (closing the lesion and treating hydrocephalus) and treatment for the neuropathic bladder addressed the major causes of mortality, although SBM may still be poorly treated in the developing world. Initial management – or mismanagement – has a profound impact on survival and long-term quality of life

Daily activities, participation, satisfaction, and functional mobility of adults with cerebral palsy more than 25 years after selective dorsal rhizotomy: a long-term follow-up during adulthood

CITATION: Berendina E. et al. 2021. Daily activities, participation, satisfaction, and functional mobility of adults with cerebral palsy more than 25 years after selective dorsal rhizotomy: a long-term follow-up during adulthood. Disability and Rehabilitation, 43(15):2191-2199, doi:10.1080/09638288.2019.1695001The original publication is available at http://www.tandfonline.com/toc/idre20/currentPurpose: To determine changes in level of accomplishment and satisfaction in daily activities and social participation, and functional mobility in adults with cerebral palsy (CP) more than 25 years after selective dorsal rhizotomy (SDR). Materials and methods: This long-term observational nine-year follow-up study included 26 adults (median age 35 years) with CP and spastic diplegia, and 26 matched typically developing adults. Assessment tools used were the Life-Habits questionnaire and the Functional Mobility Scale. Results: Most of the adults with CP were independent and satisfied with accomplishing life habits and no changes were determined, except for a small change in the Housing accomplishment level. Compared to typically developing adults, the CP cohort was more dependent in accomplishing Mobility and Recreation. However, the level of satisfaction was similar for most life habits except for Mobility. Functional mobility did not change, but correlated with Life-Habits results. Conclusions: Adults with CP showed high and stable levels of accomplishment and satisfaction in daily activities and social participation more than 25 years after SDR. This is in contrast with the literature, where functional decline was shown for individuals with CP as they age. The relation with functional mobility highlights the importance to focus the rehabilitation on maintaining walking ability in order to enable high level of daily activities and social participation in adults with CP. Implications for rehabilitation: Selective dorsal rhizotomy (SDR) is a valuable treatment option for a selective group of children with cerebral palsy (CP) in order to reduce spasticity. The long-term outcomes of SDR on level of accomplishment and satisfaction in daily activities and social participation as well functional mobility in adults with CP are not clear. More than 25 years after SDR adults with CP experienced stable and lasting high levels of functioning regarding daily activities and social participation and were satisfied with the way they accomplished life habits. Functional mobility was correlated to level of accomplishment and satisfaction in daily activities and social participation, which highlights the importance to focus rehabilitation programs on maintaining functional mobility in order to enable daily activities and social participation in adults with CP.https://www.tandfonline.com/doi/full/10.1080/09638288.2019.1695001Publishers versio

Needs of Young African Neurosurgeons and Residents: A Cross-Sectional Study.

Introduction: Africa has many untreated neurosurgical cases due to limited access to safe, affordable, and timely care. In this study, we surveyed young African neurosurgeons and trainees to identify challenges to training and practice. Methods: African trainees and residents were surveyed online by the Young Neurosurgeons Forum from April 25th to November 30th, 2018. The survey link was distributed via social media platforms and through professional society mailing lists. Univariate and bivariate data analyses were run and a P-value < 0.05 was considered to be statistically significant. Results: 112 respondents from 20 countries participated in this study. 98 (87.5%) were male, 63 (56.3%) were from sub-Saharan Africa, and 52 (46.4%) were residents. 39 (34.8%) had regular journal club sessions at their hospital, 100 (89.3%) did not have access to cadaver dissection labs, and 62 (55.4%) had never attended a WFNS-endorsed conference. 67.0% of respondents reported limited research opportunities and 58.9% reported limited education opportunities. Lack of mentorship (P = 0.023, Phi = 0.26), lack of access to journals (P = 0.002, Phi = 0.332), and limited access to conferences (P = 0.019, Phi = 0.369) were associated with the country income category. Conclusion: This survey identified barriers to education, research, and practice among African trainees and young neurosurgeons. The findings of this study should inform future initiatives aimed at reducing the barriers faced by this group

Transcranial Doppler pulsatility index is not a reliable indicator of intracranial pressure in children with severe traumatic brain injury

Background: The TCD-derived PI has been associated with ICP in adult studies but has not been well investigated in children. We examined the relationship between PI and ICP and CPP in children with severe TBI. Methods: Data were prospectively collected from consecutive TCD studies in children with severe TBI undergoing ICP monitoring. Ipsilateral ICP and CPP values were examined with Spearman correlation coefficient (mean values and raw observations), with a GEE, and as binary values (1 and 20 mm Hg, respectively). Results: Thirty-four children underwent 275 TCD studies. There was a weak relationship between mean values of ICP and PI (P = .04, r = 0.36), but not when raw observations (P = .54) or GEE (P = .23) were used. Pulsatility index was 0.76 when ICP was lower than 20 mm Hg and 0.86 when ICP was 20 mm Hg or higher. When PI was 1 or higher, ICP was lower than 20 mm Hg in 62.5% (25 of 40 studies), and when ICP was 20 mm Hg or higher, PI was lower than 1 in 75% (46 of 61 studies). The sensitivity and specificity of a PI threshold of 1 for examining the ICP threshold of 20 mm Hg were 25% and 88%, respectively. The relationship between CPP and PI was stronger (P = .001, r -0.41), but there were too few observations below 50 mm Hg to examine PI at this threshold. Conclusion: The absolute value of the PI is not a reliable noninvasive indicator of ICP in children with severe TBI. Further study is required to examine the relationship between PI and a CPP threshold of 50 mm Hg. (C) 2009 Elsevier Inc. All rights reserved