Reducing Pain and Improving Quality of Life for Patients Suffering the Acetabular Fracture

The rationale for this paper was to find out assessment tools and relevant factors that may reduce pain, and improve the quality of life and ability to perform activities of daily living in surgically and conservatively treated patients who sustained the acetabular fracture. One hundred and three patients with the acetabular injury were analysed during the 10-year retrospective case-control study. The case group consisted of 21 patients in whom the posterior acetabular wall was fractured and who were treated surgically. The control group comprised 82 patients with complex acetabular fracture in whom conservative treatment was applied. In order to assess post injury and postoperative quality of life different factors, such as the intensity and chronicity of pain, as well as the ability to resume activities of daily living, the patients were surveyed by anamnestic questionnaire to acquire the results. The quality of life was mostly better in patients from the case group who were operated on. At the follow-up, the features of pain were lower, management overall length shorter, and return to normal daily life activities faster in the surgically treated patients, compared to those who were not. In conclusion, based on our research we assume that surgery may notably decrease features of pain and improve the quality of life in patients with the acetabular injury

The Value of Stereotactic Biopsy in Improving Survival and Quality of Life for Malignant Brain Glioma Patients

The purpose of the study was to investigate possible differences in the survival and outcome of malignant brain glioma patients when treated by two different methods of surgery. During a 3-year period, 32 glioma patients underwent surgery and oncological protocol afterwards. The patients were divided into two groups according to the surgical method applied. The case group comprised 11 patients in whom a stereotactic biopsy was performed, while the control group consisted of 21 patients who were operated on by radical surgery (craniotomy and maximal reduction of the tumor mass). All survived patients were clinically examined at follow-ups (one year and 2 years following the surgery). The monitored variables for both groups were the tumor pathohistology (the tumor type), the survival rate (time between surgery and follow-up), and the outcome assessed by The Extended Glasgow Outcome Scale. Data statistical analysis was done to compare various investigated variables in two different groups of patients. The majority of patients treated by a stereotactic biopsy survived for more than 2 years following the procedure. The great part of patients treated by radical surgery died or was severely disabled at follow-up examination. The survival and outcome for the patients in whom a stereotactic biopsy was performed were notably better comparing to the patients who were treated by radical surgery. Consequently, it appears that a stereotactic biopsy is surgical option for primary treatment of selected patients with malignant brain glioma when the survival and quality of life are concerned

Operacijsko liječenje penetrirajuće rane mozga i pridružene perforirajuće ozljede oka uzrokovane metalnim objektom male brzine kretanja: prikaz slučaja i uvid u literaturu

Penetrating traumatic brain injury accompanied by perforating ocular injury caused by low-velocity foreign bodies is a life-threatening condition, a surgical emergency and a major challenge in surgical practice, representing a severe subtype of non-missile traumatic brain injury, which is a relatively rare pathology among civilians. Optimal management of such an injury remains controversial, requiring full understanding of its pathophysiology and a multidisciplinary expert approach. Herein, we report a case of penetrating brain and associated perforating eye injury and discuss relevant literature providing further insight into this demanding complex multi-organ injury. We present a case of 39-year-old male patient with transorbital penetrating brain and perforating ocular injury undergoing emergency surgery to remove a retained sharp metallic object from the left parietal lobe. Following appropriate and urgent diagnostics, a decompressive left-sided fronto-temporo-parietal craniectomy was immediately performed. A retained sharp metallic object (a slice of a round saw) was successfully removed, while primary left globe repair and palpebral and fornix reconstruction were performed afterwards by an ophthalmologist. A prophylactic administration of broad-spectrum antibiotics was applied to prevent infectious complications. Early postoperative recovery was uneventful. The patient was discharged on day 45 post-injury having moderate right-sided motor weakness, ipsilateral facial nerve central palsy, and light motoric dysphasia. The vision to his left eye was completely and permanently lost. In conclusion, management of non-missile transorbital penetrating brain injury can be satisfactory when proper clinical and radiologic evaluation, and amply, less radical surgical approach is performed early. A multidisciplinary routine is a prerequisite in achieving a favorable management outcome.Penetrirajuća ozljeda mozga i pridružena perforirajuća ozljeda oka uzrokovana stranim tijelima male brzine kretanja po život je opasno, hitno kirurško stanje koje predstavlja veliki izazov u kirurškoj opskrbi, kao i tešku podvrstu mirnodopske ozljede mozga, koja je relativno rijetka u civilnoj populaciji. Optimalno liječenje ovakve ozljede i nadalje je dvojbeno te zahtijeva potpuno razumijevanje patofiziologije njezinog razvoja, kao i multidisciplinarni ekspertni pristup. U ovom radu donosimo prikaz slučaja penetrirajuće ozljede mozga i pridružene perforirajuće ozljede oka te uvid u recentnu literaturu, kako bi podrobno raspravili o ovoj zahtjevnoj i složenoj višeorganskoj ozljedi. Muškarac u dobi od 39 godina zadobio je transorbitalnu penetrirajuću ozljedu mozga i perforirajuću okularnu ozljedu zbog čega je podvrgnut hitnom kirurškom liječenju kako bi se uklonilo oštar metalni objekt zaostalo u području lijevog tjemenog režnja. Nakon provedene žurne dijagnostike, odmah je učinjena dekompresijska ljevostrana fronto-temporo-parijetalna karniektomija te je uspješno uklonjeno zaostalo metalno strano tijelo (odsječak cirkularne pile), nakon čega je po oftalmologu učinjena primarna opskrba ozljede lijeve očne jabučice i rekonstrukcija vjeđa i forniksa kroz slojeve lijevo. Profilaktička primjena antibiotika širokoga spektra provedena je kako bi se spriječio nastanak infekcijskih komplikacija. Rani poslijeoperacijski oporavak bio je zadovoljavajući. Bolesnik je otpušten iz bolnice 45. dan nakon ozljede s umjerenom motoričkom slabošću desnih udova, istostranom centralnom facioparezom i blagom motoričkom disfazijom. Vid na lijevome oku trajno je i potpuno izgubljen. Zaključujemo kako liječenje mirnodopske transorbitalne penetrirajuće ozljede mozga može biti uspješno ako je provedena pravodobna primjerena klinička i radiološka provjera i ako je primijenjen ogovarajući manje radikalan rani kirurški pristup. Multidisciplinarna opskrba preduvjet je postizanju povoljnog učinka liječenja

The Value of Stereotactic Biopsy in Improving Survival and Quality of Life for Malignant Brain Glioma Patients

The purpose of the study was to investigate possible differences in the survival and outcome of malignant brain glioma patients when treated by two different methods of surgery. During a 3-year period, 32 glioma patients underwent surgery and oncological protocol afterwards. The patients were divided into two groups according to the surgical method applied. The case group comprised 11 patients in whom a stereotactic biopsy was performed, while the control group consisted of 21 patients who were operated on by radical surgery (craniotomy and maximal reduction of the tumor mass). All survived patients were clinically examined at follow-ups (one year and 2 years following the surgery). The monitored variables for both groups were the tumor pathohistology (the tumor type), the survival rate (time between surgery and follow-up), and the outcome assessed by The Extended Glasgow Outcome Scale. Data statistical analysis was done to compare various investigated variables in two different groups of patients. The majority of patients treated by a stereotactic biopsy survived for more than 2 years following the procedure. The great part of patients treated by radical surgery died or was severely disabled at follow-up examination. The survival and outcome for the patients in whom a stereotactic biopsy was performed were notably better comparing to the patients who were treated by radical surgery. Consequently, it appears that a stereotactic biopsy is surgical option for primary treatment of selected patients with malignant brain glioma when the survival and quality of life are concerned

A Brief Review of the History of Global and Croatian Neurosurgery

Neurokirurgija je istodobno jedna od najstarijih, ali i najmlađih medicinskih disciplina. Naime, arheološki nalazi potvrđuju opstojanje trepanacije lubanjske kosti već u mlađem kamenom dobu, dok je neurokirurgija kao zasebna disciplina utemeljena tek početkom 20. stoljeća. Opisi ozljeda glave i kralježnice, kao i trepanacije potječu već iz doba starog Egipta (papirus Edwina Smitha) te od antičkih liječnika, Hipokrata, aleksandrijske škole i Galena iz Pergama, koji je opisao vlastitu klasifikaciju lubanjskih prijeloma, dodatno usavršio trepanacijsku tehniku i znatno pridonio razumijevanju neuroanatomije i fiziologije. Nažalost, nakon toga prestalo je izučavanje središnjega živčanog sustava tijekom sljedećeg tisućljeća. Srednjovjekovni doprinos medicini i neurokirurgiji svodi se na djelovanje arapskih i perzijskih liječnika (Albukasis, Avicena), koji su prikupili, sačuvali i dodatno unaprijedili medicinsko znanje antičkog vremena, uključujući i neuroznanost. Dolaskom renesanse početkom 16. stoljeća započeo je znatan napredak anatomije, medicine i kirurgije te neuroznanosti kao preteče neurokirurgije. Kao rodonačelnici ovog doba posebice su se istaknuli Berengario da Carpi, Andreas Vesalius i Abroise Paré. Tijekom 19. stoljeća, u vrijeme znatnog napretka medicine i kirurgije, stvoreNeurosurgery is the oldest, but also the youngest medical discipline. Namely, archaeological findings confirm the existence of cranial bone trepanations in the Late Stone Age, while neurosurgery as a separate discipline was founded only at the beginning of the 20th century. Descriptions of head/spinal injuries, and trepanations, date back to ancient Egypt (Edwin Smith papyrus) and physicians like Hippocrates, the Alexandrian school, and Galen, who described his classification of cranial fractures, perfected trepanation and contributed to neuroanatomy and physiology. Unfortunately, with his disappearance, the study of the central nervous system ceased during the next millennium. Medieval contribution to neurosurgery is due to the work of Arab and Persian physicians (Albucasis, Avicenna), who collected, preserved, and improved the medical knowledge of ancient times, including neuroscience. With the arrival of the Renaissance in the early 16th century, significant advances in anatomy, medicine, surgery, and neuroscience began. Berengario da Carpi, Andreas Vesalius, and Ambroise Paré stood out as progenitors of this era. During the 19th century, at a time of progress in medicine and surgery, preconditions were created for more extensive and long-lasting neurosurgical procedures, while the era of modern neurosurgery began in the early 20th century with the pioneering activities of MacEwan, Horsley, Cushing, Elsberg, Dandy and many others. Further progress in neurosurgery was made through the use of an operating microscope, which from 1965 marked the era of modern microneurosurgery, founded by Yaşargil. The beginnings of neurosurgical activity in Croatia date back to the end of the 19th century when Theodor Wickerhauser published a record of the first craniotomy done in our country in 1886. In conclusion, modern neurosurgery as one of the most advanced medical professions is based on the achievements of its historical leaders, and on the cutting-edge diagnostic and surgical armamentaria, together with the superior neurosurgical service organization

Sigurnost i učinkovitost robotom potpomognute stereotaksijske biopsije gliomskih tumora mozga: rana institucijska iskustva i vrednovanje literature

Robot-assisted brain tumor biopsy is becoming one of the most important innovative technologies in neurosurgical practice. The idea behind its engagement is to advance the safety and efficacy of the biopsy procedure, which is much in demand when planning the management of endocranial tumor pathology. Herein, we provide our earliest institutional experiences in utilizing this mesmerizing technology. Cranial robotic device was employed for stereotactic robot-assisted brain glioma biopsy in three consecutive patients from our series: an anaplastic isocitrate dehydrogenase (IDH) negative astrocytoma (WHO grade III) located in the right trigone region of the periventricular white matter; a low grade diffuse astrocytoma (WHO grade II) of bilateral thalamic region spreading into the right mesencephalic area; and an IDH-wildtype glioblastoma (WHO grade IV) of the right frontal lobe producing a contralateral midline shifting. Robot-assisted tumor biopsy was successfully performed to get tissue samples for histopathologic and immunohistochemical analysis. The adjacent tissue iatrogenic damage of the eloquent cortical areas was minimal, while the immediate postoperative recovery was satisfactory in all patients. In conclusion, considering the preliminary results of our early experiences, robot-assisted tumor biopsy was proven to be a feasible and accurate procedure when surgery for brain glioma was not an option. It may increase safety and precision, without expanding surgical time, being similarly effective when compared to standard stereotactic and manual biopsy. Using this method to provide accurate sampling for histopathologic and immunohistochemical analysis is a safe and easy way to determine management strategies and outcome of different types of brain glioma.Robotom potpomognuta tumorska biopsija postaje jednom od najvažnijih inovativnih tehnologija u neurokirurškom radu. Razlog njezine uporabe nalazi se u daljnjem poboljšanju sigurnosti, učinkovitosti i preciznosti biopsijske metode koja je osobito značajna u planiranju opskrbe endokranijske tumorske patologije. Ovim radom donosimo prva institucijska iskustva u primjeni ove začudne tehnologije pri biopsiji gliomskih tumora mozga. Kranijski robotički uređaj korišten je pri stereotaksijskoj robotom potpomognutoj tumorskoj biopsiji u tri susljedna slučaja iz naše serije, koja je uspješno učinjena radi uzimanja uzorka tumorskoga tkiva za patohistološku i imunohistokemijsku dijagnostiku u bolesnice s anaplastičkim izocitrat dehidrogenaza (IDH) negativnim astrocitomom (SZO st. III.) smještenim u periventrukulskoj bijeloj tvari desnoga trigonuma, u bolesnika s difuznim astrocitomom niskoga stupnja malignosti (SZO st. II.) smještenim obostrano u talamičkom području sa širenjem u desni mezencefalon, kao i u bolesnika s IDH-wildtype glioblastomom (SZO st. IV.) desnog čeonog režnja s pomakom središnjih tvorba. Jatrogena lezija pripadajućeg elokventnog moždanog korteksa bila je minimalna, dok je neposredni poslijeoperacijski oporavak bio uspješan u svih bolesnika. Uzimajući u obzir preliminarne rezultate našega početnog iskustva, zaključujemo kako je robotom potpomognuta tumorska biopsija dokazano izvodljiva i primjerena metoda u kirurgiji gliomskih tumora mozga kojom se može poboljšati sigurnost i preciznost bez produljenja vremena operacije, a koja je podjednako učinkovita u usporedbi sa standardnom stereotaksijskom i manualnom biopsijom. Uporaba navedene metode omogućuje precizno uzorkovanje tumorskoga tkiva za patohistološku i imunohistokemijsku analizu na siguran i lak način, što doprinosi odabiru strategije liječenja i predviđanju ishoda različitih tipova gliomskih tumora mozga

Strategije u prevenciji komplikacija kirurškog liječenja gliomskih tumora mozga: analiza skupine slučajeva

Introduction: Brain glioma is the most common and lethal primary malignant intracranial tumor. Nonetheless, gross tumor resection remains the most successful treatment modality, which may prolong progression free survival of these patients. However, excessive surgery brings a danger of neurological, regional and systemic complications, which may be diminished/ avoided by better pre- and intra-operative care and by modern neurosurgical techniques. Aim: To analyze the incidence and type of peri- and post-operative complications in surgical brain glioma patients. Computing the results, advice on complication prevention was made. Methods: A single institution series of brain glioma patients operated on during a two-year period was analyzed. The incidence, type and time of complications were observed, as well as the patients’ gender and age, and the extent of tumor resection complications, dichotomized as peri- and post-operative variables, were correlated with investigated parameters to find out their possible association. Results: Transitory neurological deficit was the most common peri-operative complication. Seizures, meningitis, and permanent neurological deficit were commonly recorded among post operative complications. Conclusion: Patients’ gender and age, and the extent of tumor resection were not influential to the development of brain glioma complications. Aggressive surgery requires the avoidance of complications by cautious patient selection, multidisciplinary preoperative planning, and scrupulous neurosurgical technique augmented by up-to-date armamentarium.Uvod: Gliomi mozga najučestaliji su smrtonosni primarni intrakranijski tumori. Unatoč tomu, njihovo radikalno kirurško uklanjanje i nadalje ostaje najuspješnija metoda liječenja kojom se može usporiti napredovanje bolesti i donekle produljiti život ovakvih bolesnika. Međutim, agresivno kirurško liječenje može povećati opasnost nastanka neuroloških, regionalnih i sustavnih komplikacija, koje se može pokušati izbjeći boljom pripremom prije i tijekom operacije, kao i uporabom suvremenih neurokirurških tehnika. Cilj: Analizirati učestalost i vrstu perioperacijskih i poslijeoperacijskih komplikacija u kirurški liječenih bolesnika s gliomom mozga. Na temelju obrade rezultata, uspostaviti preporuke za sprječavanje nastanka komplikacija. Metode: Analizirana je skupina bolesnika operiranih zbog glioma mozga tijekom dvogodišnjeg razdoblja. Promatrana je učestalost i vrsta komplikacija, kao i vrijeme njihova nastanka. Također su zabilježeni podaci o dobi i spolu bolesnika te stupnju tumorske resekcije. Komplikacije su dihotomizirane kao perioperacijske i poslijeoperacijske varijable čija je moguća povezanost uspoređivana s istraživanim pokazateljima. Rezultati: Tranzitorni neurološki deficit bio je najučestalija perioperacijska komplikacija. Epileptički napadaj, meningitis i trajni neurološki ispad zabilježeni su kao najčešća poslijeoperacijska komplikacija. Zaključak: Spol i dob bolesnika, kao i stupanj tumorske resekcije nisu utjecali na nastanak komplikacija kirurškog liječenja glioma mozga, koje je moguće izbjeći pažljivim odabirom bolesnika, multidisciplinarnim predoperacijskim planiranjem i primjenom obzirne neurokirurške tehnike poduprte uporabom najsuvremenije operacijske opreme

Provedba specifičnoga neurokirurškog operacijskog postupnika u hitnih elektivnih i hitnih bolesnika tijekom pandemije bolesti COVID-19 u Hrvatskoj: institucijsko iskustvo

Introduction: The COVID-19 pandemic was declared on January 30, 2020. The disease has rapidly disseminated throughout Europe, reaching Croatia from late February onward, representing a great burden to the national health care system. Our institution’s capacity for emergency neurosurgery was adjusted to assure adequate degree of protection for both the patients and medical workforce. Separate COVID-19-free pathways were ensured, while regular operative program has been attuned to the existing epidemiological condition. Aim: To explain the implementation of neurosurgical protocol for urgent elective and emergency traumatic brain injury patients during the COVID-19 pandemic based on our institutional experience. Methods: The time of pandemic was divided into 3 separate two-month periods. Patients, who suffered a traumatic brain injury and were not tested for corona virus, were considered COVID positive and were included in the analysis investigating the type and severity of injury, period of hospital admission and surgery, methods of surgery, and outcome. Results: A series consisted of 16 patients who were tested for COVID-19 at hospital admission, and underwent urgent/emergency surgery before the test results became known. Surgery was performed according to the specifically designed operative COVID-19 protocol. Skull fracture and traumatic intracranial hemorrhage were mainly observed. Moderate injury was recorded less frequently, particularly during the lockdown, and post-lockdown summer. The majority of patients recuperated well, having good recovery. Conclusion: A specific operative protocol, employment of protective measures, and a separate operating theatre are mandatory for a safe and successful management of traumatic brain injury to evade transmission of the infection.Uvod: Pandemija bolesti COVID-19 proglašena je 30. siječnja 2020. Bolest se brzo proširila diljem Europe stigavši u Hrvatsku krajem veljače, što je predstavljalo veliko opterećenje nacionalnom zdravstvenom sustavu. Mogućnosti naše ustanove za pružanje hitnih neurokirurških usluga prilagođene su tako da osiguraju dostatan i podjednak stupanj zaštite bolesnika i medicinskog osoblja. Osigurani su nekontaminirani smještajni kapaciteti za COVID negativne bolesnike, a redoviti operacijski program prilagođen je trenutačnoj epidemiološkoj situaciji. Cilj: Na temelju našeg stečenog iskustva, objasniti primjenu neurokirurškoga operacijskog postupnika u hitnih elektivnih i hitnih bolesnika s traumatskom ozljedom mozga za tijekom pandemije bolesti COVID-19. Metode: Vrijeme trajanja pandemije podijeljeno je u tri dvomjesečna razdoblja. U istraživanje su uključeni oni bolesnici s traumatskom ozljedom mozga koji nisu bili testirani na koronavirus, pa su time smatrani COVID pozitivnima. Analizirani su sljedeći pokazatelji: vrsta i težina ozljede, razdoblje u kojem je bolesnik primljen u bolnicu i operiran te način i ishod kirurškog liječenja. Rezultati: Istraživanu skupinu činilo je 16 kirurški liječenih bolesnika testiranih na COVID-19 pri bolničkom primitku, koji su hitno operirani u skladu s posebno oblikovanim operacijskim postupnikom za COVID-19 prije nego što su rezultati testiranja postali poznati. Najčešće zabilježene vrste ozljede bile su prijelom lubanje i intrakranijsko krvarenje. Umjerena ozljeda mozga bila je po težini najmanje zastupljeni oblik ozljede, posebice za vrijeme trajanja zatvaranja i tijekom ljeta. U većine bolesnika zabilježen je dobar oporavak. Zaključak: Poseban operacijski postupnik, kao i primjena zaštitnih mjera u odvojenim operacijskim dvoranama, uvjet su sigurnog i uspješnog liječenja bolesnika s traumatskom ozljedom mozga kako bi se spriječilo širenje infekcije

Case-control Study of Risk Factors for Lumbar Intervertebral Disc Herniation in Croatian Island Populations

Aim: To investigate the risk factors for lumbar intervertebral disc herniation (L4/L5 or L5/S1) severe enough to require surgery of the lower spine among 9 isolated populations of Croatian islands and to evaluate predictive value, sensitivity, and specificity of a simple screening test based on the understanding of the risk factors in this population. Methods: In a sample of 1001 examinees from Croatian island populations, we identified all subjects who underwent surgery of the lower spine due to lumbar intervertebral disc herniation L4/L5 or L5/S1 and selected 4 controls matched by age, gender, and village of residence for each of them. Odds ratio was computed for the following variables: body mass index, occupation, intensity of physical labor at work, intensity of physical labor at home, smoking index, claudication index, self-assessed limitation in physical activity, level of education, socio-economic status, and family history of lumbar intervertebral disc herniation requiring surgery. Results: Comparison of 67 identified cases with 268 controls revealed the highest odds ratios (OR) for positive family history (OR 4.00; 95% confidence intervals [CI], 1.89-6.11, P<0.001), intensity of physical labor at work defined as “hard” (OR 2.94; 95% CI, 1.07-4.81, P<0.001), and body mass index of 25.7 or more (OR 2.77, 95% CI, 1.05-4.49, P=0.002). A simple screening test based on the presence of any two of these three criteria has 74% sensitivity and 82% specificity to detect persons who underwent lower spine surgery due to lumbar intervertebral disc herniation in the population aged 40 years or more. Conclusion: Occurrence of lumbar disk herniation severe enough to require surgery of the lower spine can be predicted using a very simple set of criteria. This type of screening could reduce the need for surgery in isolated communities through prevention within primary health care