Neurosurgery

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Cervical spondylotic myelopathy : a prospective study of outcome after surgery.
(2014) Harrichandparsad, Rohen.; Bhigjee, Ahmed Iqbal.
Background: The natural history of cervical spondylotic myelopathy (CSM) is mixed. Surgical decompression is offered to patients with the aim of improving functional outcome. In some patients with chronic myelopathy, the aim is to prevent further deterioration. Despite surgical decompression, the functional status of some patients may deteriorate. CSM thus has a variable prognosis and it is difficult to predict neurological recovery after surgical decompression. There is a lack of consistency in the currently available literature regarding post-operative outcomes. Objectives: 1. To prospectively assess and compare the pre and post-operative clinical and functional status of patients with CSM using the modified Japanese Orthopaedic Association (mJOA) scores and the modified Myelopathy Disability Index (mMDI) scores at baseline, 3, 6 and 12 months post surgery. 2. To prospectively assess the natural history of patients with CSM who did not undergo surgery using the mJOA and mMDI scores at baseline, 3, 6 and 12 months. 3. To identify factors which influence outcome. Materials and Methods: All eligible patients in whom a diagnosis of CSM was made from 01 January 2011 to 31 December 2012 were evaluated. A neurologist (independent of the surgical team) performed baseline mJOA and mMDI scores. This was repeated at 3, 6, 12 and in some patients 24 months after surgery. Patients who refused or were not fit for surgery were also evaluated with mJOA and mMDI scores at baseline, 3, 6, 12 and in some, 24 months later by a 8 of 113 neurologist. These patients formed the natural history group. A minimum of 12 months follow up was obtained in all patients with a total of 540 months of follow up. The following factors were evaluated: age at presentation; gender; cigarette smoking; duration of symptoms; HIV status; presence of T2WI cord signal cord abnormality on MRI; number of cervical disc levels operated upon / affected; surgical approach used and post-operative complications. We also assessed recovery / progression of individual aspects of the mJOA: upper limb; lower limb; sensation and sphincters in both groups. Severity of CSM was assessed as mild if baseline mJOA score was ≥ 12 and moderate-severe if baseline mJOA score was < 12. Results: Surgery was associated with significant improvement in clinical recovery as assessed by mJOA scores at 3, 6 and 12 months post-operatively with p-values of 0.0002, 0.0001 and 0.0067 respectively. Upper limb function improved after surgery as assessed by the upper limb component of the mJOA score at 3, 6 and 12 months with p-values of 0.0096, 0.0030 and 0.0459 respectively. Lower limb function also improved significantly as assessed by the lower limb recovery scores at 3, 6 and 12 months with p-values of 0.0256, 0.0011 and 0.0107 respectively. Sensation and sphincter function did not improve after surgery. There was significant functional recovery as assessed by mMDI scores at 3, 6 and 12 months after surgery with p values of 0.0001, 0.0001 and 0.0023 respectively. There was no significant clinical or functional improvement in the non-surgical group when looking at overall mJOA and mMDI scores at 3, 6 and 12 months. Furthermore, there was no improvement in upper limb, lower limb, sensation or sphincter function in the non-surgical group as assessed by individual components of the mJOA score at 3, 6 and 12 months. 9 of 113 When assessing factors that could predict outcome we found that the patients’ age, gender, smoking status and duration of symptoms had no effect on outcome. The presence of T2WI cord signal abnormality on baseline MRI was associated with more severe CSM at presentation (p=0.036), but this did not affect outcome. Those with moderate-severe CSM at baseline had a better recovery at 12 months (p=0.025). The occurrence of intra-operative complications resulted in a worse outcome with both clinical and functional recovery rates worse at 3 months. Clinical recovery as assessed by mJOA score normalised at 12 months (p=0.235), but these patients were still functionally impaired as assessed by mMDI at 12 months (p=0.005). Conclusions: Patients with CSM benefit from surgical decompression regardless of baseline severity, with significant clinical and functional improvement noted at least 12 months post-operatively. Upper and lower limb function improves significantly, but sensation and sphincter function do not recover. The occurrence of intra-operative complications results in a worse outcome and this negative effect is still seen 12 months post-operatively. Patients who are managed non-operatively do not show significant improvement and 42% have some clinical deterioration at 12 months. Identification of patients with mild CSM (mJOA score ≥ 12) who can be safely managed non-operatively remains a challenge, however it appears that this is a reasonable option in patients with mild CSM and no T2WI cord signal abnormality on MRI.
An exploratory analysis of alternative approaches in distance learning programmes for nurses.
(1995) Kortenbout, Wilhelmina Petronella.; Uys, Leana Ria.
An exploratory retrospective study conducted on two differing educational programmes, both of which were for the diploma in community health nursing. The aims of the study were: i) To propose a conceptual framework in order to compare distance learning programmes in community health nursing. ii) To describe and compare two such programmes based on this framework: one content-based and the other community / problem based. The research design used case study methodology, after the development of a model for the education of professional nurses which was derived from literature. The constructs of the model were used as propositions in a case study protocol. The four constructs were each made up of two elements and each element consisted of the poles of a continuum by which that feature in a programme could be identified. The constructs were: a) The Conceptual Programme which included the elements of Base and Structure; Base being either institution or community and structure either content or process. b) The Student with elements of Professional or Personal attributes. Professional attributes were either empowered or disempowered and personal either self directing or passive. c) The Context which had Components and Relationships as elements. The former comprised either limited formal health services or all-embracing health related sectors, whilst the latter specified relationships would either be seen as linkages with unilateral formal communications or partnerships where collegial relations impacted on both parties involved. d) The Concrete Resources included both human and material resources. Human resources were either limited or additional and material either limited or varied. Application of the Conceptual Programme analysis demonstrated that programme A was institution and content based whilst programme B was community / problem (process) based. Programme documentation and student assignment and projects were analyzed in terms of the remaining three constructs. An interview with a tutor for each programme followed after they had read the case reports. A third interview was then held with a key person who had overseen both programmes and read case and interview reports in order to validate both content and the use of the model as framework for analysis. The following trends emerged: i) The content programme was associated with more disempowered and passive students as those were defined in this study. ii) The content programme also used more limited formal health sector settings for learning and in this linkage type relationships dominated although three instances of partnerships did occur, and some community based groups were used by students. iii) The content programme used one tutor per contact session for lectures with students and, cost, in 1991 currency, R150 per student to deliver. iv) The community / problem based programme showed a stronger trend to empowered and self directing students with several clear instances being documented. v) There was a greater variety of settings used for learning in this programme. vi) Several instances of partnership relationships occurred despite the limited contact time between students and communities or health settings. vii) The community / problem-based programme needed two facilitators per contact session at a cost of R1130 (1991) as small group discussions were the main strategy for learning. viii) Student evaluations of both programmes showed that students viewed them in much the same way despite the differences that were found. This indicates that student evaluations on their own provided insufficient evidence about the nature of a programme. ix) The community / problem based programme cost about 20% more to deliver than the content programme out of a total expenditure of R186 000 (1991 value). x) The model was revised to collapse professional and personal attributes into one element and to add another element 'metacognition' to the construct student. 'Access' was also recommended as an additional construct with elements of barriers and supports. This new model needs to be tested and reviewed by peers. The revised model for the education of professional nurses could be a useful yardstick for evaluating existing educational programmes, selecting newly proposed programmes and guiding policy formation.
Extradural spinal mass lesions in HIV sero-positive adults.
(2017) Gonya, Sonwabile.; Enicker, Basil Claude.; Aldous, Colleen Michelle.
Abstract available in PDF file.
Management problems in aneurysmal subarachnoid haemorrhage.
(1988) Golek, Jerzy.; van Dellen, James Rikus.; Bullock, Malcolm Ross.; Kennedy, W. F. C.
A retrospective review was made of the case records, angiograms and computed tomography (CT) relating to a total of 263 patients with subarachnoid haemorrhage (SAH) due to ruptured berry aneurysms who were admitted to the Department of Neurosurgery, Wentworth Hospital during the four years 1983-1986. The part of the thesis concerning vasospasm (VS) includes two independent studies on calcium blocker Nimodipine (NO) in the prevention and treatment of VS done by the author. The aim of the thesis is to analyse the management problems of aneurysmal SAH, and investigate factors influencing outcome in order to establish the best possible management policy. The results are discussed and related to the recent data from literature. The main factors influencing outcome were: clinical condition of the patient, the timing of admission and surgery, hypertension and hyperglycaemia on admission, presence of vasospasm and related CT appearance of a thick layer of blood or clot in subarachnoid haemorrhage (CT-Fisher 3). The systemic administration of the calcium blocker nimodipine did not reverse or prevent delayed vasospasm and caused serious adverse effects i.e. hypotension and hyperglycaemia. The results of the thesis suggest a change in management policy and timing of surgery should depend. on clinical condition of the patient on admission (Hunt & Hess grading)(HH I/II grade (HH as possible regardless of timing of admission and results of radiological investigations (CT, angiography). Early surgery (1-3 days) should be the aim of the effort including referral, transport and hospital organisation. III grade (HH surgery should be performed soon after day 10 post-SAH. Particular attention should be paid to the careful preparation and selection of patients for angiography. IV/V grade (HH in specialised units as s000n as possible, preferably neurological or neurosurgical wards, and operated on as soon as their grade improves or, in selected (by surgeon, radiologist and anaesthetist) cases by delayed surgery ( after day 10 post-SAH).
Retrospective chart review of surgical management of compound elevated skull fractures.
(2019) Maharaj, Prashanth.; Enicker, Basil Claude.
Background: Traumatic skull fractures have been traditionally classified into those that involve the base or vault with distinct entities linear or depressed. Compound elevated skull fracture is a newer entity with scanty reports in the literature. Objective: To describe the clinical presentation, neuro-radiology findings by development of a classification system, medical and surgical management, and complications of patients with compound elevated skull fractures at a busy Neurosurgical Department in Durban, South Africa. Methods: Medical records of consecutive patients admitted from January 2005 to December 2018 with compound elevated skull fractures at Inkosi Albert Luthuli Central Hospital were retrospectively evaluated. Data was analysed for demographics, clinical presentation, mechanisms of injury, neuro-radiology findings, management and outcomes. Neuro-radiological images were used to develop a classification system. Results: Eighteen patients were included in this series with a median age of 28 years, median admission Glasgow Coma Scale was 12. Ten patients presented with focal neurological deficits which included hemiparesis [n=8, 44%] and unilateral afferent pupil deficit [n=2, 11%]. Intra-cerebral haematoma was the most common associated neuro-radiological finding [n=10, 55%] followed by acute extradural haematoma [n=4, 22%]. Three distinct neuro-radiological subtypes were identified. All patients underwent surgical debridement and of which 11 [61%] required duroplasty and 10[55%] re-placement of elevated bone flap. Septic complications included meningitis [n=5, 27%], brain abscess [2, 11%] and surgical site infection [n=1, 5%]. Seventeen patients had favourable outcomes at discharge (Glasgow Outcome Scale 4 or 5). Conclusion: Compound elevated skull fracture is an additional subtype of skull vault fracture. Use of the originally developed classification system is important and infrequently described type of skull fracture. We recommend early surgical intervention which includes careful management of dura and elevated bone fragment reduces morbidity from septic complications.

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