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. In South Africa,  neurosurgeons have had limited involvement in this field owing to a perceived lack of options, leaving the care of these patients largely in the hands of paediatric  neurologists and orthopaedic surgeons. A committed team-based approach, where a neurosurgeon is part of the decision-making process, can however significantly improve functional outcomes in patients with spasticity. Key to the evaluation and therapeutic decision-making is the focus on function – not only the range of  movement or the presence of spasticity. Some techniques can completely remove spasticity and contractures, but these mostly leave a patient with more functional impairment than they had before the surgery. With the careful combination of botulinum toxin injections and oral baclofen, these patients, who may benefit from further orthopaedic and neurosurgical procedures, can be identified and helped in reducing the function-limiting spasticity. With the emphasis on function as an individualising factor, significant improvements may follow minor interventions, e.g. performing a surgical procedure to allow reduced hip adductor spasticity, thereby allowing improved hygiene and less pain in a child in whom it was previously not possible to abduct the hips enough to change a nappy. Functional improvement does not necessarily equate to walking. We describe the process of evaluating patients with spasticity and outline the surgical decision-making process that helps towards an individualised therapeutic strategy in 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. It is 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 the brain, 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 of the epileptic focus, certain neuromodulation techniques may benefit the patient. Successful outcomes of epilepsy surgery techniques vary from 50% to 80% in rendering patients free of their epilepsy; many more patients can expect improvement in the severity or frequency of their 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 best outcomes. 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

Surgical treatment for 'brain compartment syndrome' in children with severe head injury

No Abstract. South African Medical Journal Vol. 96(9) (Part 2) 2006: 969-97

Four decades of conjoined twins at Red Cross Children's Hospital - lessons learned

No Abstract. South African Medical Journal Vol. 96(9) (Part 2) 2006: 931-94

Endoscopic third ventriculostomy in post-tubercular meningitic hydrocephalus

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The relationship between transorbital ultrasound measurement of the optic nerve sheath diameter (ONSD) and invasively measured ICP in children: Part I: repeatability, observer variability and general analysis

Purpose: The aim of this study was to investigate the relationship between optic nerve sheath diameter (ONSD) measurement and invasively measured intracranial pressure (ICP) in children. Methods: ONSD measurement was performed prior to invasive measurement of ICP. The mean binocular ONSD measurement was compared to the ICP reading. Physiological variables including systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), pulse rate, temperature, respiratory rate and end tidal carbon dioxide (ETCO2) level were recorded at the time of ONSD measurement. Diagnostic accuracy analysis was performed at various ICP thresholds and repeatability, intra- and inter-observer variability, correlation between measurements in different imaging planes as well the relationship over the entire patient cohort were examined in part I of this study. Results: Data from 174 patients were analysed. Repeatability and intra-observer variability were excellent (α = 0.97–0.99). Testing for inter-observer variability revealed good correlation (r = 0.89, p < 0.001). Imaging in the sagittal plane demonstrated a slightly better correlation with ICP (r = 0.66, p < 0.001). The ONSD measurement with the best diagnostic accuracy for detecting an ICP ≥ 20 mmHg over the entire patient cohort was 5.5 mm, sensitivity 93.2 %, specificity 74 % and odds ratio (OR) of 39.3. Conclusion: Transorbital ultrasound measurement of the OSND is a reliable and reproducible technique, demonstrating a good relationship with ICP and high diagnostic accuracy for detecting raised ICP

The relationship between transorbital ultrasound measurement of the optic nerve sheath diameter (ONSD) and invasively measured ICP in children: Part I: repeatability, observer variability and general analysis

Purpose: The aim of this study was to investigate the relationship between optic nerve sheath diameter (ONSD) measurement and invasively measured intracranial pressure (ICP) in children. Methods: ONSD measurement was performed prior to invasive measurement of ICP. The mean binocular ONSD measurement was compared to the ICP reading. Physiological variables including systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), pulse rate, temperature, respiratory rate and end tidal carbon dioxide (ETCO2) level were recorded at the time of ONSD measurement. Diagnostic accuracy analysis was performed at various ICP thresholds and repeatability, intra- and inter-observer variability, correlation between measurements in different imaging planes as well the relationship over the entire patient cohort were examined in part I of this study. Results: Data from 174 patients were analysed. Repeatability and intra-observer variability were excellent (α = 0.97–0.99). Testing for inter-observer variability revealed good correlation (r = 0.89, p &lt; 0.001). Imaging in the sagittal plane demonstrated a slightly better correlation with ICP (r = 0.66, p &lt; 0.001). The ONSD measurement with the best diagnostic accuracy for detecting an ICP ≥ 20 mmHg over the entire patient cohort was 5.5 mm, sensitivity 93.2 %, specificity 74 % and odds ratio (OR) of 39.3. Conclusion: Transorbital ultrasound measurement of the OSND is a reliable and reproducible technique, demonstrating a good relationship with ICP and high diagnostic accuracy for detecting raised ICP