Purpose of study

Cauda Equina Syndrome (CES) is a surgical emergency. With Physiotherapists increasingly taking on first-contact and spinal triage roles, screening for CES must be as thorough and effective as possible. This study explores whether Physiotherapists are asking the correct questions, in the correct way and investigates their experiences when screening for this serious condition.

Background

Previous surgery is known to increase the risk of complications during spine surgery, but few studies have quantified the dose-response effect using multivariate models to account for confounders. We quantified the effect of the number of prior spine surgeries on perioperative complications in patients undergoing surgery for lumbar degenerative disorders.

To determine presenting features, treatment modalities and associated outcome following treatment of spinal dural arteriovenous fistulas in a tertiary centre.

Retrospective cohort study of patients with SDAVF assessed at a single tertiary referral centre, between 1999 and 2009. Medical records were used to identify intervention type, pre- and post-intervention Aminoff-Logue disability score (ALDS), recurrence rate, follow-up time and discharge status. Statistical analysis was performed using Wilcoxon signed rank.

26 patients were identified with 23 receiving intervention. Two were unavailable for follow up. Endovascular embolization was performed successfully in 13 patients, recurrence occurred in 6 of these, 3 of which were subsequently treated surgically. Surgery was the initial treatment for 10 patients due to either unsuccessful embolization attempt or proximity of the fistula to spinal artery feeders; only 1 of these recurred. ALDS-gait reduced (improved) by a mean of 0.33 points following intervention but this was not statistically significant (P=0.0645). There was negligible change in micturition and bowel ALDS. Improvement in ALDS was greater in patients treated with surgery first and also in patients whose fistula did not recur. Mean follow-up was 38 months with 56% of working age patients returning to work.

Both embolisation and surgery achieved the primary aim of reducing disease progression, leading to an improved ALDS. Outcome was superior if initially treated surgically and recurrence occurred more frequently in patients treated endovascularly. The small number of patients in our cohort emphasise the need for further studies into this group of patients.

Purpose: To compare the postoperative cerebrospinal fluid (CSF) leak rate in two consecutive cohorts of patients undergoing intradural spinal tumour excision with 2 different dural closure techniques.

Methods and Result: Data for this study was collected retrospectively from case notes. Between January 1994 and December 2001 forty seven intradural (thirty two extramedullary and fifteen intramedullary) spinal tumour excisions were performed. The dural incision was closed using vicryl 6.0. Operations of nine patients in this group (19 %) were complicated by CSF leak. From 2002 onwards the closure method for dural incisions was changed to single layer continuous prolene 6.0 suture in conjunction with a check valsalva manoeuvre prior to closure of wound incision in an attempt to reduce the incidence of CSF leak. Fifty three (thirty three extramedullary and twenty intramedullary) patients underwent intradural spinal tumour excision between January 2002 and October 2008. Three (5.7%) patients developed cerebrospinal fluid leak and one (1.9%) patient developed a pseudomeningocele post operatively. All four patients were subsequently managed with a lumbar drain. In both groups of patients good exposure of the proximal and distal aspect was achieved prior to dural closure. Statistical analysis comparing the outcome of both groups was performed using Fisher’s exact test – p values calculated were 0.0381 (one-tailed) and 0.0618 (two-tailed).

Conclusion: Single layer continuous prolene suture in conjunction with a check valsalva manoeuvre is superior to vicryl alone for the closure of the dura post intradural spinal tumour excision. The reduction in the leak rate may be due to the valsalva manoeuvre itself rather than the different suture material. Along with good exposure to the proximal and distal aspect of the incision we feel that this can reduce post operative cerebrospinal fluid leak in intradural spinal tumour excision operations.

Study Design: Retrospective case review.

Objective: To assess factors influencing functional outcome, recurrence and survival following surgery for intradural spinal tumours

Subjects: Between January 1994 and December 2001, 115 patients had surgery for intradural spinal tumours: 76 extramedullary (48 male, mean age 54 years): 39 intramedullary (22 male, mean age 44 years).

Outcome measures and analysis: Functional outcome: Frankel scale. Recurrence: new symptoms with tumour growth. Death: post-operative or disease progression. Univariate and multivariate analysis was performed to identify features predicting post-operative functionally useful Frankel scale (4–5), recurrence and survival.

Results: 64 extramedullary tumours were excised, 12 debulked. 21 intramedullary tumours were excised, 13 debulked, 5 biopsied. Commonest tumours: meningioma, schwannoma, ependymoma, astrocytoma. 14 intramedullary tumours received radiotherapy. Mean follow-up was 45 months (range 4–117 months). There were 12 recurrent tumours. There were 8 deaths (2 post-operative, 6 disease-progression). 23% had complications (CSF leak, meningitis, wound infection/dehiscence). Functionally 96% of extramedullary tumours were unchanged/improved, 82% of intramedullary tumours were unchanged/improved. Multivariate analysis demonstrated that recurrence (Odds Ratio 28.2; 95% Confidence Interval 2.3–342.4) was the only significant factor influencing survival for intramedullary tumours. No factors investigated predicted functional outcome or recurrence in intramedullary tumours. No factors predicted any outcome in extramedullary tumours.

Conclusions: Our results were comparable to other studies. The two cases of MRSA meningitis (one death, one paralysis) reflect the growing problem of MRSA in neurosurgical units. Recurrence predicted poor survival in intramedullary tumours.

Study Design: Retrospective case review

Summary of Background Data: The Chiari malformation is a condition characterised by herniation of the posterior fossa contents below the level of the foramen magnum.

Objectives: To present the long term outcome and complication rate following hindbrain decompression for this condition.

Methods: We retrospectively analysed the results of patients who underwent hind brain decompression between 1994 and 2003. There were 70 cases with a mean age of 32 years. Follow up was carried out with clinical examination and repeat MRI scans. The mean follow up was 4.7 years. Thirty-six patients had associated syringomyelia. Patients underwent hind brain decompression through a small posterior fossa craniectomy, opening of the foramen magnum with or without removal of arch of C1.

Results: One patient died and one had a stroke which resolved except for mild facial weakness. Long term follow up revealed that 50% of the patients were asymptomatic following surgery and another 26% had marked improvement in their symptoms. One patient deteriorated post-operatively and the remainder (23%) had unchanged condition. Of the patients presenting with scoliosis 67% had no further progression in their curve.

Conclusion: This is the largest series presented from a single centre with pre- and postoperative MRI fol1ow up. Our results compare favourably with previously published literature.