The establishment and development of neurosurgery services in Papua New Guinea

BACKGROUND: Papua New Guinea (PNG) is a developing Pacific Nation of 7.3 million people. Although neurosurgery training was introduced to PNG in the year 2000, it was in 2003 that a neurosurgery service was established. Prior to this time, neurosurgery in PNG was performed by general surgeons, with some assistance from visiting Australian neurosurgeons. Neurosurgical training was introduced to PNG in 2000. The model involved a further 3 years of training for a surgeon who had already completed 4 years of general surgical training. We aim to review the output, outcomes and impact achieved by training the first national neurosurgeon. METHODS: The data on activity (output) and outcomes were collected prospectively from 2003-2012. Ongoing mentoring and continuing professional development were provided through annual neurosurgical visits from Australia. There were serious limitations in the provision of equipment, with a lack of computerized tomographic or MR imaging, and adjuvant oncological services. RESULTS: There were 1618 neurosurgery admissions, 1020 neurosurgical procedures with a 5.74 % overall mortality. Seventy percent of cases presented as emergencies. There were improved outcomes, particularly for head injuries, whilst hydrocephalus was managed with an acceptable morbidity and revision rate. CONCLUSIONS: The training of a neurosurgeon resulted in PNG patients receiving a better range of surgical services, with a lower mortality. The outcomes able to be delivered were limited by late presentations of patients and lack of resources including imaging. These themes are familiar to all low- and middle-income countries (LMICs) and this may serve as a model for other LMIC neurosurgical services to adopt as they consider whether to establish and develop neurosurgical and other sub-specialist surgical services.

Seeking tools for image fusion between computed tomography, structural and functional magnetic resonance methods for applications in neurosurgery

OBJECTIVE: To evaluate tools for the fusion of images generated by tomography and structural and functional magnetic resonance imaging. METHODS: Magnetic resonance and functional magnetic resonance imaging were performed while a volunteer who had previously undergone cranial tomography performed motor and somatosensory tasks in a 3-Tesla scanner. Image data were analyzed with different programs, and the results were compared. RESULTS: We constructed a flow chart of computational processes that allowed measurement of the spatial congruence between the methods. There was no single computational tool that contained the entire set of functions necessary to achieve the goal. CONCLUSION: The fusion of the images from the three methods proved to be feasible with the use of four free-access software programs (OsiriX, Register, MRIcro and FSL). Our results may serve as a basis for building software that will be useful as a virtual tool prior to neurosurgery.

[Imaging for disorders in neurology and neurosurgery]

Imaging has become increasingly important for diagnosis and treatment of disorders in neurology and neurosurgery. Often, however, physicians are uncertain which imaging modality to chose for diagnosis and which techniques can be used to help for treatment. To answer a specific question clinicians have to rely on history and clinical findings. According to a cardinal clinical symptom or sign the imaging technique with the highest sensitivity and specificity for the given problem is chosen. In this review imaging techniques for the most common cardinal symptoms and signs in neurology and neurosurgery which need imaging for management are discussed.

Patent foramen ovale and neurosurgery in sitting position: a systematic review

We have conducted a systematic review of air embolism complications of neurosurgery in the sitting position and patent foramen ovale (PFO) closure. It assesses the risk and benefit of PFO closure before neurosurgery in the sitting position. The databases Medline, Embase, and Cochrane Controlled Trial Register were systematically searched from inception to November 2007 for keywords in both topics separately. In total, 4806 patients were considered for neurosurgery in sitting position and 5416 patients underwent percutaneous PFO closure. The overall rate of venous air embolism during neurosurgery in sitting position was 39% for posterior fossa surgery and 12% for cervical surgery. The rate of clinical and transoesophageal echocardiography detected paradoxical air embolism was reported between 0% and 14%. The overall success rate for PFO closure using new and the most common closure devices was reported 99%, whereas the average risk of major complications is <1%. On the basis of our systematic review, we recommend screening for PFO and considering closure in cases in which the sitting position is the preferred neurosurgical approach. Our proposed management including the time of PFO closure according to available data is presented. However, the conclusions from our systematic review may be limited due to the lack of level A evidence and from using data from observational cohort studies. Thus, definite evidence-based recommendations require prospective evaluation of the issue in well-designed studies.

The silent loss of neuronavigation accuracy: a systematic retrospective analysis of factors influencing the mismatch of frameless stereotactic systems in cranial neurosurgery

BACKGROUND Neuronavigation has become an intrinsic part of preoperative surgical planning and surgical procedures. However, many surgeons have the impression that accuracy decreases during surgery. OBJECTIVE To quantify the decrease of neuronavigation accuracy and identify possible origins, we performed a retrospective quality-control study. METHODS Between April and July 2011, a neuronavigation system was used in conjunction with a specially prepared head holder in 55 consecutive patients. Two different neuronavigation systems were investigated separately. Coregistration was performed with laser-surface matching, paired-point matching using skin fiducials, anatomic landmarks, or bone screws. The initial target registration error (TRE1) was measured using the nasion as the anatomic landmark. Then, after draping and during surgery, the accuracy was checked at predefined procedural landmark steps (Mayfield measurement point and bone measurement point), and deviations were recorded. RESULTS After initial coregistration, the mean (SD) TRE1 was 2.9 (3.3) mm. The TRE1 was significantly dependent on patient positioning, lesion localization, type of neuroimaging, and coregistration method. The following procedures decreased neuronavigation accuracy: attachment of surgical drapes (DTRE2 = 2.7 [1.7] mm), skin retractor attachment (DTRE3 = 1.2 [1.0] mm), craniotomy (DTRE3 = 1.0 [1.4] mm), and Halo ring installation (DTRE3 = 0.5 [0.5] mm). Surgery duration was a significant factor also; the overall DTRE was 1.3 [1.5] mm after 30 minutes and increased to 4.4 [1.8] mm after 5.5 hours of surgery. CONCLUSION After registration, there is an ongoing loss of neuronavigation accuracy. The major factors were draping, attachment of skin retractors, and duration of surgery. Surgeons should be aware of this silent loss of accuracy when using neuronavigation.

Integrated Segmentation of Brain Tumor Images for Radiotherapy and Neurosurgery

Image-based modeling of tumor growth combines methods from cancer simulation and medical imaging. In this context, we present a novel approach to adapt a healthy brain atlas to MR images of tumor patients. In order to establish correspondence between a healthy atlas and a pathologic patient image, tumor growth modeling in combination with registration algorithms is employed. In a first step, the tumor is grown in the atlas based on a new multi-scale, multi-physics model including growth simulation from the cellular level up to the biomechanical level, accounting for cell proliferation and tissue deformations. Large-scale deformations are handled with an Eulerian approach for finite element computations, which can operate directly on the image voxel mesh. Subsequently, dense correspondence between the modified atlas and patient image is established using nonrigid registration. The method offers opportunities in atlasbased segmentation of tumor-bearing brain images as well as for improved patient-specific simulation and prognosis of tumor progression.

What is New and Innovative in Emergency Neurosurgery? Emerging Diagnostic Technologies Provide Better Care and Influence Outcome: A Specialist Review

The development of emergency medical services and especially neurosurgical emergencies during recent decades has necessitated the development of novel tools. Although the gadgets that the neurosurgeon uses today in emergencies give him important help in diagnosis and treatment, we still need new technology, which has rapidly developed. This review presents the latest diagnostic tools, which offer precious help in everyday emergency neurosurgery practice. New ultrasound devices make the diagnosis of haematomas easier. In stroke, the introduction of noninvasive new gadgets aims to provide better treatment to the patient. Finally, the entire development of computed tomography and progress in radiology have resulted in innovative CT scans and angiographic devices that advance the diagnosis, treatment, and outcome of the patent. The pressure on physicians to be quick and effective and to avoid any misjudgement of the patient has been transferred to the technology, with the emphasis on developing new systems that will provide our patients with a better outcome and quality of life.

Predictive value of cerebrospinal fluid (CSF) lactate level versus CSF/blood glucose ratio for the diagnosis of bacterial meningitis following neurosurgery.

The value of cerebrospinal fluid (CSF) lactate level and CSF/blood glucose ratio for the identification of bacterial meningitis following neurosurgery was assessed in a retrospective study. During a 3-year period, 73 patients fulfilled the inclusion criteria and could be grouped by preset criteria in one of three categories: proven bacterial meningitis (n = 12), presumed bacterial meningitis (n = 14), and nonbacterial meningeal syndrome (n = 47). Of 73 patients analyzed, 45% were treated with antibiotics and 33% with steroids at the time of first lumbar puncture. CSF lactate values (cutoff, 4 mmol/L), in comparison with CSF/blood glucose ratios (cutoff, 0.4), were associated with higher sensitivity (0.88 vs. 0.77), specificity (0.98 vs. 0.87), and positive (0.96 vs. 0.77) and negative (0.94 vs. 0.87) predictive values. In conclusion, determination of the CSF lactate value is a quick, sensitive, and specific test to identify patients with bacterial meningitis after neurosurgery.

Neurosurgery / Editor in chief, John Boyd Coates, Jr. ; editors for neurosurgery, R. Glen Spurling [and] Barnes Woodhall ; associate editor, Elizabeth M. McFetridge.

Includes bibliographical references and indexes.

Pedunculopontine nucleus deep brain stimulation produces sustained improvement in primary progressive freezing of gait

Objective: To assess the efficacy of bilateral pedunculopontine nucleus (PPN) deep brain stimulation (DBS) as a treatment for primary progressive freezing of gait (PPFG). ------ ----- Methods: A patient with PPFG underwent bilateral PPN-DBS and was followed clinically for over 14 months. ------ ----- Results: The PPFG patient exhibited a robust improvement in gait and posture following PPN-DBS. When PPN stimulation was deactivated, postural stability and gait skills declined to pre-DBS levels, and fluoro-2-deoxy-d-glucose positron emission tomography revealed hypoactive cerebellar and brainstem regions, which significantly normalised when PPN stimulation was reactivated. ------ ----- Conclusions: This case demonstrates that the advantages of PPN-DBS may not be limited to addressing freezing of gait (FOG) in idiopathic Parkinson's disease. The PPN may also be an effective DBS target to address other forms of central gait failure.