Surgical Management Research Articles

Tailored resection for persistent extramural vascular invasion in locally advanced rectal cancers.

Extramural vascular invasion (EMVI) is a bad prognostic feature in rectal cancer and cancers that remain EMVI positive after neoadjuvant therapy are at high risk for having involved circumferential resection margins. Conventional total mesorectal excision (TME) resections are inadequate in such cases and often lead to positive margins. We propose a technique for the surgical management of locally advanced tumours with persistent EMVI after neoadjuvant therapy. Ten such tumours were resected using a "beyond TME" (b-TME) approach with or without lateral pelvic lymph node dissection or seminal vesical excision. A b-TME approach, customized to the anatomy of the tumour allowed for an R0 resection with a negative circumferential resection margin (CRM) in all 10 cases. A tailored b-TME approach can achieve good results in cases at high risk for CRM involvement.

Resection of Calcified and Giant Thoracic Disc Herniation Through Bilateral Postero-Lateral Approach and 360° Cord Release: A Technical Note

Background/Objectives: Surgical treatment of thoracic disc herniation (TDH) is risky and technically demanding due to its proximity to the spinal cord and the high possibility of the TDH being calcified (up to 40%), making the resection even more complex. Calcified TDH may be resected from an anterior via thoracotomy/thoracoscopy, lateral extra-cavitary, or a postero-lateral approach. Here, we present our experience in managing such pathology with an original technique Methods: This original technique, used successfully in more than 40 patients, is introduced, with a precise description of the surgical anatomy and the surgical steps to take. Indications for surgical management and neurological outcomes are also analyzed. This surgical approach consisted of transverso-pediculectomy, most often bilaterally, partial vertebral body drilling, 360° release of the cord, and short fixation. Results: A total of 44 patients were collected, with a mean age of 52.4 ± 11.7 years. Seven patients (15.9%) had complete calcifications, and thirty-one had partial calcifications (70.5%), while the remaining six did not have signs of calcifications. There were only 4 intraoperative complications (2 dural tears and 2 loss of evoked potentials). The TDH could be resected in total for 39 patients (88.6%) and partially, according to the “floating” technique, in 5 patients (11.4%). In the postoperative follow-up, all of the patients except two (presenting with sensory aggravation) reported an improvement in neurological conditions leading to an overall risk of neurological aggravation of 4.5%. Conclusions: The bilateral postero-lateral approach provides a large decompression of the cord (360°) and gives safe access to the TDH, even calcified, permitting high rates of total resection. It also prevents any prejudicial pressure on the spinal cord, reducing the risk of severe postoperative deficits and permitting optimal instrumentation (pedicle screw-based) of the spinal segment. The surgical sequence to resect the bony structures around the spinal cord is of great importance.

Novel Algorithm for Surgical Management of Cervical Ossification of Posterior Longitudinal Ligament: A Retrospective Cohort Study With 2-Year Follow-Up.

With the development of new technologies, the surgical algorithm for ossification of posterior longitudinal ligament (OPLL) in the cervical spine also needs to be updated. The aim of this study is to elucidate a new surgical classification algorithm to guide the choice of surgical approaches for cervical OPLL based on its location and extent. In this algorithm, anterior controllable antedisplacement and fusion (ACAF) will be used as a new surgical option. This is a single-centered, retrospective, cohort study utilizing a novel algorithm based on the following three criteria: (1) the positional relationship between ossification and uncinate process (UP), (2) the K-line, and (3) the ossification segment for surgical decision-making. Patients diagnosed with cervical OPLL who received surgical intervention guided by the algorithm were included. Patient demographics, Japanese Orthopedic Association (JOA) scores, surgical time, imaging data before and 2 years after surgery, and the occurrence of complications were extracted from the database. Paired t-test was used for intragroup comparison, and one-way ANOVA test was used for the intergroup analyses. Based on this novel algorithm, 15 patients with Type I, 8 patients with Type II a, 2 patients with Type II b1, 5 patients with Type II b2 were included. The decision-making for the surgical techniques used in each patient followed the recommendation of the novel algorithm. The postoperative JOA scores of all types of patients improved significantly (p < 0.05), and the invasion rates of vertebral canal had also been significantly reduced (p < 0.05). In terms of restoring cervical curvature, patients with Type I (receiving ACAF) and Type II b2 (receiving laminectomy with instrumented fusion) benefited more from surgery (p < 0.05). A new algorithm guiding the choice of surgical approach for cervical OPLL was validated in a series of 30 patients. Through this analysis, we obtained on their clinical outcomes and complications. ACAF surgery is an ideal choice for Type I patients, with ossification located between UPs, while for patients with ossification exceeding UPs, it is better to perform anterior cervical corpectomy and fusion or posterior surgery.

Implications of molecular classifications in glioma surgery.

The incorporation of molecular markers into neuro-oncology has transformed our understanding of adult diffuse gliomas. While surgical resection is the mainstay of treatment for many patients with gliomas, surgical management strategies warrant re-exploration in the context of characteristic molecular profiles. We reviewed the neurosurgical and neuro-oncological literature for studies investigating surgery in molecularly defined cohorts of adult diffuse gliomas. We discuss key molecular markers associated with the three subtypes of adult diffuse glioma: glioblastoma IDH-wildtype, astrocytoma IDH-mutant, and oligodendroglioma IDH-mutant and 1p/19q codeleted. We additionally discuss surgical strategies and extent of resection in these tumors, framing them in the context of key molecular alterations. Finally, we briefly discuss the practical utility of molecular markers in guiding surgical decision making. Molecular markers in gliomas are of growing relevance to surgical intervention. Advancements in preoperative and intraoperative molecular diagnostics will increase the utility of molecular biomarkers in informing surgical decision-making for patients with gliomas.

Abstract 4119260: Anomalous Origin Of Left Circumflex Artery From Right Pulmonary Artery Resulting In Heart Failure: A Rare Vascular Steal Phenomenon

Background: Anomalous origin of coronary arteries from the pulmonary artery usually presents at a younger age. However, we encountered a case of a 62-year-old female with an anomalous origin of the left circumflex (LCx) artery from the right pulmonary artery. Case summary: A 62-year-old female presented with complaints of dyspnea and angina on exertion for 1 month and had paroxysmal nocturnal dyspnea for the last 4-5 days. She also had an episode of ventricular tachycardia which required DC cardioversion. She had diabetes mellitus type 2 and hypertension. ECG showed diffuse horizontal ST segment depression in precordial, and limb leads and ST segment elevation in aVR suggesting subendocardial ischemia. The echocardiogram showed hypokinesia in basal, mid-inferior and inferolateral segments and LVEF of 42%. There was a marked reduction in global longitudinal strain (average GLPS of -9.2%). Her coronary angiogram revealed extensive collaterals to the left circumflex artery (from the left anterior descending artery and right coronary artery). The left circumflex artery was arising from the pulmonary artery. Exact localization of origin was done by simultaneous contrast injections in the right pulmonary artery and LAD. The anomalous origin of LCx from the right pulmonary artery was hooked using a Tiger catheter. The patient was advised for surgical management; however, the patient has opted for medical therapy. Conclusion: The anomalous origin of coronary arteries from pulmonary arteries is usually detected in childhood e.g. ALCAPA and is associated with other congenital heart diseases. Anomalous origin of LCx from the right pulmonary artery is a rare variant. It can result in a steal phenomenon which may result in angina, heart failure and risk of sudden cardiac arrest.

SURG-45. OUTCOMES OF PATIENTS RECEIVING SURGICAL RESECTION AND STEREOTACTIC RADIOSURGERY VS. STEREOTACTIC RADIOSURGERY ALONE FOR MOTOR CORTEX METASTASES

Abstract BACKGROUND Local therapy for brain metastases typically involves stereotactic radiosurgery (SRS), with surgical resection considered for larger and/or symptomatic tumors. For lesions in eloquent areas, surgical management is controversial given the risks of neurologic deficits. This study compared clinical outcomes in patients with motor cortex metastases who received surgery + SRS or SRS alone. METHODS Patients treated for motor cortex metastases from 1/2018 – 12/2022 were identified. Demographic/preoperative variables included age, gender, race, tumor histology, adjuvant therapies, pre-treatment neurological exam, and Karnofsky Performance Scale. Treatment variables included the number of brain metastases, maximum tumor diameter, and radiation dose/number of fractions. Outcome measures included post-treatment neurological exam, seizures, and overall survival (OS). RESULTS 351 charts were identified – 80 surgery + SRS and 271 SRS alone. 50 consecutive patients in each group were included in this analysis. Surgery + SRS patients were younger (59.0 vs. 63.9; P=0.020) with larger tumors (2.8 vs. 0.83cm; P&amp;lt;0.001), while the SRS only group had more brain metastases per patient (2 vs. 6; P&amp;lt;0.001). No differences were seen in the remaining demographic/preoperative variables. Pre-treatment, surgery + SRS patients had significantly increased frequency (45/50, 90% vs. 25/50, 50%; P&amp;lt;0.001) and severity (4 vs. 5; P=0.001) of motor deficits, and a higher likelihood of seizures (25/50, 50% vs. 8/50, 16%; P&amp;lt;0.001). Despite the surgery + SRS group being more symptomatic pre-treatment, the frequency and severity of motor deficits and seizures was similar between cohort’s post-therapy. Surgery + SRS patients also demonstrated higher rates of pre- to post-treatment improvement in motor function (29/45, 64% vs. 3/25, 12%; P&amp;lt;0.001) and longer OS from the date of treatment (7.5 vs 4 months; P=0.021). CONCLUSION Given the equivalent neurological outcomes, higher rates of functional improvement, and improved oncologic outcomes, surgery should be a consideration for patients with brain metastases in eloquent areas, particularly those with symptomatic lesions.

Outcomes of external versus internal fixation for traumatic lower limb fractures in low- and middle-income countries.

Lower limb fractures are common in low- and middle-income countries (LMICs) and represent a significant burden to the existing orthopaedic surgical infrastructure. In high income country (HIC) settings, internal fixation is the standard of care due to its superior outcomes. In LMICs, external fixation is often the surgical treatment of choice due to limited supplies, cost considerations, and its perceived lower complication rate. The aim of this systematic review protocol is identifying differences in rates of infection, nonunion, and malunion of extra-articular femoral and tibial shaft fractures in LMICs treated with either internal or external fixation. This systematic review protocol describes a broad search of multiple databases to identify eligible papers. Studies must be published after 2000, include at least five patients, patients must be aged > 16 years or treated as skeletally mature, and the paper must describe a fracture of interest and at least one of our primary outcomes of interest. We did not place restrictions on language or journal. All abstracts and full texts will be screened and extracted by two independent reviewers. Risk of bias and quality of evidence will be analyzed using standardized appraisal tools. A random-effects meta-analysis followed by a subgroup analysis will be performed, given the anticipated heterogeneity among studies, if sufficient data are available. The lack of easily accessible LMIC outcome data, combined with international clinical guidelines that are often developed by HIC surgeons for use in HIC environments, makes the clinical decision-making process infinitely more difficult for surgeons in LMICs. This protocol will guide research on surgical management, outcomes, and complications of lower limb shaft fractures in LMICs, and can help guide policy development for better surgical intervention delivery and improve global surgical care.

Challenges and outcomes of cataract surgery after vitrectomy.

This review examines the challenges and outcomes of cataract surgery after pars plana vitrectomy (PPV), focusing on surgical techniques, timing, and complication management. Cataract formation remains the primary complication post-PPV, affecting approximately 80-100% of patients within two years. Nuclear sclerotic cataracts are most common, occurring in 60-100% of patients over 50, followed by posterior subcapsular cataracts (4-34%), which primarily affect younger and diabetic patients. PPV disrupts the normal oxygen gradient in the vitreous, resulting in a more uniform oxygen distribution and accelerating cataract formation.Post-PPV eyes present unique surgical challenges due to anatomical alterations, including zonular instability and capsular changes characterized by increased fragility, the potential for tears, and altered elasticity. Newer intraocular lens power calculations show promise, but unexpected refractive outcomes may occur. The choice between combined phacovitrectomy and sequential surgeries remains debated, with patient-specific factors guiding the approach. Visual outcomes vary depending on preexisting vitreoretinal pathologies and baseline vision before PPV. Further randomized controlled trials are needed to establish treatment guidelines and improve predictive models. Post-PPV cataract surgery presents unique challenges, including anatomical alterations and an increased risk of capsular complications. These necessitate careful consideration of the surgical approach and highlight the need for further research to optimize outcomes and establish treatment guidelines.

EPID-28. TRENDS IN LOW GRADE GLIOMA PROGNOSIS AND THE EVOLVING IMPACT OF GROSS TOTAL RESECTION ACROSS FIFTY YEARS: A MULTICOHORT ANALYSIS

Abstract OBJECTIVE Significant advancements in neurosurgical planning, approach, and practice over the past five decades have improved the surgical management of diffuse low and high-grade gliomas. We sought to evaluate the extent to which LGG survival outcomes have evolved over the past fifty years using glioma registry datasets with histopathological groups defined by WHO diagnostic criteria and supplemented with next generation genome-sequencing. METHODS Three datasets (SEER, TCGA, and GENIE) were used to evaluate trends in prognosis following LGG diagnosis and resection between 1975 and present (GBM as a comparator cohort). The primary outcomes evaluated were longitudinal disease-specific survival and overall survival, with secondary fixed-timepoint outcomes evaluated at 12-months, 24-months, and 60-months. Subjects from SEER were categorized by histology, while subjects from TCGA and GENIE were included based IDH mutation status with available histopathology. RESULTS A total of 39,958 adult patients were included. Overall survival increased for both LGG and GBM between 1975 and 2010, however only LGG outcomes continued to improve following 2010 (2010-; HR=0.955, 95%CI 0.926 to 0.986). Evaluation of the interaction between resection extent and diagnosis year revealed a progressive increase in the survival benefit of GTR in recent years, particularly for LGG. Independent of other available clinical/molecular features and considering the interaction term between year of diagnosis and resection extent, the gap in independent prognostic benefit associated with GTR between LGG and GBM has significantly widened (2010-2020 vs 1990-2000, p&amp;lt;0.05). CONCLUSION Over the past three decades, consistent improvements in LGG outcomes were observed while prognosis following GBM diagnosis has remained largely unchanged following 2010. Notably, we observed increasing prognostic value of achieving GTR particularly in patients with LGG.

Challenges and Considerations in Diagnosing and Managing p16+-Related Oropharyngeal Squamous Cell Carcinoma (OPSCC) with Neck Metastasis: Implications of p16 Positivity, Tobacco Exposure, and De-Escalation Strategies

Background: The incidence of patients showing neck metastasis and no obvious primary tumor at the initial diagnostic evaluation or neck cancer of unknown primary (NCUP) is rising. It is estimated that a relevant part of these tumors arises in the tonsillar crypts or base of the tongue and are p16+-related. However, today, the detection rate of the primary tumor is suboptimal. Identifying the primary tumor and its biomolecular characterization is essential since it influences the treatment administered, possibly reducing radiation fields and providing de-escalation to primary surgical management. However, p16 IHC (immunohistochemistry) might not be sufficient to diagnose HPV-related OPSCC. The other subset of patients discussed are the HPV-positive patients who have a history of tobacco exposure and/or p53 mutations. Possible factors that could negatively influence the outcomes of these patients are investigated and discussed below. So, this paper aims to analyze the diagnostic, bio-molecular, clinico-radiological, morphological, prognostic and therapeutical aspects of p16-positive OPSCC, highlighting the possible bias that can occur during the diagnostic and prognostic process. Methods: A narrative review was conducted to investigate the biases in the diagnostic and therapeutic process of two groups of patients: those who are p16-positive but HPV-negative patients, and those who are p16-positive and HPV-positive with exposure to traditional risk factors and/or p53 mutations. The keywords used for the literature research included the following: NCUP, OPSCC, p16IHC, HPV testing, p16 positive HPV negative OPSCC, p16 positive HPV positive OPSCC, tonsillectomy, tobacco exposure, p53 mutations, cystic neck metastasis, extranodal extension (ENE), radiotherapy, de-escalation and neck neck dissection. Results: HPV-positive OPSCC has specific clinico-radiological features. Bilateral tonsillectomy should be considered for the identification of the primary tumor. P16 IHC alone is not sufficient for diagnosing HPV-related OPSCC; additional detection methods are required. The role of tobacco exposure and p53 mutations should be investigated especially in cases of HPV-positive tumors. Extranodal extension (ENE) must be taken into consideration in the prognostic staging of HPV-positive tumors. Surgical primary treatment involving neck dissection (ND) and bilateral tonsillectomy followed by adjuvant radiation may represent the most appropriate approach for N3 cases. Diagnosis, prognosis and therapeutical implications must be addressed considering clinical, biomolecular and morphological aspects. At least today, the numerous biases that are still present influencing the diagnostic and prognostic process do not permit considering de-escalation protocols. Conclusions: A precise and accurate diagnosis is required in order to adequately stage and manage p16+ OPSCC, particularly with neck metastasis. The role of tobacco exposure and/or p53 mutations must be considered not only in p16+ OPSCC but especially in HPV-positive OPSCC. Until a more accurate diagnosis is possible, ENE should be considered even in p16+HPV+ OPSCC. Primary surgery with unilateral ND and bilateral tonsillectomy might be the treatment of choice given the numerous diagnostic and prognostic pitfalls. Therefore, it is inappropriate and risky to propose de-escalation protocols in routine clinical practice due to the risk of undertreatment.

Surgical management of a large cystic trochlear nerve schwannoma mimicking a brainstem glioma: a case report

IntroductionIntracranial schwannomas represent a rare group of intracranial tumors, with purely motor nerve schwannomas being the rarest of them. The anatomical proximity of these tumors to the brainstem may present a radiological challenge in differentiating them from intra–axial brainstem tumors, which can influence further decision–making and treatment options.MethodsWe report on a 47–year–old male patient who was diagnosed with a large cystic intracranial tumor with radiological features suggestive of an intrinsic brainstem glioma.ResultsAfter discussing treatment options and risks based on a presumed radiological diagnosis, microsurgical treatment via lateral–suboccipital craniotomy in semi–sitting position, under continuous intraoperative neuromonitoring was performed. Intraoperative findings proved that the tumor was an extra–axial schwannoma originating from the left trochlear nerve. Gross total removal of the lesion was achieved.ConclusionDue to their rarity, non–specific symptoms and the possibility to mimicking intra–axial brainstem tumors on imaging, these tumors may present a diagnostic challenge and should be taken into account during treatment decision-making.

Endodontic and Surgical Management of Trauma-Induced Combined Internal and External Root Resorption with Periapical Cyst: A Case Report

Root resorption, involving the breakdown of hard tissues like dentin and cementum, can result from trauma and subsequent infection, potentially leading to tooth loss. This case report details the management of combined internal and external root resorption with a periapical cyst in a 32-year-old male. After trauma, the maxillary left central incisor (#21) presented with root resorption and a displaced apex. Endodontic treatment using MTA and surgical enucleation of the cyst were performed. A 12-month follow-up showed successful resolution and tissue regeneration. This case emphasizes the effectiveness of combining advanced endodontic and surgical techniques for complex resorption cases.

SURG-55. NOVEL IQ-DOME APPROACH FOR SUPERIOR SEMICIRCULAR CANAL DEHISCENCE REPAIR REDUCES REVISIONAL SURGERY RATE

Abstract Superior Semicircular Canal Dehiscence (SSCD) is characterized by a thinning of the bony ceiling of the superior semicircular canal, manifesting in auditory and vestibular deficits. Surgical repair is the standard treatment modality of SSCD, with conventional methods including plugging or recapping the defective canal with bone wax, bone chips, muscle, and others. Previous research has shown multiple complications with these conventional materials, including a high rate of failure of the primary repair and the need for revisional surgeries. To address this challenge, we investigated a novel surgical sealing technique using IQ-Dome, a titanium mesh plate overlying the arcuate eminence. We aim to assess the efficacy of IQ-Dome in the repair of SSCD compared to conventional material while evaluating outcome measures including postoperative symptom resolution, complication, and revisional surgery rates. We performed a retrospective analysis of patients undergoing SSCD repair via the middle cranial fossa approach at UCLA between 2017 and 2021. We compared demographics and post-operative outcomes between the application of IQ-Dome and conventional materials. A total of 160 patients undergoing SSCD repair were included in our study, with 80 patients receiving IQ-Dome and 80 patients receiving non-IQ-Dome approaches. 60% of patients in the IQ-Dome cohort and 66.7% of patients in the non-IQ-Dome cohort were female. The mean ages of patients were 45.7 years (range 13-78) in the IQ-Dome cohort and 48.9 years (range 17-69) in the non-IQ-Dome cohort. The surgical revision rates for the IQ-Dome and non-IQ-Dome cohorts were 5.7% and 8.5%, respectively. There was no significant difference in postoperative complications between groups. Thus, IQ-Dome is a safe approach for the surgical management of SSCD, decreasing failure and revision rate by nearly 3% in our patient population and offering an alternative surgical sealing repair intervention. Future studies with larger sample sizes are warranted to further assess the efficacy of IQ-Dome.

Outcomes for Degenerative Cervical Myelopathy Following Implementation of the AO Spine International Guidelines: A Single-Centre Service Evaluation.

Degenerative cervical myelopathy (DCM) is a syndrome of symptomatic cervical spinal cord compression due to degenerative spinal changes. Until recently there was no formal consensus on exactly which patients are suitable for surgical or conservative management. The AO Spine international guidelines were introduced to address this issue, based on the best available current evidence. However, their implementation into routine clinical practice has not yet been reported. The objective was to evaluate surgical outcomes following the implementation of the AO Spine guidelines at our spinal neurosurgical centre. A service evaluation was conducted using data collected from electronic healthcare records for 259 patients, with outcomes of interest including change in mJOA score and complications. Data from 193 patients were included in the final analysis. There was a mean improvement of the mJOA score by 1.53 points, 1.44 point and 1.92 points at post-operative intervals of 3months (P < .001), 6months (P < .001) and 12months (P < .001). The percentage (number) of patients whose increase in mJOA score was greater than or equal to the minimal clinically importance difference (MCID) was 41% (44/107), 34% (33/96) and 43% (49/114) at these respective time intervals. Intraoperative complications occurred in 28 patients (11.7%). No association was found between BMI and postoperative change in mJOA score. Our results are comparable to those from best practice data and suggest adherence to international guidelines provides a service that promotes meaningful recovery for patients with DCM. Therefore, our results offer support for implementation of the AO Spine international guidelines in clinical practice.

Traumatic Diaphragmatic Rupture Leading to Tension Gastrothorax: A Critical Case Report and Surgical Insight

Traumatic diaphragmatic rupture (TDR) is a serious but relatively uncommon injury, often resulting from blunt trauma, particularly motor vehicle accidents. Among these, blunt TDR presents with more severe outcomes than penetrating injuries, including higher mortality rates. A life-threatening complication of TDR is gastrothorax, which occurs when the stomach herniates into the thoracic cavity, leading to elevated intrathoracic pressure and potentially fatal consequences such as respiratory failure or cardiac arrest. This case reported a 23-year-old male who sustained a motor vehicle collision, presenting with progressive shortness of breath, nausea, and vomiting 15 hours post-injury. Imaging confirmed a diaphragmatic rupture with associated tension gastrothorax. Immediate intervention with nasogastric tube placement provided symptom relief, followed by exploratory laparotomy to repair the diaphragmatic defect. The patient's recovery was uneventful, demonstrating the critical importance of early diagnosis and timely surgical management in cases of TDR with gastrothorax. Traumatic diaphragmatic rupture occurs in approximately 0.8–1.6% of trauma cases, with motor vehicle accidents being the leading cause. Due to its potential for delayed diagnosis, the rupture is often missed initially, leading to higher rates of morbidity and mortality. Early detection is critical, as it can prevent serious complications such as bowel herniation into the thoracic cavity, respiratory distress, or even death.

Treatment of Spontaneous Subarachnoid Hemorrhage: A 20‐Year National Inpatient Sample Review

BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is a major source of morbidity and mortality, and its management has undergone foundational changes over thepast 2 decades. We reviewed the National Inpatient Sample to outline the changes in severity of illness, surgical management, and patient outcomes over time. METHODS A retrospective cohort of admissions for spontaneous SAH in the National Inpatient Sample from 2001 to 2020 was reviewed, including those who underwent microsurgical or endovascular surgery to secure a ruptured aneurysm. National incidence was calculated, and multivariable regression was used to identify changes in incidence and outcome through time, segmented by epoch. RESULTS Review of the National Inpatient Sample identified 448 655 patients with SAH, of whom 181 590 underwent surgical aneurysm treatment. The incidence of spontaneous SAH fell −0.097 per 100 000 person‐years each year (95%CI, −0.144 to −0.049). Among patients surgically treated for aneurysmal SAH, the proportion of patients &lt;50 years old fell from 40% to 30% between first and final epochs, and the proportion of those in the lowest stroke scale category, roughly equivalent to Hunt and Hess grade 1 or 2, fell from 66% to 45%. The proportion treated by microsurgery fell from 70% to 23% in favor of endovascular surgery. Hospital mortality among these treated cases was stable at 13% throughout the study period despite increasing illness severity indices. After adjustment, there was a 42% reduction of odds of hospital mortality in the final epoch compared with the first. CONCLUSION The incidence of hospitalization for spontaneous SAH fell between 2001 and 2020. Patients undergoing surgery to secure an aneurysm were more severely ill through time yet experienced a stable hospital mortality rate.

Surgically managed traumatic spinal cord injury in Singapore: a descriptive study across two level one trauma centres

Study designCase SeriesObjectivesTo provide an updated understanding of the incidence of surgically managed Traumatic Spinal Cord Injury (TSCI) in Singapore and to identify factors affecting discharge disposition.SettingPatients were identified from two level one trauma centres in Singapore.MethodsAll patients who underwent surgical management for acute TSCI between January 2020 to December 2021 were included. Demographics, injury details, peri-operative condition, hospital length of stay (LOS) and discharge disposition were evaluated. The overall characteristics of TSCI were summarised using descriptive statistics. The difference between discharge destinations was compared using chi-square test or t test. Variables with p values < 0.3 were selected for multivariable analysis.ResultsForty-four patients were included. Median age was 65. The most common SCI aetiology was fall from standing height or less (54.6%). Accidents involving personal mobility devices, bicycles and motor vehicles made up the next largest group (20.5%). Thirty-nine cases (88.6%) involved the cervical region. There were two cases of inpatient mortality. Twenty-one patients (50%) were discharged home, 21 (50%) were discharged to a community hospital (CH) or nursing home (NH). The median LOS in an acute hospital was 41 days. Multivariable logistic regression analysis revealed that functional independence measure (FIM) score on discharge was an independent factor that influenced discharge disposition (p = 0.037).ConclusionA public health focus on falls prevention, the development of geriatric spinal rehabilitation programs, and the consideration of a national registry are recommended for the comprehensive management of TSCI in Singapore.

Surgical and dermatological management of asymptomatic congenital ear canal atresia in a male Wirehaired Pointing Griffon dog

AbstractA 1‐year‐old, male, entire Wirehaired Pointing Griffon was evaluated for asymptomatic right congenital ear canal atresia. Head computed tomography confirmed congenital ear canal atresia diagnosis. Surgical resection and anastomosis of the ear canal followed by video otoscopy was performed. An intact, but flaccid tympanic membrane, suspected from impacted ear canal debris, was identified. One week postoperatively, bilateral yeast otitis externa was diagnosed and successfully treated with topical anti‐fungal therapy. Five months postoperatively, the stoma remained patent, the dog was asymptomatic, and computed tomography with video otoscopy revealed a taut tympanic membrane bulging into the horizontal ear canal. Myringotomy, cytology, bacterial cultures, susceptibility testing, middle ear saline lavage and pre‐emptive topical antibiotic therapy were pursued. Cultures yielded no bacterial growth. Four weeks later, the tympanic membrane was visibly normal, and the stoma was unchanged. This case report is the first to describe interdisciplinary management of asymptomatic congenital ear canal atresia and might support early surgical intervention as a reasonable option.

Microbial profile of diabetic foot osteomyelitis from the northwest of England

BackgroundOsteomyelitis of the diabetic foot is a common and challenging complication affecting patients with diabetic foot ulcers and infections. The complexity of these infections lies in their polymicrobial nature, high rates of persistence and recurrence. This study examined the microbiological profile of diabetic foot osteomyelitis from a teaching hospital in Northwest England and their resistance patterns to understand its impact on infection persistence and to direct effective treatment.MethodsA retrospective review of 105 patients who underwent surgical management for diabetic foot osteomyelitis between 2019 and 2024. We analysed three consecutive culture samples for each patient to assess for the microbiological profile and resistance patterns of these infections and to monitor infection recurrence and persistence rates.ResultsA total of 105 patients were identified. Infection eradication was noted in 42% of the cohort, infection persistence in 18%, and late infection recurrence in 40%. Polymicrobial growth was evident in 72% of our study sample. Gram-positive bacteria made up the majority of the bacterial isolates in all 3 culture samples, 74.81% in sample 1, 69.31% in sample 2, and 55.1% in sample 3. Staphylococcus aureus was the most prevalent gram-positive bacteria, at 52.38% in sample 1, 36.19% in sample 2, and 18.09% in sample 3, followed by Haemolytic Streptococcus, Enterococcus and Corynebacterium. The frequently identified gram-negative bacteria were Pseudomonas in sample 1 (7.61%), E. coli and Proteus in sample 2 (5,71%), Pseudomonas and Proteus in sample 3 (2.85%). Gram-positive bacteria were resistant to penicillin and macrolides with resistance of staphylococcus aureus to clarithromycin identified among all 3 culture samples. Gram-negative bacteria were most resistant to amoxicillin. Staphylococcus aureus was responsible for infection persistence in most of our cohort (12/19) 63.15%. Among those patients, Staphylococcus was resistant to clarithromycin in 6 of the cases. The 5-year mortality rate for our study sample was 32.38%.ConclusionThis study highlights the prevalence of polymicrobial growth and multi-drug resistant pathogens in the scope of diabetic foot osteomyelitis. It highlights the predominance of Staphylococcus aureus and its resistant strains among patients affected by diabetic foot osteomyelitis in Greater Manchester.

Surgical Management of Neurogenic Thoracic Outlet Syndrome: A Systematic Review and Meta-analysis

Surgical Management of Neurogenic Thoracic Outlet Syndrome: A Systematic Review and Meta-analysis