Ukrainian Neurosurgical Journal

Pediatric neurosurgery in Ukraine in 2001-2020. Availability, workforce, performance indicators

Sat, 30 Mar 2024 00:00:00 +0200

Objective: to analyze the development dynamics of pediatric neurosurgical care in Ukraine in 2001-2020.

Materials and methods. The number of pediatric neurosurgical beds, pediatric neurosurgeons, hospitalization rates and surgical treatment of children in neurosurgical departments of Ukraine in 2001‒2020 were analyzed. Data for the years 2014-2020 were unavailable for departments located in temporarily non-government-controlled territories.

Results. In 2020, there were 22 pediatric neurosurgery departments in Ukraine, with a total of 290 pediatric neurosurgical beds, representing a 26.6% increase compared to 2001. Pediatric neurosurgical departments or pediatric units with neurosurgical beds were operational in almost all regions. The distribution of pediatric neurosurgical beds in Ukraine did not statistically differ from countries with high-income levels (p=0.9987). The increased number of beds contributed to more than doubling the provision of neurosurgical beds per child population. In 2001, there were 17 beds per 1 million children, compared to 38 beds in 2020.

In 2020, the number of pediatric neurosurgeons in Ukraine doubled compared to 2001 reaching 58 in 2020 (9.2% of the total number of neurosurgeons in Ukraine and 2.5% of the total number of pediatric neurosurgeons globally). The provision of pediatric neurosurgeons in Ukraine increased more than threefold from 2001 to 2020, reaching 7.7 per 1 million children, meeting the Ministry of Health of Ukraine's standard (7.5). Consequently, the workload per pediatric neurosurgeon decreased almost fourfold, with one specialist per 129,895 children.

In 2020, the number of children hospitalized in neurosurgical departments was 9,045, operated on ‒ 3,144, representing a 15.8% decrease and a 3.3% increase, respectively compared to 2001. Per 1 million child population, the hospitalization rate increased by 53, 8% (1201 and 781), the surgery rate increased by 88.7% (417 and 221).Despite the decrease in the number of operated patients over 20 years, surgical activity in neurosurgical institutions of the country increased from 28.3% in 2001 to 34.8% in 2020 (by 23%), postoperative lethality during this period decreased from 2,1 to 1.0% (by 52%).Significant fluctuations in hospital morbidity (HM) rate of children for general neurosurgical pathology and its individual types were recorded during the studied period. In 2020, an increase in these indicators was noted compared to 2001: HM for pediatric neurosurgical pathology in general increased by 53.7% (from 781 to 1,201 cases per 1 million child population), for acute craniocerebral trauma - by 17,5% (from 595 to 699), for hydrocephalus - 5.1 times (from 29 to 149), for neuro-oncological diseases - 3.2 times (from 31 to 100), for congenital anomalies of the nervous system - 4 times ( from 15 to 60), for vascular lesions of the nervous system - 5.1 times (from 5 to 26), for acute spinal trauma - twice (from 9 to 18).

Conclusions. Ukraine is a country with high availability of pediatric neurosurgical care. Over the past 20 years, there has been an increase in the provision of pediatric neurosurgery beds and pediatric neurosurgeons. In the first 13 years of the 21st century the trend towards a significant increase in both absolute and relative rates of hospitalization and surgery for children with neurosurgical pathology in subsequent years as a result of the annexation of Crimea, military actions in Donbas and the coronavirus epidemic has changed to a trend towards a decrease in these rates. However, in general, only the absolute number of hospitalized children decreased over 20 years, while the absolute number of operated on and the level of hospitalization and operated on increased. Surgical activity also increased accompanied by a decrease in postoperative lethality.

Surgical treatment of degenerative stenotic lesions of the lumbar spine. Own experience of using minimally invasive techniques

Ivan O. Kapshuk, Yuriy E. Pedachenko — Sat, 30 Mar 2024 00:00:00 +0200

Lumbar spinal stenosis is a multifactorial progressive condition mainly affecting older individuals, characterized by narrowing of the natural anatomical pathways passage of nerve structures, resulting in typical clinical symptoms. The disease affects about 103 million people in worldwide with an incidence of absolute lumbar spinal stenosis 19.4% among individuals aged 60-69 years. In the United States, about 600,000 surgical interventions for lumbar spinal stenosis are performed annually.

This disease is one of the most common causes of lumbar pain and lower limbs in the elderly individuals, accompanied by claudication and ultimately leading to disability. The main cause of clinical symptoms of the lumbar spinal stenosis is the discrepancy between the sizes of nerve structures and their osteofibrous sheaths, resulting from gradually developing degenerative-dystrophic changes.

Objective: To compare the outcomes of surgical treatment of patients with degenerative stenotic lesions of the lumbar spine using open and minimally invasive methods.

Materials and methods. The results of surgical treatment of 97 patients with lumbar spinal stenosis aged from 28 to 81 years on the basis of the Department of Minimally Invasive and Laser Spinal Neurosurgery of the State Institution " A.P. Romodanov Neurosurgery Institute, Ukraine", " Neurosurgical Department №20 of Vinnytsia Regional Clinical Psychoneurological Hospital named after Acad. O.I. Yushchenko" of Vinnytsia Regional Council and "Spinex" Medical Center following all clinical research protocols. Patients were divided into four groups depending on the surgical intervention method.

Results. The development of concepts regarding the mechanisms of occurrence and treatment methods of lumbar spinal stenosis are highlighted, as well as personal experience of using minimally invasive treatment techniques for this pathology in combination with the use of the ERAS (Enhanced Recovery After Surgery) protocol of perioperative patient management. It was found that the duration of hospital stay for patients with lumbar spinal stenosis statistically significantly desreased when using minimally invasive decompression (p≤0.05) and the ERAS rehabilitation protocol (p≤0.05). When comparing the average length of stay in the hospital of patients of the four groups, a statistically significant (p≤0.05) shorter length of stay in the hospital was observed for patients who underwent minimally invasive decompression using the ERAS rehabilitation protocol. The greatest reduction in pain intensity (according to the Numeric Pain Scale (NPS)) at 6 months post- intervention and rehabilitation was also noted in patients of this group.

Conclusions. The use of minimally invasive techniques, the correct choice of surgical procedure volume (interbody fusion is desirable in surgery for degenerative spinal diseases) combined with Enhanced Recovery after Surgery protocol (ERAS) significantly improves postoperative well-being of patients, accelerates patient mobilization, and reduces the length of stay in the hospital.

Clinical and neuroimaging predictors of the outcome of microsurgical intervention against the background of cerebral aneurysms rupture

Viktoriya A. Kazantseva, Mykola O. Zorin — Sat, 30 Mar 2024 00:00:00 +0200

Objective: minimization of the risks of complications of microsurgical intervention (MI) for cerebral aneurysm (CA) rupture due to established clinical and neuroimaging predictors.

Material and methods. Evaluation of microsurgical treatment of 418 patients in the acute period of cerebral aneurysms (CA) rupture in the 2013-2018 period, that were operated at the Vascular Neurosurgery Center of the Dnipropetrovsk Regional Clinical Hospital named after I.I. Mechnikov, taking into account factors that may have an influence on favorable or unfavorable functional consequences. Age, gender, as well as clinical-neurological and neuroimaging assessment of the condition of patients according to the severity of aneurysmal subarachnoid hemorrhage (SAH) according to the Hunt-Hess classification, WFNS, level of consciousness impairment according to the Glasgow Coma Scale (GCS) were studied. The severity of aneurysmal subarachnoid hemorrhage was evaluated according to the Fisher prognostic scale according to the performed spiral computed tomography (SCT). Cerebral angiospasm (CAS) was evaluated according to cerebral angiography (CAG), and its severity according to transcranial dopplerography (TCD) on the day of hospitalization and surgery. The performed microsurgical intervention (MI) was evaluated according to the Glasgow Outcome Scale (GOS). The study was both retrospective and prospective.

Results. Among 77 (18.4%) patients with adverse consequences of MI according to 1-3 points of GOS, a dependence was reliably found on the level of consciousness disturbance according to GCS, the severity of meningeal and focal symptoms, the severity of parenchymal hemorrhage, CAS manifestations on the day of surgery according to TCD, the duration of surgery after the rupture of CA (p<0.001). There was no statistically significant relationship between age, sex, localization, form and side of CA rupture. Also, a strong inverse correlation was found between GCS and classification of SAH according to WFNS rs=‒0.96 (95% CI 0.96-0.97) and Hunt-Hess rs=‒0.81 (95% CI 0.77-0.84) during hospitalization.

Conclusions. The effectiveness of MI in the case of CA rupture depends on the severity of prognostic criteria of clinical and neurological examination - evaluation by the GCS, neurological disorders, severity of parenchymal hemorrhage, manifestations of CAS on the day of surgery for TCD, the duration of surgery after CA rupture. Revealed relationship between the score according to the GOS, classifications of SAH according to the WFNS and Hunt-Hess significantly simplifies diagnostic measures during the examination of patients in the acute period of CA rupture.

Minimally Invasive Interventions on Ganglion Impar in Treatment of Patients with Coccygodynia

Dmytro M. Romanukha, Vadym V. Biloshytsky — Sat, 30 Mar 2024 00:00:00 +0200

Chronic pelvic pain (CPP) is usually treated conservatively, but in patients who do not respond to treatment, ganglion impar (GI) interventions are used as an alternative way to reduce pain.

Objective ‒ to study the course of pain syndrome and functional status in patients with coccygodynia (CD) and CPP during the application of minimally invasive interventions on GI.

Materials and methods. The analysis of the results of 56 interventions on GI in 50 patients was performed. Inclusion criteria were patients with coccyx pain for ≥3 months aged 23 to 71 years (mean age 47.9±14.8years) who did not respond to conservative treatment methods. 15 (35.7%) of the study participants were male and 27 (64.3%) were female. Interventions were performed on the patients according to five different methods, which were divided into two groups: the first group (n=34) ‒ GI block (GIB) with a local anesthetic and a steroid (patients with CD in whom medical conservative methods of treatment were not effective). The second group (n=14) consisted of persons with recurrent pain syndrome, resistant forms of CD and CPP, including after previously performed steroid injections: n=2 – neurolysis of GI with ethyl alcohol; n=2 – neurolysis of GI by phenol; n=3 – radio frequency modulation of GI; n=7 – radiofrequency ablation of GI.

Results. 14.0% of all study participants had post-traumatic CD (history of falling on the coccyx), the vast majority of 86.0% ‒ idiopathic CD. Pain intensity was significantly lower post-intervention compared to baseline VAS mean of 7.6±1.5 cm: 2.5±0.9 cm one-week post-procedure, 1.5±1.9 cm one month, 1.3±1.5 cm three months, 2.1±1.2 cm six months. The average score according to the Karnovsky Scale (KS) before and after the procedure was 73.3±6.3% and 83.9±4.9%, respectively.

Conclusions. Interventions on ganglion impar are an effective method of treating patients with coccygodynia of various etiology, which significantly reduce pain according to the VAS scale (p<0.001) and improve the quality of life according to the KS (p<0.001) in dynamics after 1, 3, 6 months. Minimally invasive interventions on ganglion impar make it possible to reduce tissue trauma, to quickly recover for patients after the procedure, and to minimize any complications. In the first and second groups of the study, there was a decrease in the pain on the VAS from 8.0 cm to 2.0 cm (p<0.0001) and from 7.0 cm to 2,7 cm (p<0.001) before and after the procedure, respectively. In the first and second groups of the study, there was an improvement in the indicator of functional status according to the KS from 70% (95% сonfidence interval (CI) 60‒90%) to 90% (95% CI 70‒100%, p<0.0001) and from 70% (95% CI 70‒90%) to 90% (95% CI 80‒100%, p=0.001) before and after the procedure, respectively.

Clinical biomechanics of the spine in three unsolved problems. A brief analytical review

Volodymyr V. Medvediev, Myroslava O. Marushchenko — Sat, 30 Mar 2024 00:00:00 +0200

Chronic pathology of the spine, especially its forms, such as degenerative disc disease (DDD), is one of the most common in the human population and a marker for a person. Even though this pathology lacks the burden of mortality, its existence and consequences worsen the quality of life. Hypotheses of the high prevalence of DDD often appeal to a person's upright gait and the function of the spine as a movable vertical support, which means a permanent significant axial load of the intervertebral discs (IVDs). Therefore, finding out the magnitude of such a load, its dependence on the body's position in space, and types of motor activity is an essential practical task of the biomechanics of the spine as a separate interdisciplinary direction of biomedical research.

Despite all the efforts and significant activity during the 70s and 80s of the last century, the central questions of clinical biomechanics of the spine still need to be explored. It is visible from the state of development of three "legendary" problems ‒ elucidation of intradiscal pressure against the background of usual types of physical activity, the role of sitting in the promotion of DDD of the lumbar region, and determination of the role of intra-abdominal pressure in reducing the axial load of this region of the spine. For example, the results of the investigations can state that assessment of intradiscal pressure against the background of human behavioral activity has so far been the focus of a disproportionately small number of works, which, due to the weakness of the accompanying visualization and the technical unreliability of the sensors did not obtain a sufficient empirical base for statistically significant conclusions. Therefore, the urgent task of the future is developing and using a more accurate, reliable, miniature, and durable intradiscal pressure monitoring technique, which would make it possible to evaluate this parameter on large samples of volunteers with conditionally intact IVD and against the background of pathology. In this regard, the assumptions about the role of sitting in the development of DDD of the lumbar spine remain unverified.
Similarly, the research on the phenomenon of intra-abdominal pressure needs to determine under what conditions and mechanisms this factor can affect the magnitude of the axial load on the lumbar spine. Also, constructing more insightful models of the biomechanics of the spine is only possible with expanding ideas about the composition, vascularization, and innervation of the IVD, biology, and pathology of IVD cells. The practical outcome of all these studies is delineation of the most dangerous types of motor activity in the promotion of DDD, which will bring us closer to understanding the drivers of DDD and thus improving the means of preventing and treating this ubiquitous pathology.