Bilateral anterior cingulotomy is a palliative procedure occasionally used for cancer pain, and human studies suggest anterior cingulate cortex is active in dyspnoeic states.A case of debilitating thoracic wall pain due to malignant mesothelioma relieved by bilateral anterior cingulotomy is described and changes in dyspnoea investigated.Improvements in pain, dyspnoea and the extent to which either symptom bothered the patient was seen for 2 months after surgery before disease progression led to death 5 months after surgery. Quality of life improvements were also seen for 2 months after surgery and pain relief was sustained from surgery to death. Arterial blood gas and lung function tests were unchanged by surgery, suggesting a reduction in pain and dyspnoea awareness by cingulotomy.Bilateral anterior cingulotomy effectively relieved both pain and dyspnoea. The role of the anterior cingulate cortex in pain and autonomic control of respiration is discussed alongside the evidence for this palliative procedure for cancer pain.
Objectives: Documentation of urgent referrals to neurosurgical units and communication with referring hospitals is critical for effective handover and appropriate continuity of care within a tertiary service. Referrals to our neurosurgical unit were audited and we found that the majority of referrals were not documented and this led to more calls to the on-call neurosurgery registrar regarding old referrals. We implemented a new referral system in an attempt to improve documentation of referrals, communication with our referring hospitals and to professionalise the service we offer them. Methods: During a 14-day period, number of bleeps, missed bleeps, calls discussing new referrals and previously processed referrals were recorded. Whether new referrals were appropriately documented and referrers received a written response was also recorded. A commercially provided secure cloud-based data archiving telecommunications and database platform for referrals was subsequently introduced within the Trust and the questionnaire repeated during another 14-day period 1 year after implementation. Results: Missed bleeps per day reduced from 16% (SD ± 6.4%) to 9% (SD ± 4.8%; df = 13, paired t-tests p = 0.007) and mean calls per day clarifying previous referrals reduced from 10 (SD ± 4) to 5 (SD ± 3.5; df = 13, p = 0.003). Documentation of new referrals increased from 43% (74/174) to 85% (181/210), and responses to referrals increased from 74% to 98%. Conclusion: The use of a secure cloud-based data archiving telecommunications and database platform significantly increased the documentation of new referrals. This led to fewer missed bleeps and fewer calls about old referrals for the on call registrar. This system of documenting referrals results in improved continuity of care for neurosurgical patients, a significant reduction in risk for Trusts and a more efficient use of Registrar time.
Introduction: Rising NHS waiting lists are a major problem following the COVID-19 pandemic. In our institution, surgical waiting time for elective functional neurosurgical procedures, such as deep brain stimulation (DBS) and radiofrequency ablation (RFA), reached >1.5 years by the end of 2022. During 2023, reduced operating room availability, intraoperative MRI (iMRI) suite closure for refurbishment, and ongoing strikes threatened to increase waiting times further. Methods: Our previous surgical workflow for DBS and RFA procedures was examined. Several aspects were identified, and changes implemented to increase efficiency. Procedure numbers, waiting times, lead placement accuracy, and complication rates before and after these changes were compared. Results: Prior to 2023, an average of 0.8 new procedures were performed per surgical list. Introduction of a new workflow in 2023 allowed an average of 1.6 new procedures per surgical list (100% increase in productivity). In 2023, 95 DBS and 31 RFA procedures were performed on 79 surgical lists. This represents a 52% increase over “pre-pandemic” activity in 2019 (74 DBS, 9 RFA) on 102 available surgical lists. Mean (SD) targeting accuracy (0.8 [0.4] mm) was comparable to previous years (0.9[0.3] mm). In 2023, there were no infections requiring hardware removal and only one asymptomatic haemorrhage following an RFA procedure. The surgical waiting time was reduced from >1.5 years to <4 months by the end of 2023. Conclusion: Changes in surgical workflow, with neurosurgeons working in parallel, maximise surgical efficiency and productivity, significantly increasing the number of DBS and RFA procedures without compromising accuracy and safety.
Deep brain stimulation (DBS) can provide dramatic essential tremor (ET) relief, however no Class I evidence exists.Analysis methods: I) traditional cohort analysis; II) N-of-1 single patient randomised control trial and III) signal-to-noise (S/N) analysis. 20 DBS electrodes in ET patients were switched on and off for 3-min periods. Six pairs of on and off periods in each case, with the pair order determined randomly. Tremor severity was quantified with tremor evaluator and patient was blinded to stimulation. Patients also stated whether they perceived the stimulation to be on after each trial.I) Mean end-of-trial tremor severity 0.84 out of 10 on, 6.62 Off, t = - 13.218, p < 0.0005. II) N-of-1: 60% of cases had 12 correct perceptions (p = 0.001), 20% had 11 correct perceptions (p = 0.013). III) S/N: > 80% tremor reduction occurred in 99/114 'On' trials (87%), and 3/114 'Off' trials (3%). S/N ratio for 80% improvement with DBS versus spontaneous improvement was 487,757-to-1.DBS treatment effect on ET is too large for bias to be a plausible explanation. Formal N-of-1 trial design, and S/N ratio method for presenting results, allows this to be demonstrated convincingly where conventional randomised controlled trials are not possible.This study is the first to provide Class I evidence for the efficacy of DBS for ET.
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