RESUMEN
Tension pneumocephalus (TP) after spinal surgery is very rare with only a few cases reported in the English literature. Most cases of TP occur rapidly after spinal surgery. Traditionally, TP is managed using burr holes to relieve intracranial pressure. However, our case highlights a rare delayed presentation of TP and pneumorrhacis 1 month after routine cervical spine surgery. It is to our knowledge the first case of TP after spinal surgery to be treated using dural repair and supportive care. A 75-year-old woman presented with TP after having routine cervical decompression and stabilisation for cervical myelopathy. She re-presented 1 month after her initial operation with a leaking wound and altered mental status, which deteriorated rapidly shortly after admission. This, in combination with her radiographic features, influenced the decision to explore her surgical wound emergently. She made a full recovery and was discharged after 2 weeks in hospital. We hope to emphasise the need for a high index of suspicion for cerebrospinal fluid leaks and the low threshold to return to theatre to repair a potential dural defect, as well as illustrate that TP after spinal surgery can be treated successfully without burr holes.
RESUMEN
Introduction Insertion of external ventricular drain (EVD) is a widely accepted, routinely performed procedure for treatment of hydrocephalus and raised intracranial pressure. The purpose of this study was to investigate whether a surgeon's experience affects the associated complication rate. Methods This retrospective study included all adult patients undergoing EVD insertion at a single centre between July 2013 and June 2015. Medical records were retrieved to obtain details on patient demographics, surgical indication, risk factors for infection and use of anticoagulants or antiplatelets. Surgeon experience, operative time, intraoperative antibiotic prophylaxis, need for revision surgery and EVD associated infection were examined. Information on catheter tip position and radiological evidence of intracranial haemorrhage was obtained from postoperative imaging. Results A total of 89 patients were included in the study. The overall infection, haemorrhage and revision rates were 4.8%, 7.8% and 13.0% respectively, with no significant difference among surgeons of different experience. The mean operating time for patients who developed an infection was 22 minutes while for those without an infection, it was 33 minutes (p=0.474). Anticoagulation/antiplatelet use did not appear to increase the rate of haemorrhage. The infection rate did not correlate with known risk factors (eg diabetes and steroids), operation start time (daytime vs out of hours) or duration of surgery although intraoperative (single dose) antibiotic prophylaxis seemed to reduce the infection rate. There was also a correlation between longer duration of catheterisation and increased risk of infection. Conclusions This is the first study demonstrating there is no significant difference in complication rates between surgeons of different experience. EVD insertion is a core neurosurgical skill and junior trainees should be trained to perform it.
Asunto(s)
Competencia Clínica , Drenaje , Hidrocefalia/cirugía , Hipertensión Intracraneal/cirugía , Curva de Aprendizaje , Complicaciones Posoperatorias/etiología , Ventriculostomía , Adulto , Anciano , Drenaje/métodos , Femenino , Humanos , Hidrocefalia/complicaciones , Hipertensión Intracraneal/etiología , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
Alteration in the glycosaminoglycan hyaluronan (HA) has been demonstrated in numerous renal diseases. We have demonstrated that renal proximal tubular epithelial cells (PTCs) surround themselves in vitro with HA in an organized pericellular matrix or 'coat', which is associated with cell migration, and also form pericellular HA cable-like structures which modulate PTC-mononuclear leukocytes interactions. The aim of this study was to characterize potential regulatory mechanism in the assembly of PTC-HA into pericellular cables. HA cables are generated by PTCs in the absence of serum. Immunohistochemical analysis demonstrates the incorporation of components of the inter-alpha-inhibitor (IalphaI) family of proteins and versican into HA cables. Addition of an antibody to IalphaI/PalphaI (pre-alpha-inhibitor) inhibits cable formation. In contrast, inhibition of tumor necrosis factor-alpha-stimulated gene 6 (TSG-6) has no effect on cable formation, suggesting that their generation is independent of the known heavy-chain transfer activity of TSG-6. Overexpression of HAS3 is associated with induction of HA cable formation, and also increased incorporation of HA into pericellular coats. Functionally, this resulted in enhanced HA-dependent monocyte binding and cell migration, respectively. Cell surface expression of CD44 and trypsin-released cell-associated HA were increased in HAS3-overexpressing cells. In addition, hyaluronidase (hyal1 and hyal2) and bikunin mRNA expression were increased, whereas PalphaI HC3 mRNA expression was unchanged in the transfected cells. The data demonstrate the importance of IalphaI/PalphaI in cable formation and suggest that expression of HAS3 may be critical for HA cable assembly.