Neurosurgery Procedures Research Articles

A Retrospective Cohort Study Evaluating the Use of the Modified Early Warning Score to Improve Outcome Prediction in Neurosurgical Patients.

IntroductionThe modified early warning score (mEWS) has been used to identify decompensating patients in critical care settings, potentially leading to better outcomes and safer, more cost-effective patient care. We examined whether the admission or maximum mEWS of neurosurgical patients was associated with outcomes and total patient costs across neurosurgical procedures.MethodsThis retrospective cohort study included all patients hospitalized at a quaternary care hospital for neurosurgery procedures during 2019. mEWS were automatically generated during a patient’s hospitalization from data available in the electronic medical record. Primary and secondary outcome measures were the first mEWS at admission, maximum mEWS during hospitalization, length of stay (LOS), discharge disposition, mortality, cost of hospitalization, and patient biomarkers (i.e., white blood cell count, erythrocyte sedimentation rate, C-reactive protein, and procalcitonin).ResultsIn 1,408 patients evaluated, a mean first mEWS of 0.5 ± 0.9 (median: 0) and maximum mEWS of 2.6 ± 1.4 (median: 2) were observed. The maximum mEWS was achieved on average one day (median = 0 days) after admission and correlated with other biomarkers (p < 0.0001). Scores correlated with continuous outcomes (i.e., LOS and cost) distinctly based on disease types. Multivariate analysis showed that the maximum mEWS was associated with longer stay (OR = 1.8; 95% CI = 1.6-1.96, p = 0.0001), worse disposition (OR = 0.82, 95% CI = 0.71-0.95, p = 0.0001), higher mortality (OR = 1.7; 95% CI = 1.3-2.1, p = 0.0001), and greater cost (OR = 1.2, 95% CI = 1.1-1.3, p = 0.001). Machine learning algorithms suggested that logistic regression, naïve Bayes, and neural networks were most predictive of outcomes.ConclusionmEWS was associated with outcomes in neurosurgical patients and may be clinically useful. The composite score could be integrated with other clinical factors and was associated with LOS, discharge disposition, mortality, and patient cost. mEWS also could be used early during a patient's admission to stratify risk. Increase in mEWS scores correlated with the outcome to a different degree in distinct patient/disease types. These results show the potential of the mEWS to predict outcomes in neurosurgical patients and suggest that it could be incorporated into clinical decision-making and/or monitoring of neurosurgical patients during admission. However, further studies and refinement of mEWS are needed to better integrate it into patient care.

Swallowing Disorders in Patients with Chiari Malformation Type I After Decompression Neurosurgery

The present study aimed to investigate postoperative swallowing disorders in patients diagnosed with CM I after decompression neurosurgery. We selected 54 patients after decompression neurosurgery procedure for CM I from January 2017 to December 2019. We evaluated the speech-language assessment (CSLSA) 24 h after post-surgical extubation. CSLSA observed aspects of posture, sensitivity, tone, and extraoral and intraoral mobility of the FAO and visualizing the functions of breathing, phonation, articulation, chewing, and swallowing. We correlated the severity of the dysphagia and the presence of associated malformations in the CM I patients. In our study, 39 patients were female (mean age 41.3 ± 47.1 years). Thirty-seven patients had associated malformations (p = 0.0243): 21 patients syringomyelia, 11 basilar invagination, and 5 syringomyelia and basilar invagination. Dysphagia was present in 37 of the cases (68.5%; p = 0.0016). Dysphonia in 13 (24.1%; p = 0.4785) and dysarthria in 3 (5.6%; p = 0.0042). We observed in the CSLSA: orofacial hypomobility (29 patients — 53.7%; p = 0.0204), orofacial hyposensitivity (26 patients — 48.1%; p = 0.3023), reduced GAG reflex (24 patients — 44.5%; p = 0.1041), ineffective cough (19 patients — 35.2%; p = 0.0022), ineffective saliva swallowing (18 patients — 33.3%; p = 0.0396), dyspnea (13 patients — 24.1%; p = 0.4785), orofacial hypotonia (11 patients — 20.4%; p = 0.0004), altered cervical auscultation (10 patients — 18.5%; p = 0.0003), and dysarthria (3 patients — 9.3%; p = 0.0042). The presence of associated malformations significantly influenced the appearance of swallowing disorders, the severity of oropharyngeal dysphagia, the post-surgical complications (17 patients — 31.5%; p < 0.001), and the clinical outcomes (p = 0.0029) of patients with CM type I. Decompressive neurosurgery for CM I had low rates of post-surgical complications overall. However, there was a high incidence of dysphagia. The presence of associated malformations is related with poorer prognosis and greater severity of oropharyngeal dysphagia in patients with CM I.

High-definition two-dimension video telescope operating monitor-assisted brain and spinal surgery in pediatrics: is it an acceptable substitute for microscopic surgery?

Vision and ergonomics are crucial variables for successful outcomes during neurosurgery procedures. Two-dimension video telescope operating monitor (VITOM) exoscope has emerged as an alternative, which is cheaper than microscope. The aim of this study is to evaluate the clinical utility of 2D VITOM and to compare its merits and demerits with respect to microscope. VITOM 2D (Karl Storz, Germany) was used in 9 cranial and 5 spinal pediatric cases. While KINEVO operative microscope (Carl Zeiss, Germany) was used in 12 cranial and 6 spinal pediatric patients. All surgeries were performed by single senior neurosurgeon. The author's experience and opinions, as well as qualitative data, were analyzed. A comparison was made on image quality, illumination, field of view, and magnification of the operative field and ergonomics. Seven out of 9 cranial pediatric cases were switched from VITOM 2D to operative microscope due to low-image definition in depth of cranial cavity. Poor visualization of bleeding source in surgical field was another major drawback. Two cranial cases in which exoscope were used exclusively, included superficial tumors. In all 5 spinal cases, VITOM 2D was successfully used without any major difficulty. The exoscope's advantages were observed in ergonomics and ease in switching to naked eyes, but the microscope's field of view, illumination, magnification, and user-friendliness was considered superior. 2D-VITOM is best suited for spinal and superficial cranial tumors. However, a lot of modifications are to be done especially in optics to become a substitute for operative microscope.

Machine learning-based prediction of emergency neurosurgery within 24 h after moderate to severe traumatic brain injury

BackgroundRapid referral of traumatic brain injury (TBI) patients requiring emergency neurosurgery to a specialized trauma center can significantly reduce morbidity and mortality. Currently, no model has been reported to predict the need for acute neurosurgery in severe to moderate TBI patients. This study aims to evaluate the performance of Machine Learning-based models to establish to predict the need for neurosurgery procedure within 24 h after moderate to severe TBI.MethodsRetrospective multicenter cohort study using data from a national trauma registry (Traumabase®) from November 2011 to December 2020. Inclusion criteria correspond to patients over 18 years old with moderate or severe TBI (Glasgow coma score ≤ 12) during prehospital assessment. Patients who died within the first 24 h after hospital admission and secondary transfers were excluded. The population was divided into a train set (80% of patients) and a test set (20% of patients). Several approaches were used to define the best prognostic model (linear nearest neighbor or ensemble model). The Shapley Value was used to identify the most relevant pre-hospital variables for prediction.Results2159 patients were included in the study. 914 patients (42%) required neurosurgical intervention within 24 h. The population was predominantly male (77%), young (median age 35 years [IQR 24–52]) with severe head injury (median GCS 6 [3–9]). Based on the evaluation of the predictive model on the test set, the logistic regression model had an AUC of 0.76. The best predictive model was obtained with the CatBoost technique (AUC 0.81). According to the Shapley values method, the most predictive variables in the CatBoost were a low initial Glasgow coma score, the regression of pupillary abnormality after osmotherapy, a high blood pressure and a low heart rate.ConclusionMachine learning-based models could predict the need for emergency neurosurgery within 24 h after moderate and severe head injury. Potential clinical benefits of such models as a decision-making tool deserve further assessment. The performance in real-life setting and the impact on clinical decision-making of the model requires workflow integration and prospective assessment.

Delayed HSV-1 Encephalitis Relapse After Epilepsy Surgery: A Case Report

BACKGROUND AND IMPORTANCE: Herpes simplex virus 1 encephalitis (HSVE) can be a rare postoperative complication after neurosurgery. We present the case of a patient with postoperative, twice recurrent HSVE after 20 years, the longest latency period reported after neurosurgery. CLINICAL PRESENTATION: A 21-year-old man with a history of HSVE at 13 months and intractable epilepsy presented for surgical resection of seizure focus. The patient underwent left temporal craniotomy and resection of left temporal encephalomalacia. Five days after discharge, the patient presented with fever and headache and was found to have herpes simplex virus 1 (HSV-1)–positive cerebral spinal fluid. The infection was treated with acyclovir, with subsequent symptomatic improvement. Six weeks later the patient represented with recurrent symptoms and HSV-1–positive cerebral spinal fluid. This recurrence was treated with a prolonged course of acyclovir, followed by suppressive valacyclovir therapy, resulting in symptomatic improvement. CONCLUSION: HSV-1 encephalitis is a rare but previously reported complication after neurosurgery procedures. In patients with relapse of HSVE, the latency period can range from weeks to years after primary infection, and multiple relapses are rare. We present the case of a patient with twice recurrent, postoperative HSV-1 encephalitis 20 years after initial infection. We aim to emphasize that HSV status should be considered during treatment planning in patients with a history of HSVE being treated for HSV-related illnesses, and HSVE should remain on the differential in these patients when presenting with fever and neurological symptoms after surgery, regardless of time since initial infection.

Outcomes of Cranioplasty after Craniectomy

Objective: Craniectomy is a widely used procedure in neurosurgery that results in more cranioplasties to repair skull defects. The complication rate after cranioplasties seems to be higher than elective craniotomies so this study was conducted to determine the outcome of cranioplasty after craniectomy.&#x0D; Materials &amp; Methods: The patients included in this study had craniectomy and cranioplasty for any indication. Patients included had variables, such as age, sex, underlying pathology, craniectomy and cranioplasty dates, the material used for cranioplasty (autologous bone or methyl methacrylate), and methods of cranioplasty flap fixation (sutures or titanium plates and screws) follow up period and complications.&#x0D; Results: It was concluded that patients in the age group of 41 – 60 years (5 cases), males (7 cases), cranioplasty performed after 6 months (5cases) with autologous bone graft (8cases) were associated with more complications.&#x0D; Conclusion: The overall rate of complications associated with cranioplasties is not negligible, however, early cranioplasty in young patients with the use of polymethyl methacrylate may be associated with less complication rate.&#x0D; Keywords: Decompressive, Craniectomy, Cranioplasty, Autologous, Polymethyl Methacrylate

Frailty Assessment in the Emergency Department for Patients ≥80Years Undergoing Urgent Major Surgical Procedures.

To evaluate, in a cohort of adults ≥80years old, the frailty status at the emergency department (ED) admission, for the in-hospital death risk stratification of patients needing major surgical procedures. Single-center prospective observational cohort study. The study was conducted in the ED of a teaching hospital. We enrolled all patients ≥80years old consecutively admitted to the ED for conditions requiring urgent surgical procedures, between 2018 and2021. Clinical variables and frailty status assessed in the ED were evaluated for the association with all-cause in-hospital death. The parameters evaluated were frailty [assessed by the Clinical Frailty Scale (CFS)], comorbidities, physiological parameters, type of surgery needed, laboratory values at admission. Cox regression analysis was used to identify independent risk factors for poor outcomes. The study enrolled 1039 patients aged ≥80years [median age 85years (interquartile range 82-89); 445 males (42.8%)]. Overall, 127 patients (12.2%) were classified as nonfrail (CFS score 1-3), 722 (69.5%) as mild frail (CFS score 4-6), and 190 (18.3%) as frail (CFS score 7-9). The covariate-adjusted analysis revealed that severe frailty [hazard ratio (HR) 12.55, 95% CI 2.96-53.21, P= .016], ≥3 comorbidities (HR 2.08, 95% CI 1.31-3.31, P= .002), shock at ED presentation (HR 3.58, 95% CI 2.16-5.92, P < .001), anemia (HR 1.88, 95% CI 1.17-3.04, P= .009), and neurosurgery procedures (HR 3.97, 95% CI 1.98-7.96, P < .001) were independent risk factors for in-hospital death. In patients aged ≥80years undergoing urgent surgical procedures, the evaluation of functional status in the ED could predict the risk of in-hospital death. Frail patients have an increased risk of death and major complications, whereas those with mild frailty have a similar prognosis compared with the more fit ones. Nonsurgical management should be considered in the case of severely frail and comorbid patients aged ≥80years needing neurosurgery or abdominal surgery.

Length of preoperative hospital stay is the dominating risk factor for surgical site infection in neurosurgery: A cohort data-driven analysis.

Background: The number of days of preoperative hospital stay (PHS) is a modifiable variable that has shown contradictory surgical site infection (SSI) risk factor results in neurosurgery. We sought to pinpoint the day of PHS length related with a marked increase of risk of SSI.Methods: From a tertiary teaching hospital, January 2015–December 2017, prospectively collected nonpercutaneous neurosurgery procedures with standard antibiotic prophylaxis and 1-year follow-up were evaluated. SSI risk factors were assessed through multiple logistic regression models with different thresholds of PHS.Results: A total of 1012 procedures were included in the study. Incidence of SSI was 4.4%. The median PHS was higher in those with SSI than in those without (1 day, interquartile range [IQR]: 7 vs. 0 days, IQR: 1, respectively, P = 0.002). By the amount of six days of PHS, this exposure risk past the threshold of significance for impact on wound infection (OR 2.8; CI 1.23–6.39, P = 0.014). Operative time past 4 h (OR 2.11; CI 1.12-3.98; P = 0.021), and in some models, previous surgery at same admission were also identified by multivariate analysis as increasing postoperative SSI risk.Conclusion: The gradual increase of the SSI OR associated with longer PHS days was the highest risk factor of SSI in our cohort of patients. Studies directed to reduce this complication should consider the PHS.

A Pilot Quality Improvement Project to Reduce Intraoperative MRI Hypothermia in Neurosurgical Patients.

Introduction:Intraoperative hypothermia increases patient morbidity, including bleeding and infection risk. Neurosurgical intraoperative magnetic resonance imaging (iMRI) can lead to hypothermia from patient exposure and low ambient temperature in the MRI suite. This quality improvement project aimed to reduce the risk of hypothermia during pediatric neurosurgery laser ablation procedures with iMRI. The primary aim was to increase the mean lowest core temperature in pediatric patients with epilepsy during iMRI procedures by 1 °C from a baseline mean lowest core temperature of 34.2 ± 1.2 °C within 10 months and sustain for 10 months.Methods:This report is a single-institution quality improvement project from March 2019 to June 2021, with 21 patients treated at a pediatric hospital. After identifying key drivers, temperature-warming interventions were instituted to decrease hypothermia among patients undergoing iMRI during neurosurgery procedures. A multidisciplinary team of physicians, nurses, and MRI technologists convened for huddles before each case. Interventions included prewarmed operating rooms (ORs), blanket coverings, MRI table and room; forced-air blanket warming, temperature monitoring in the OR and iMRI environments; and the MRI fan turned off.Results:Data were analyzed for five patients before and nine patients after the institution of the temperature-warming elements. The sustainment period included 15 patients. The mean lowest intraoperative temperature rose from 34.2 ± 1.3 °C in the preintervention period to 35.5 ± 0.6 °C in sustainment (P = 0.004).Conclusion:Hybrid OR and MRI procedures increase hypothermia risk, which increases patient morbidity. Implementation of a multidisciplinary, multi-item strategy for patient warming mitigates the risk.

Understanding the Natural History of Postoperative Pain and Patient-Reported Opioid Consumption After Elective Spine and Nerve Surgeries With an Automated Text Messaging System.

There is a gap in understanding how to ensure opioid stewardship while managing postoperative neurosurgical pain. To describe self-reported opioid consumption and pain intensity after common neurosurgery procedures gathered using an automated text messaging system. A prospective, observational study was performed at a large, urban academic health system in Pennsylvania. Adult patients (≥ 18 years), who underwent surgeries between October 2019 and May 2020, were consented. Data on postoperative pain intensity and patient-reported opioid consumption were collected prospectively for 3 months. We analyzed the association between the quantity of opioids prescribed and consumed. A total of 517 patients were enrolled. The median pain intensity at discharge was 5 out of a maximum of pain score of 10 and was highest after thoracolumbar fusion (median: 6, interquartile range [IQR]: 4-7). During the follow-up period, patients were prescribed a median of 40 tablets of 5-mg oxycodone equivalent pills (IQR: 28-40) and reported taking a median of 28 tablet equivalents (IQR: 17-40). Responders who were opioid-naive vs opioid-tolerant took a similar median number of opioid pills postoperatively (28 [IQR: 17-40] vs 27.5 [17.5-40], respectively). There was a statistically significant positive correlation between the quantity of opioids prescribed and used during the 3-month follow-up (Pearson R = 0.85, 95% CI [0.80-0.89], P < .001). The correlation was stronger among patients who were discharged to a higher level of care. Using real-time, patient-centered pain assessment and opioid consumption data will allow for the development of evidence-based opioid prescribing guidelines after spinal and nerve surgery.

Nursing planning in complex pediatric neurosurgery procedures in a reference surgery center

Surgical Centers are essential and extremely complex sectors in health institutions, where the teams that compose them must act together so that the main objectives are achieved: that is, the patients' surgeries happen in the best possible way, with the minimization of damages and welcoming patients and their families. The need for a multidisciplinary approach is intensified in surgeries with unique specificities, such as pediatric neurosurgeries, where problems are anticipated and interventions are performed before patients are harmed. The article is an experience report of the activities of the Nurse at the Surgical Center of a Large University Hospital in the interior of the state of São Paulo related to the planning and execution of pediatric neurosurgery procedures. The results include the description of direct and indirect care activities in nursing care planning, the nursing process, the main nursing diagnoses found in pediatric neurosurgery patients.

Analysis of a Novel Entry Point for Freehand Ventriculostomy Using Computerized Tomography Scans.

BackgroundExternal ventricular drain (EVD) placement is one of the most common procedures in neurosurgery. Neurosurgeons generally prefer to access the ventricles via Kocher’s point since it is the most common point of entry to this area; however, this point is used to describe different anatomic landmarks and is not well-defined.ObjectiveThe present study aims to describe and provide an anatomical assessment of a novel ventriculostomy access point developed by the authors using computerized tomography (CT) scans performed on 100 patients.Materials and methodsData were collected from 100 randomly selected patients with normal ventricular anatomy found on their 1.0 mm-slice CT scans performed at the Burdenko Neurosurgical Center from March 2019 to June 2021. The CT inclusion criteria were: CT slices < or = to 1 mm and absence of brain herniation. Patients with brain mass lesions, severe brain edema, and pneumocephalus were excluded. Age, gender, and ventricular size were not exclusion criteria.ResultsThe mean patient age was 43.58 years (range 4-73), with 50 men and 50 women. The mean Evan’s index was 25.7 % (SD=4.38 %, range 10.2-41.0 %). No differences were found between the angles of EVD placement on either side (89.50±1.22 degrees on the right and 89.60±1.14 degrees on the left). Hence, nearly all EVD cases had been placed perpendicularly to the skull surface at a pinpoint location.ConclusionThe proposed point of successful ventriculostomy placement in this study was 3 cm from the bregma along the coronal suture. The angle of EVD placement was approximately 90 degrees in almost all patients and was independent of the patient’s age and the side of the head that was entered. Little correlation was found between the value of the entry angle and Evan’s index. The point is simply identifiable, and its entry is easily accessible in practice.

Incidence of emergency neurosurgical TBI procedures: a population-based study

BackgroundThe rates of emergency neurosurgery in traumatic brain injury (TBI) patients vary between populations and trauma centers. In planning acute TBI treatment, knowledge about rates and incidence of emergency neurosurgery at the population level is of importance for organization and planning of specialized health care services. This study aimed to present incidence rates and patient characteristics for the most common TBI-related emergency neurosurgical procedures.MethodsOslo University Hospital is the only trauma center with neurosurgical services in Southeast Norway, which has a population of 3 million. We extracted prospectively collected registry data from the Oslo TBI Registry – Neurosurgery over a five-year period (2015–2019). Incidence was calculated in person-pears (crude) and age-adjusted for standard population. We conducted multivariate multivariable logistic regression models to assess variables associated with emergency neurosurgical procedures.ResultsA total of 2151 patients with pathological head CT scans were included. One or more emergency neurosurgical procedure was performed in 27% of patients. The crude incidence was 3.9/100,000 person-years. The age-adjusted incidences in the standard population for Europe and the world were 4.0/100,000 and 3.3/100,000, respectively. The most frequent emergency neurosurgical procedure was the insertion of an intracranial pressure monitor, followed by evacuation of the mass lesion. Male sex, road traffic accidents, severe injury (low Glasgow coma score) and CT characteristics such as midline shift and compressed/absent basal cisterns were significantly associated with an increased probability of emergency neurosurgery, while older age was associated with a decreased probability.ConclusionsThe incidence of emergency neurosurgery in the general population is low and reflects neurosurgery procedures performed in patients with severe injuries. Hence, emergency neurosurgery for TBIs should be centralized to major trauma centers.

A retrospective analysis of characteristics and perioperative outcomes of rhino-orbital-cerebral mucormycosis in COVID-19 patients posted for surgical debridement under general anaesthesia in a tertiary care hospital

Abstract Background: Rhino-orbital-cerebral mucormycosis (ROCM) has increasingly been reported in patients with severe acute respiratory syndrome coronavirus-2 (SARS CoV-2) disease-2019 (COVID-19) from India. Methods: A retrospective study was done to analyse the demographic and clinical characteristics, treatment received for COVID-19 during the hospital stay, perioperative outcomes in ROCM patients posted for surgical debridement under general anaesthesia from May 2021 to July 2021 at our tertiary care teaching hospital in Tirupati, southern India. Results: Overall, 350 patients with ROCM and COVID-19 had undergone surgical debridement under general anaesthesia Mucormycosis was predominantly seen in males (65.7%). Majority of the cases (40%) were in the age group between 41-50 years. Common comorbidities were: pre-existing diabetes mellitus (DM) (70%), hypertension (32%), new-onset DM/hyperglycaemia (22%) and cardiac disease (8%). The most common sites involved in mucormycosis were the nose and paranasal sinuses (100%) followed by rhino-orbital (63.1%). A history of hospital admission for COVID-19 management was evident in 89.7%; 40.7% of the patients had received oxygen therapy during their hospital stay. The use of corticosteroids for the treatment of COVID-19 was noted in 73.2%. The types of surgical procedures done were: functional endoscopic sinus surgery (FESS) (98.5%) and neurosurgery procedures (3.4%). Revision surgery was performed in 18.5% of the cases. Perioperative complications observed were anticipated difficult intubation during pre-operative airway assessment 35.7%, intraoperative hypertension 8.5%. A patient had developed intraoperative cardiac arrest, post-operative-delayed recovery and needed ventilator requirement. Outcomes of ROCM patients associated with COVID-19 were: discharged 91.7%, death 8.3%. Conclusions: Diabetes mellitus, rampant use of corticosteroids in the treatment of COVID-19 appear to have contributed to the development of ROCM. Early diagnosis, a thorough pre-operative evaluation, surgical debridement are likely to result in better prognosis in COVID-19 patients with ROCM.

Bleeding contour detection for craniotomy

ObjectiveBleeding impairs observation during neurosurgery, and excessive bleeding endangers the life of a patient. Thus, hemostasis is important during neurosurgery. The detection of bleeding areas is a prerequisite for hemostasis. MethodsTo the best of our knowledge, this paper is the first to present results on the detection of neurosurgical craniotomy bleeding scenarios, i.e., scalp incision bleeding, skull incision bleeding, and dura matter-incision bleeding. This is realized via a workflow that combines craniotomy image data preparation and a Mask R-CNN framework. Bleeding images on a porcine skin tissue with a simulated blood injected by a syringe are taken by a visible light camera, and the video frames of the scalp incision, skull incision, and dura matter-incision bleeding are extracted from neurosurgical videos. ResultsThe precision of bleeding areas detection for the simulated bleeding scenario and the three craniotomy phase scenarios were 94.40%, 84.44%, 89.48%, and 90.46%. ConclusionThe contours of the neurosurgical craniotomy bleeding regions can be detected along with the bleeding areas. SignificanceIt is beneficial for neurosurgeons to identify the bleeding areas by sending prioritized alerts for bleeding events. Furthermore, it is valuable for a task-level medical robot designed for a neurosurgical procedure, such as craniotomy, or a high-level robot designed for an entire neurosurgery procedure.

PATIENT SAFETY CHECKLIST IN NEUROANAESTHESIA: AN IMPACT ON PROTOCOL AND OUTCOME.

BACKGROUND: Surgical safety checklists is a common tool to prevent human fallacies and may help in avoiding complications .Major surgeries like neurosurgery need a thorough preparation and a specic checklist tailored to neurosurgery which may serve the purpose .So we intend to follow the neurosurgical safety checklist to elude anticipated complications. Objectives 1. To identify the adherence to various elements of the Modied WHO SSC for neurosurgery. 2. To analyse how a mandatory speciality-specic checklist practice can help in early identication of those interventions that are specic to neurosurgery, which can otherwise be overlooked. METHODOLOGY: Ÿ Study Design: Observational study Ÿ Duration of study: From May 2021 to August 2021. Ÿ Sampling Method: Convenience sampling Ÿ Sampling Procedure: Systematic Random Sampling. RESULT: This study was carried out in 77 patients undergoing various neurosurgery procedures and was found that none of the patients had diagnosis, procedure written on the name tag in pre-op period and ICP monitoring tools were not available. It was found that the anaesthesiologist as a safety list coordinator can implement the checklist ensuring minimal complications related to the surgery and also active involvement of all the members. CONCLUSION: The implementation of surgical safety checklist for Neurosurgery, by a designated checklist co-ordinator, can rectify anaesthetic and surgical facets promptly, without increasing the time required for the operation and also reduces the risk for post-op recovery.

Accurate placement of parieto-occipital shunt ventricular catheter: use of craniometrics and technical note.

Ventriculoperitoneal shunt insertion is one of the most commonly performed procedures in neurosurgery but has arelatively high complication rate. One important source of complications is shunt malposition from erroneousplacement of the parieto-occipital burr hole or poor shunt trajectory. There are significant variations in the freehandparieto-occipital approach amongst neurosurgeons that are derived from variations in technique or experience. Thepatient's skull shape or size is also often not taken into consideration if fixed measurements are used to define theburr hole entry point. The authors suggest a variation to the technique of ventricular catheter placement by relyingon the patient's own craniometrics and skull landmarks. The technique is illustrated and supported by analysis of a case series of 25 patients undergoing shunt placement. By this method, all shunts were positioned in the lateral ventricle. Using a 3-point scale, the catheter position wasevaluated: grade 1, free floating in cerebrospinal fluid; grade 2, touching the choroid plexus or ventricular wall; andgrade 3, tip within the parenchyma. The catheter position was grade 1 in sixteen (64%) cases and grade 2 in nine(36%) cases; none was grade 3. Only one shunt malfunction occurred from proximal shunt obstruction in theseries. The use of this technique aims to reduce operator and patient variability as contributors to shunt malposition, toincrease user reproducibility and decrease the learning curve for trainees. Further prospective study could bedesigned to validate the technique.

Postoperative 30-day emergency department utilization after 7294 cranial neurosurgery procedures at a tertiary neuroscience center.

Hospital readmission and the reduction thereof has become a major quality improvement initiative in organized medicine and neurosurgery. However, little research has been performed on why neurosurgical patients utilize hospital emergency rooms (ERs) with or without subsequent admission in the postoperative setting. This study was a retrospective, single-center review of data for all surgical cranial procedures performed from July 2013 to July 2016 in patients who survived to discharge. The study was approved by the institutional review board of the participating medical center. The authors identified 7294 cranial procedures performed during 6596 hospital encounters in 5385 patients. The rate of postoperative ER utilization within 30 days after surgical hospitalization across all procedure types was 13.1 per 100 surgeries performed. The two most common chief complaints were pain (30.7%) and medical complication (18.2%). After identification of relevant surgical and patient factors with univariable analysis, a multivariable backward elimination logistic regression model was constructed in which Ommaya reservoir placement (OR 2.65, p = 0.0008) and cranial CSF shunt placement (OR 1.40, p = 0.0001) were associated with increased ER utilization. Deep brain stimulation electrode placement (OR 0.488, p = 0.0004), increasing hospital length of stay (OR 0.935, p < 0.0001), and increasing patient age (OR 0.988, p < 0.0001) were associated with lower rates of postoperative ER utilization. One-half (50%) of ER visit patients were readmitted to the hospital. New/worsening neurological deficit chief complaint (OR 1.99, p = 0.0088), fever chief complaint (OR 2.41, p = 0.0205), altered mentation chief complaint (OR 2.71, p = 0.0002), patient chronic kidney disease (OR 3.31, p = 0.0037), brain biopsy procedure type (OR 3.50, p = 0.0398), and wound infection chief complaint (OR 31.4, p = 0.0008) were associated with increased rates of readmission to the hospital from the ER in multivariable analysis. The authors report the rates of and reasons for ER utilization in a large cohort of postoperative cranial neurosurgical patients. Factors identified were associated with both increased and decreased use of the ER after cranial surgery, as well as variables associated with readmission to the hospital after postoperative ER visitation. These findings may direct future quality improvement via prospective implementation of care pathways for high-risk procedures.

Focused ultrasound for functional neurosurgery.

Brain lesioning is a fundamental technique in the functional neurosurgery world. It has been investigated for decades and presented promising results long before novel pharmacological agents were introduced to treat movement disorders, psychiatric disorders, pain, and epilepsy. Ablative procedures were replaced by effective drugs during the 1950s and by Deep Brain Stimulation (DBS) in the 1990s as a reversible neuromodulation technique. In the last decade, however, the popularity of brain lesioning has increased again with the introduction of magnetic resonance-guided focused ultrasound (MRgFUS). In this review, we will cover the current and emerging role of MRgFUS in functional neurosurgery. Literature review from PubMed and compilation. Investigated since 1930, MRgFUS is a technology enabling targeted energy delivery at the convergence of mechanical sound waves. Based on technological advancements in phased array ultrasound transducers, algorithms accounting for skull penetration by sound waves, and MR imaging for targeting and thermometry, MRgFUS is capable of brain lesioning with sub-millimeter precision and can be used in a variety of clinical indications. MRgFUS is a promising technology evolving as a dominant tool in different functional neurosurgery procedures in movement disorders, psychiatric disorders, epilepsy, among others.

Post Anesthesia Care Unit Nurses’ Experience Caring for Opioid Tolerant Patients

<h3>Introduction</h3> Nearly 20% of same-day surgery patients regularly consume opioids, with the majority undergoing orthopedic or neurosurgery procedures for relief from chronic pain. Many have become opioid intolerant and subsequently, experience more pain and consume more opioids postoperatively than opioid naïve patients. Despite higher dosing, their pain is often unrelieved. Evidence-based guidelines include <i>preoperative identification</i> of opioid tolerant patients; however, postoperative nurses often learn of their patient's tolerance only after the patient exhibits an extreme reaction to pain. These experiences can be stressful and lead to nurse compassion fatigue and moral distress, particularly in a fast-paced post anesthesia care unit (PACU). <h3>Identification of the problem</h3> Several studies examine perioperative nurses' experiences with opioid tolerant patients in managing pain, though none explore the day-to-day personal challenges faced by nurses in the care of these patients. <h3>Purpose of the Study</h3> To explore PACU nurses' experiences in caring for opioid tolerant patients. <h3>Methodology</h3> A narrative research design was used. Six full-time PACU nurses with one or more years of PACU experience were recruited in Fall 2020. Subjects were asked to discuss an experience caring for an opioid tolerant patient and how they felt afterward. They were also asked to identify supports that would help them care for these patients. <h3>Results</h3> Interviews will be analyzed inward, outward, back in time, and forward in time to understand the participants' experience through five contexts – personal (feelings, reaction), social (environment, other people), past, present, future, and situation (professional practice). <h3>Discussion</h3> Narrative threads and their interpretation will be discussed to better understand how nurse's feelings are expressed and directed in professional practice. <h3>Conclusion</h3> This study made it possible to think about nursing practice in a new light through honoring experiences that are difficult to share yet are an important source of knowledge. <h3>Implications for perianesthesia nurses and future research</h3> Insights into the nature, causes, and strategies used to handle experiences caring for opioid tolerant patients will be identified as well as ways to better support nurses in the practice environment.