Microvascular decompression for neurovascular conflicts in the cerebello-pontine angle: which role for endoscopy?

Background

Microvascular decompression (MVD) is the surgical intervention designed to resolve neurovascular conflicts (NCs) in the cerebellopontine angle (CPA). Today, endoscopy is commonly used in many neurosurgical procedures. This study aims to retrospectively assess the usefulness of endoscopy during MVD, focusing on microscopic endoscopic-assisted (MEA) MVD.

Methods

Between January 2010 and December 2012, 141 patients underwent MVD procedures: 119 (84.5 %) were affected by idiopathic trigeminal neuralgia (TN), 20 (14 %) by hemifacial spasm (HFS), 1 by glossopharyngeal neuralgia (GN) and 1 by TN and GN simultaneously; 128 (91 %) MVD were first time procedures, while 13 (9 %) were recurrences (10 TN, 3 HFS). Visualization techniques used were: pure microscopic in 89 (63 %) cases, fully endoscopic in 12 (8.5 %) and MEA in 40 (28.5 %). The MEA technique was used when the conflict was not clearly identified under microscopic view or it was not certainly resolved.

Results

Overall, a NC was found in 130 (92 %) cases, while 11 patients had no intraoperative evidence of NC. Considering specifically the 40 MEA cases, 12 (8.5 % overall) conflicts not clearly visible with the microscope were revealed and solved, a complete conflict resolution was confirmed in 13 (9 % overall) cases, while an incomplete conflict resolution was shown in four cases (3 % overall).

Conclusion

Pure microscopic MVD remains the technique of choice. The endoscope is a useful adjunctive imaging tool in confirming NCs identified by the microscope, revealing conflicts missed by the microscopic survey alone and verifying adequate nerve decompression.     

Microvascular decompression in patients with coexistent trigeminal neuralgia,hemifacial spasm and glossopharyngeal neuralgia

Background

Trigeminal neuralgia(TN), hemifacial spasm (HFS) and glossopharyngeal neuralgia (GPN) were referred to hyperactive dysfunction syndromes (HDSs) of the cranial nerves. These symptoms may occur synchronously or metachronously, but the combination of three diseases is extremely rare.

Methods

From 2007 through 2013, six patients with coexistent GPN-HFS-TN were treated in our department. The combined symptoms occurred on the same side in three and on both sides in three. These patients underwent nine microvascular decompression (MVD) procedures in total. The clinical data including operative findings were respectively analyzed, and the etiological factors as well as treatment strategies were discussed.

Results

Intraoperatively, in all the cases a small posterior fossa was found, which was crowded with cranial nerve roots and cerbellar vesels. Postoperatively, spasm was stopped immediately in four and within 3 months in two; the symptom of TN disappeared immediately in four and within 2 weeks in two; the symptom of GPN was relieved immediately in four and improved with medication in two. During the up to 77 months’ follow-up, no changes, recurrence or any dysfunctions of cranial nerves were observed in any of the patients.

Conclusions

The combination of HFS-TN-GPN is extremely rare and is often associated with a looped VBA and a smaller posterior fossa. However, MVD is still a good choice for treatment. To achieve a safe and effective outcome, dissection of the caudal cranial nerves and proximal transposition of the vertebral artery before decompression of the affected nerve roots are strongly recommended.     

A recommendation on the basis of long-term follow-up resultsof our microvascular decompression operation for hemifacial spasm

Background

Microvascular decompression (MVD) for hemifacial spasm (HFS) has been popular, but it may take enough time to master this special operative technique and procedure. This may induce uneven distribution of the number of MVD operations in each institute, possibly resulting in an overall unsatisfactory quality of MVD surgeons. Nakanishi’s approach to MVD operations has the feature of using a, “supine, no retractor” technique, which would achieve various benefits for patients and medical professionals. We would like to recommend this approach for MVD surgeons on the basis of our follow-up outcomes.

Methods

A questionnaire, which was based on the method of evaluation for the long-term results of post-MVD operation as recommended by the Japanese Society of MVD, was sent by mail to the 154 HFS patients who had received Nakanishi’s approach at our hospital.

Results

Except for 42 patients who had changed their residences, 89 patients (79.5 % of 112) fully answered. The mean postoperative follow-up term was 13.0 years. The 76.4 % of the patients was estimated as excellent. Postoperative deafness was not present. The average value of satisfaction degree for the results of the MVD operation was 87.9 %.

Conclusions

This study revealed that Nakanishi’s approach produced good results equivalent of other approaches for HFS patients. This approach is considered to have many advantages comparing to the other approaches. Therefore, we would like to recommend that Nakanishi’s approach would contribute to overall advancement of the level of MVD surgeons.     

A proposal for standardized analysis of the results of microvascular decompression for trigeminal neuralgia and hemifacial spasm

Background

The purpose of this study was to evaluate and analyze overall postoperative results from microvascular decompression (MVD) by combining the cure rate of symptoms with the complication rate. A new scoring system for obtaining objective surgical results from MVD for trigeminal neuralgia (TN) and hemifacial spasm (HFS) is proposed to document treatment results using consistent criteria in a standardized manner.

Method

Surgical results combining complications , if any, were obtained from a questionnaire sent to patients who had undergone surgery for TN or HFS in recent years and had been followed-up for more than 1?year after surgery (TN patients, n?=?54; HFS patients, n?=?81) When surgical outcome is complete resolution of symptoms, the efficacy of surgery (E) is designated E-0, but when moderate symptoms are still persist postoperatively, the score is designated E-2. When no complications are seen after surgery, the complication score (C) is C-0, while the score is C-2 if troublesome complications remain. In addition, total evaluation of the results (T) is judged by combining the E and C scores. For example, when E is 0, and C is C-2, the total evaluation is scored as T-2, which is diagnosed as fair.

Findings

The response rate of the questionnaire was 80.7% (109/135). Overall surgical data were evaluated and analyzed using our new scoring system. Analysis of the collected data revealed an outcome of T-0 was 70% (35/50 patients) and T-1 was 24% (12/50) and T-2 was 6% (3/50) in TN, whereas in HFS, T-0 was 61% (36/59) and T-1 was 27.1% (16/59) and T-2 was 6.8% (4/59) and T-3 was 5.1% (3/59).

Conclusion

The total results of MVD should be evaluated and analyzed by combining the cure rate of symptoms together with the complication rate. This new scoring system could allow much more objective analysis of the results of following MVD. Adopting this scoring system to objectively judge treatment results for TN and HFS, individual surgeons can compare their own overall surgical results with those of other institutes. Comparative results of MVD can also be provided to patients considering therapy to allow informed decision-making on the basis of good quality evidence.     

Usefulness of the endoscope in microvascular decompression for trigeminal neuralgia and MRI-based prediction of the need for endoscopy

Background

Microvascular decompression (MVD) is a documented effective treatment of trigeminal neuralgia (TN). Lately, reports on endoscopy-assisted microvascular decompression (eaMVD) with better outcome and less risk have emerged. This study was undertaken to verify under which circumstances the endoscope proved essential in identifying the neurovascular conflict (NVC) during eaMVD for TN, and to assess the possibility to predict the need for the endoscope on preoperative magnetic resonance imaging (MRI).

Methods

Retrospective analysis of 97 patients with TN undergoing eaMVD at the Oslo University Hospital – Rikshospitalet, 1999–2009. To assess the NVC and anatomical variations, surgical reports were evaluated. MRI was available in 66 patients. The MRIs were evaluated by a blinded neuroradiologist.

Results

In 27 of the 97 patients (27.8 %), the endoscope was a significant aid in identifying the NVC, due to a bony ridge obscuring the view of the fifth nerve, a very distal vascular compression, or a combination of both. The preoperative MRI over-diagnosed the presence of a bony ridge. However, the MRI-based fraction of microscopically visible trigeminal nerve (FVN) in the cerebellopontine angle cistern proved diagnostic (ROC curve, AUC 0.89, p?=?<0.001) with an optimal cut-off value of 0.35. Hence, if less than 35 % of the trigeminal nerve is visible on preoperative MRI, the endoscope will be needed to identify the NVC.

Conclusions

The endoscope is a valuable tool during MVD for TN, especially under anatomical circumstances such as a bony ridge hiding the direct microscopic view of the NVC. These anatomical circumstances can be predicted with good accuracy on preoperative MRI.     

Emprical factors associated with Brainstem auditory evoked potential monitoring during microvascular decompression for hemifacial spasm and its correlation to hearing loss

Background

Cranial nerve VIII is at risk during microvascular decompression (MVD) for hemifacial spasm (HFS). The primary aim of this study is to evaluate the empirical factors associated with brainstem auditory evoked potential monitoring and its correlation to post operative hearing loss (HL) after MVD for HFS.

Methods

Pre-operative and post-operative audiogram data and BAEP from ninety-four patients who underwent MVD for HFS were analyzed. Pure tone audiometry (PTA) and Speech Discrimination Score (SDS) were performed on all patients before and after surgery. Intraoperative neurophysiological data were reviewed independently. HL was assessed using the AAO-HNS classification system for non-serviceable hearing loss (Class C/D), defined as PTA >50 dB and/or SDS <50 % within the speech range of frequencies.

Results

Patients with HL had higher rates of loss in the amplitude of wave V and prolongation in the interpeak latency of peak I-V latency during MVD. Gender, age, side, and MVD duration did not increase the risk of HL. There was no correlation between successive number of BAEP changes (reflective of the number of surgical attempts) and HL. There was no association between the speed of recovery of BAEPs and HL.

Conclusions

Patients with new post-operative HL have a faster rate of change in the amplitude of wave V and the interpeak I-V latency during intraoperative BAEP monitoring for HFS. Our alarm criteria to inform the surgeon about impending nerve injury might have to be modified and prospectively tested to prevent rapid change in BAEPs.     

Management of symptomatic hemifacial spasm or trigeminal neuralgia

Hemifacial spasm (HFS) or trigeminal neuralgia (TN) is a kind of hyperactivity disorder of cranial nerves caused by vascular compression. However, sometimes, the disease may arise from nerve damage produced by tumors, which was called as symptomatic HFS/TN. Until now, little is known about the exact mechanism and the necessity of microvascular decompression (MVD) regarding the tumor-induced HFS/TN, which is necessary to be retrospectively analyzed in a considerable sample. Among the 4021 patients who underwent MVD in our department between 2006 and 2014, 44 were finally diagnosed as symptomatic HFS or TN. These patients were focused in this study and their clinical features as well as intraoperative findings and postoperative outcomes were retrospectively investigated. Data analysis exhibited the symptomatic HFS/TN cases accounted for 1.1 % in the study, which were caused by epidermoid in 18 (40.9 %) and meningioma in 15 (34.1 %) followed by neuroma in 7 (15.9 %) as well as aneurysm in 2 (4.5 %) and arteriovenous malformation in 2 (4.5 %). Compared to those with idiopathic HFS/TN, younger females were more susceptible (p?<?0.05). After resection of the neoplasm, the offending vessel was identified in 26 (59.1 %), which were followed by MVD process. Postoperatively, the symptoms relief rate was 88.6 %. Our study showed that surgical management of patients with symptomatic HFS/TN may lead to a satisfactory result, yet those primary lesions should be removed firstly. In some cases, a microvascular decompression process might be unnecessary afterward, but the entire nerve root should be checked to exclude any vessel in contact with.     

Validation and evaluation of the volumetric measurement of cerebellopontine angle cistern as a prognostic factor of microvascular decompression for primary trigeminal neuralgia

Background

The aim of this study was to analyze the prognostic factors of trigeminal neuralgia (TN) after microvascular decompression (MVD), and to evaluate the volumetric parameters of the cerebellopontine angle (CPA) cistern as a pathogenic factor and imaging predictor.

Methods

This retrospective study included 70 patients with primary TN treated with pure MVD, followed up for at least 1 year and evaluated by high-resolution MR imaging. The volume of the CPA cistern was calculated bilaterally, and the “Cistern Deviation Index” was defined to represent degree of deviation of the CPA cistern. Clinical data and volumetric parameters were compared between patients with TN and age- and sex-matched controls without TN, and between the recurrent and non-recurrent patients.

Results

The transposition procedure had a better outcome than the interposition procedure (P?<?0.001). There was a significant difference in the volume of CPA cistern between the affected and unaffected side (152.1?±?50.1 vs. 179.9?±?63.7 mm³, P?<?0.001) in patients with TN, while no significant difference between the right and left side (158.7?±?44.6 vs. 163.1?±?49.8 mm³, P?=?0.162) in controls. The Cistern Deviation Index was significantly larger in controls than in patients with TN (P?=?0.048), and in the non-recurrent patients than in recurrent patients (P?=?0.040).

Conclusion

We demonstrated that the volumetric parameters of the CPA cistern are a marker for understanding the pathogenesis of TN and useful for predicting the recurrence after MVD. The Cistern Deviation Index might contribute to deciding the surgical approach.     

The long-term outcome of nerve combing for trigeminal neuralgia

Background

The purpose of our study was to describe and evaluate the long-term clinical outcome of nerve combing for idiopathic trigeminal neuralgia (TN) with and without vascular compression.

Methods

The study included 60 trigeminal neuralgia patients, 28 of which (Group A) had no visible vascular compression intraoperatively and 32 of which (Group B) had trigeminal nerve root entry zone (REZ) compressed by vascular structure. All patients were considered medical failures prior to the surgeries. All of them underwent trigeminal nerve combing. The following outcome measures were assessed: pain relief, recurrence, complication and time to pain relief.

Results

The median duration of follow-up was 52 months (range 48–96 months) in group A and 56 months (range 48–96 months) in group B. Excellent relief and good relief were noted in 23 patients (82.1 %) and two patients (7.1 %) from group A, respectively, and in 20 (62.5 %) and eight patients (25 %) from group B. The major complication of both groups was facial numbness. And the total complication rate was 15.8 % in group A and 18.8 % in group B. Recurrence was found in one patient in group A and in two in group B by the end of follow-up.

Conclusion

Trigeminal nerve combing is effective in treating TN, but has a much higher pain relief rate in patients without vascular compression than those with vascular compression.     

Prognostic value of microvessel density in prostate cancer: a tissue microarray study

Purpose

Angiogenesis is an important part in tumor progression and intratumoral microvessel density (MVD) has proven a prognostic factor in several solid tumors. However, its value in prostate cancer is still unclear, especially in small biopsy samples. We evaluated the prognostic potential of MVD in a large, homogeneous cohort of prostate cancers and its correlation with other pathologic parameters.

Methods

We used a tissue microarray (TMA) containing samples of 3,261 prostatectomy specimens from patients with prostate cancer. MVD was determined by counting vessels in a blinded fashion after immunohistochemical staining with an antibody against CD31. The results were compared with pre- and postoperative clinical and pathological parameters and clinical follow-up data.

Results

MVD was higher in TMA spots containing cancer as compared to benign tissue (P < 0.001). There was no significant correlation of MVD with preoperative parameters, but with pathological T-classification and Gleason score (P < 0.001, each) of the prostatectomy specimens. Furthermore, a higher MVD correlated with tumor location in the peripheral zone (P = 0.01). Follow-up data were available for 1,521 patients. In a univariable analysis, an MVD of ≥36 per spot was a significant predictor of PSA recurrence after radical prostatectomy (P = 0.03). However, it failed to provide an independent prognostic factor when combined with standard predictors in a multivariable analysis.

Conclusions

MVD in prostate cancer is closely related to other factors contributing to tumor aggressiveness. However, the implementation of this parameter into routinely performed pathological reports does not seem to be warranted.     

Microvascular decompression surgery is effective for the laterocollis subtype of spasmodic torticollis: a long-term follow-up result

Background

Spasmodic torticollis (ST) is characterized by sustained, involuntary, and painful spasms of specific muscle (s), which results into abnormal posture of the neck and head. Although various treatments for ST have been introduced, none of them shows absolute effectiveness. Earlier research from our department showed that microvascular decompression (MVD) surgery is effective in the short-term for ST patients with confirmed accessory nerve compression. However, the long-term outcome of MVD remains unknown.

Method

Twelve ST patients with confirmed accessory nerve compression received MVD surgery of their accessory nerves. We utilized the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) to evaluate the long-term outcome (5.4?±?0.87 years).

Results

The MVD lowered total TWSTRS scores by 42.8 % in all ST patients. This result, however, only counted for moderate relief. Interestingly, we observed that the laterocollis (LC) subtypes of ST (n?=?3) obtained a higher TWSTRS score improvement (86.9?±?6.2 %), compared to that of the non-LC (28.1?±?12 %) (P?=0.0001). Additionally, the disability (92.7?±?2 %) subscale score in the LC subtypes had the most prominent improvement compared to the pain (88.1?±?5.1 %) and severity (81.3?±?10.5 %).

Conclusions

In the cases of confirmed accessory nerve compression, the MVD could be considered as a treatment alternative for ST, especially for the LC subtypes.     

Preoperative assessment of hemifacial spasm by the coronal heavily T2-weighted MR cisternography

Background

Microvascular decompression (MVD) has become a well-established surgical procedure for hemifacial spasm (HFS). Before surgery, it is essential to evaluate any possible deformity of the brainstem and establish the precise location of the offending vessels. In the present study of HFS patients we examined coronal sections taken by heavily T2-weighted MR cisternography in addition to routine axial sections, and assessed the usefulness of these images through comparison with intraoperative findings.

Methods

Eighty patients with HFS underwent preoperative coronal heavily T2-weighted MR cisternography before microvascular decompression surgery. Three neurosurgeons examined the preoperative axial and coronal MR images and evaluated vessel invagination into the brainstem. The usefulness of coronal sections was assessed statistically by the Mann-Whitney U test.

Results

Invagination of the offending vessel into the brainstem was observed in 24 cases (30.0%). In 19 patients, it was predicted preoperatively that compression of the flocculus and brainstem would be required in order to approach the offending vessels. Coronal MR cisternography was significantly more useful in cases with vessel invagination into the brainstem than in cases without invagination.

Conclusions

Coronal sections obtained by MR cisternography are able to demonstrate the severity of vessel invagination into the brainstem as well as revealing the presence of the offending vessel. This information is helpful for planning a suitable approach to the root exit zone.     

Elective laparoscopic cholecystectomy for symptomatic uncomplicated gallstone disease: do the symptoms disappear?

Background

Symptomatic gallstone disease is considered an indication for cholecystectomy. A considerable proportion of patients may experience persistent symptoms after surgery. The purpose of the present study was to find out the rate of symptom persistence after elective laparoscopic cholecystectomy (LC) performed for symptomatic uncomplicated gallstone disease and, in particular, to clarify whether the recurrence rate differs according to the severity of preoperative symptoms.

Methods

During a 10-year period (1992–2001), 1,101 patients underwent elective LC at Turku City Hospital for Surgery. A questionnaire concerning the intensity of preoperative symptoms, persistence of symptoms postoperatively, and overall satisfaction with the outcome of the procedure was sent to patients. A total of 677 patients [mean age (range) 59 (21–94) years; 554 (83.1 %) females] with uncomplicated gallstone disease returned the completed form.

Results

Overall, 380 (57 %) patients reported attacks of intense upper abdominal pain, and 287 (43 %) reported episodic mild abdominal symptoms as the prevailing preoperative symptom. Two hundred and forty-eight (37 %) patients continued to have abdominal symptoms after the operation. Among those with predominantly mild abdominal symptoms preoperatively, 119 (41 %) reported the persistence of symptoms after the operation, while in the group with mainly severe upper abdominal pain attacks, 129 (33 %) patients had recurrences (p = 0.052).

Conclusions

According to our data, more than one-third of patients with symptomatic uncomplicated gallstone disease experienced persistent symptoms after elective LC. Patients with mild preoperative symptoms seemed to have more recurrences than those with severe symptoms, although the difference was not statistically significant.     

A New Subfascial Approach in Open Thyroidectomy: Efficacy for Postoperative Voice, Sensory, and Swallowing Symptoms. A Randomized Controlled Study

Background

After open thyroidectomy, patients usually complain of voice, sensory, and swallowing symptoms. We approached the thyroid via the subfascial method to reduce these symptoms and compared postthyroidectomy symptoms with the conventional subplatysmal method.

Methods

Eighty-six patients undergoing thyroidectomy were recruited and randomized into either a conventional subplatysmal approach group (subplatysmal, 42 patients) group or a subanterior fascia of strap muscle approach group (subfascial, 44 patients). Voice symptoms were assessed using the Voice Handicap Index questionnaire and acoustic voice analysis. Sensory alterations were evaluated by the light touch and pain touch methods. Swallowing symptoms were assessed using the Swallowing Impairment Score (SIS) questionnaire, barium swallowing time, and hyoid bone movement range. Each variable was measured preoperatively, and at 2 weeks and 3 months after thyroidectomy.

Results

In both groups, the subjective symptoms of voice, sensation, and swallowing were significantly worsened at 2 weeks after operation, but improved 3 months after operation. Patients in the subplatysmal group had worse SIS scores than patients in the subfascial group (p = 0.016) and delayed barium swallowing time 2 weeks after operation (p = 0.008 compared to preoperative level). In the cohort over 50 years of age, SIS score did not recover to preoperative levels in the subplatysmal group 3 months after operation (p = 0.005 compared to preoperative level).

Conclusions

The subfascial approach may be an effective method for reducing postthyroidectomy swallowing symptoms based on swallowing impairment score, especially in patients over 50 years of age.     

SPan-1 Is a Useful Prognostic Marker for Patients with Stage IV Gastric Cancer Who Underwent Palliative Gastrectomy: A Retrospective Multivariate Study

Background

We retrospectively investigated prognostic factors to be used in selecting the patients with stage IV gastric cancer (GC) who have an unfavorable prognosis after palliative gastrectomy.

Methods

A total of 146 GC patients at stage IV who had undergone palliative gastrectomy were enrolled. Various clinicopathological parameters were evaluated for prognosis.

Results

Surgical morbidity and hospital mortality occurred in 35 (23.9 %) and 4 (2.7 %) patients, respectively. The overall 5-year survival rate and the median survival time were 11.2 % and 13.2 months, respectively. Of the 146 patients, 64 had uncomfortable symptoms associated with GC and 76 had no such symptoms. Of the 64 patients with uncomfortable symptoms, 60 (93.7 %) experienced relief of these symptoms after palliative surgery. Multivariate analysis for patients without uncomfortable symptoms associated with GC revealed that the number of incurable factors and serum SPan-1 level were independent prognostic factors.

Conclusions

Patients with stage IV GC who had multiple incurable factors and a high level of serum SPan-1 might not be candidates for palliative gastrectomy for the purpose of prognostic benefit.     

Improvement of Gastroesophageal Reflux Symptoms After Standardized Laparoscopic Sleeve Gastrectomy

Background

Gastroesophageal reflux disease (GERD) is present in half of morbidly obese patients. Published data reporting the results of laparoscopic sleeve gastrectomy (LSG) in patients with GERD are contradictory. We have shown in a previous study that symptoms of GERD can be reduced for up to 12 months after LSG with careful attention to surgical technique. The present study prospectively evaluated the effect of a standardized LSG technique on the incidence of postoperative GERD symptoms in a larger sample, and followed patients for up to 22 months.

Methods

This was a concurrent cohort study. All patients who underwent LSG at our center completed a standard multidisciplinary preoperative evaluation and were followed prospectively.

Results

A total of 382 patients underwent surgery. There were no cases of death or fistula. GERD was diagnosed in 170 patients (44.5 %) preoperatively, and hiatal hernia (HH) was detected in 142 patients (37.2 %) intraoperatively. Between 6 and 22 months postoperatively, 373 patients were completely evaluated. Ten (2.6 %) had GERD symptoms 6–22 months postoperatively, and 94 % of patients with preoperative GERD symptoms were asymptomatic at follow-up 6–22 months after LSG. Only 1 patient (0.5 %) of a subgroup of 174 without HH or esophagitis at preoperative evaluation had GERD at follow-up.

Conclusions

Our results confirm that, contrary to previous reports of LSG in the literature, careful attention to surgical technique can result in significantly reduced GERD symptoms up to 22 months postoperatively suggesting that LSG does not predispose patients to GERD during that period.     

Primary Hyperparathyroidism: An Analysis of Failure of Parathyroidectomy

Background

Preoperative imaging in patients undergoing surgery for primary hyperparathyroidism (PHPT) is used primarily to facilitate targeted parathyroidectomy. Failure of preoperative localisation mandates a bilateral exploration. It is thought that the results of imaging may also predict the success of surgery. The aims of this study were to assess whether the findings on preoperative localisation influenced outcomes following parathyroidectomy for PHPT and to explore factors underlying failure to cure at surgery.

Methods

We analysed outcomes of all patients who underwent first-time surgery for PHPT in two centres over a 5-year period to determine an association with demographic characteristics and findings on preoperative imaging. Records of patients not cured by initial surgery were reviewed to explore factors underlying failure to cure.

Results

The failure rate (persistent disease) in the entire cohort was 5 % (25/541) (bilateral neck explorations, 5 %; unilateral exploration, 7 %; targeted approach, 4 %), while two patients developed recurrent disease. In patients who had undergone dual imaging with an ultrasound scan and ^99mTc-sestamibi scintigraphy, failure rates with “lateralised and concordant” imaging, “nonconcordant” imaging, and “dual-negative” imaging were 2, 9, and 11 %, respectively (p = 0.01). Of the 25 patients with persistent disease, multigland disease (MGD) was present in 52 % (13/25) and ectopic adenoma in 24 % (6/12).

Conclusions

Patients with PHPT who do not have lateralised and concordant dual imaging are at higher risk of persistent disease. A significant proportion of failures are due to the inability to recognise the presence and/or extent of MGD.     

Predictors of early mortality after hip fracture surgery

Purpose

The aim of this study was to examine causes and potential risk factors for 30-day mortality after hip fracture surgery (HFS) at a high-volume tertiary-care hospital.

Methods

We retrospectively reviewed 467 patients who underwent HFS at our institution. Multivariate analysis was undertaken to identify potential predictors of early mortality.

Results

The 30-day mortality rate was 7.5 % (35/467). The most common causes of death were pneumonia (37.1 %, 13/35), acute coronary syndrome (31.4 %, 11/35) and sepsis (14.3 %, 5/35). Surgery after 48 hours of admission had a significantly higher 30-day mortality rate (11 % versus 4 %, p?=?0.006). There was a significant difference in age (p?=?0.034), admission source (p??<?0.001), preoperative haemoglobin (p?<?0.001), walking ability (p ?=?0.004), number of comorbidities (p ?=?0.004) and pre-existing dementia (p ?=?0.01), cardiac disease (p ?<?0.001), chronic obstructive pulmonary disorder (COPD) (p ?=?0.036) and renal failure (p ?=?0.007) between the 30-day mortality group and the rest of the cohort. Surgical delay greater than 48 hours, admission source and pre-existing cardiac disease were identified as the strongest predictors of 30-day mortality.

Conclusion

Surgical delay is an important but avoidable determinant of early mortality after HFS. Respiratory and cardiac function needs to be optimised postoperatively with early intervention in patients with signs of cardiovascular compromise or infection.     

Repeated large-volume epidural blood patches for the treatment of spontaneous intracranial hypotension

Purpose

Refractory headache from spontaneous intracranial hypotension can be debilitating for patients. This report describes the use of repeated high-volume epidural blood patches to treat this condition.

Clinical features

A 39-yr-old male presented with a history and diagnostic imaging findings consistent with spontaneous intracranial hypotension. The associated intractable and incapacitating headache was unrelieved by meperidine and a 20 mL lumbar autologous blood patch. Two weeks later, a second epidural blood patch of 45 mL autologous blood administered in the lower thoracic epidural space achieved partial relief. With symptoms persisting despite oral analgesics, a third blood patch was undertaken one month after the initial procedure. On this occasion, administration of 32 mL autologous blood into the mid-thoracic epidural space resulted in complete and lasting resolution of the headache.

Conclusion

The ideal volume of blood injectate to achieve maximal effectiveness for an epidural blood patch is unknown. While many clinicians use a predetermined maximal volume, a volume titrated to patient symptoms is a suggested alternate approach.