STUDY DESIGN:Retrospective cohort study. OBJECTIVES:To assess the impact of frailty, using modified 5-item frailty index (mFI-5), and sarcopenia, using temporalis muscle thickness (TMT), on motor and functional outcomes in patients with acute traumatic central cord syndrome (ATCCS). SUMMARY OF BACKGROUND DATA:Patients who suffer from ATCCS often are elderly patients who may be frail and sarcopenic. It would be useful to know the impact it has on their outcome, to see how they fair and identify the areas that need improvement. METHODS:Receiver operating characteristic analysis determined the optimal cut-off value of TMT at 3.965 mm. Patients were considered sarcopenic if their average TMT value was less than 3.965 mm. Primary outcomes were significant improvement in the American Spinal Injury Association Motor Score (AMS) scores at 6 and 12 months. Secondary outcomes were significant improvement in Functional Independence Measure (FIM) at 6 months, and significant recovery of Modified Japanese Orthopedic Association (mJOA) at 6 months. Logistic regression was performed to assess the influence of mFI-5 and TMT on these outcomes. RESULTS:A total of 80 patients were used in this study. Significant improvement in AMS improvement (71.4% vs. 90.4%, P=0.028), significant improvement in FIM (42.9% vs. 71.2%, P=0.013), and significant recovery in mJOA (14% vs. 38%, P=0.039) were all significantly lower in sarcopenic patients. Multivariate analysis found that the presence of sarcopenia was inversely related to significant improvement in FIM at 6 months (OR 0.026, 95% CI 0.002-0.414, P=0.010). The MFI score of 0 was positively associated with significant improvement in FIM at 6 months (OR 64.189, 95% CI 2.643-1412.016, P=0.010). CONCLUSIONS:Frailty and sarcopenia have a significant effect on motor and functional outcomes in ATCCS patients.

Mastering neuroanatomy is a cornerstone of neurosurgical training. Conventional neuroanatomy teaching is conducted with 2-dimensional (2D) images in a lecture format. These 2D methods of teaching neuroanatomy may not be adequate in inculcating a telescopic 3-dimensional (3D) visualisation of neuroanatomy which is necessary in neurosurgery. One such manner of nurturing a 3D understanding of anatomy is with the use of 3D stereoscopic photographs of cadaveric specimens. We conducted a neuroanatomy course comprised of such 3D stereoscopic images, to gauge its effectiveness in neuroanatomical learning amongst neurosurgical trainees of differing seniorities. A 10-session neuroanatomy course was conducted over 3 months in our institution. This course was prepared by the senior author and was composed of 3D stereoscopic visualisation (3DSV) of cadaveric dissections based on the 3D Rhoton collection. The course was administered to neurosurgical practitioners of differing experience and seniority, with each session lasting 2 to 3 hours, with audience interaction. Post-course surveys were conducted to assess usefulness - by utilising questions from the extended Kirkpatrick model, comparing 3DSV to 2D delivery and self-ratings of learner satisfaction and self-confidence. Analysis of the results included analysis of medians and proportions. Twenty-one participants responded to the survey. Learners were medical officers, junior residents, senior residents and consultants, with the median learner being a junior resident. There was strong agreement amongst learners that the course was enjoyable (85.7

Acute traumatic central cord syndrome (ATCCS) is the most common form of incomplete spinal cord injury. Treatment recommendations for ATCCS patients are largely from North America, and their applicability to Asian populations remains uncertain. Scoring systems such as the Acute Traumatic Central Cord Syndrome Score (ATCCSS), Central Cord Score (CCScore), and Subaxial Cervical AO Spine Injury Score (Subaxial AOSIS) can guide treatment, standardize practice, and improve outcomes. We aimed to validate and compare the predictive capabilities of ATCCSS, CCScore, and Subaxial AOSIS in a Southeast Asian population for surgical decision making, functional outcomes, and timing of surgery. We conducted a multicenter retrospective cohort study in Singapore from 2010 to 2023. The ATCCSS, CCScore, and Subaxial AOSIS were calculated for all patients and other relevant presenting, and radiological and surgical variables were collected. The primary outcome measure was significant motor recovery in the American Spinal Injury Association motor score (AMS) on 12-month follow-up. Secondary outcomes were significant motor recovery in the AMS score on 6-month follow-up, significant improvement in the Functional Independence Measure (FIM) score on 6-month follow-up, and significant recovery in the modified Japanese Orthopaedic Association (mJOA) score on 6-month follow-up. The predictive ability of the scores in predicting surgical management, meaningful recovery, and predicting timing of surgery was evaluated using receiver operating curve, with area under the curve (AUC) along with the corresponding 95% confidence intervals (CIs). Cutoff points were described for operative management and for the timing of surgery. A total of 116 patients were included with a mean age of 64.7 years (standard deviation = 12.9). The majority (86.2%) were male, and 65 (56.0%) patients underwent operative management. There was significant AMS improvement at 12 months in 95 (84.8%) of patients, significant AMS improvement at 6 months in 94 (83.2%) of patients, significant improvement in FIM at 6 months in 73 (62.9%) patients, and significant recovery in mJOA score in 67 (57.8%) of patients at 6 months. There were no significant differences in outcomes between operative and conservative management for functional outcomes. The median ATCCSS was 2 (interquartile range [IQR] 1), CCScore was 7 (IQR 4), and Subaxial AOSIS was 8 (IQR: 6). The ATCCSS had the highest predictive performance for the decision for operative management, with an AUC of 0.81 (95% CI: 0.73-0.89) compared with the other scores. All three scores did not predict motor and functional improvements well. The scores performed well for decision making in timing of surgery, with ATCCSS performing the best in predicting early surgery (AUC = 0.88, 95% CI: 0.81-0.95). The cutoff values for early surgery were 2.5 for ATCCSS and 8.5 for CCScore. Scoring systems in ATCCS performed well in decision making for surgery and timing of surgery but did not predict motor and functional recovery in a Southeast Asian cohort.

BACKGROUND:Sarcopenia has been purported to be a pre-operative risk factor that affects patient outcomes in oncological surgery, but no study as of yet has investigated the effect of sarcopenia in patients with spinal tumours. Psoas muscle measurements, including the psoas muscle index (PMI), are an objective way to determine sarcopenia. OBJECTIVES:We investigated if PMI could predict post-operative outcomes (length of hospital stay and post-operative complications) in surgically treated spinal tumour patients in a multi-ethnic Asian population. METHODS:We conducted a retrospective cohort study of patients with spinal tumours who underwent surgery at our tertiary institution from January 2016 to January 2020. PMI was measured on T2-weighted MRI sequences, at the middle of the L3 vertebral body and measurements were collected by 2 independent raters. The primary outcome was length of hospital stay (LOS), and the secondary outcome was post-operative complications. ROC curve was used to attain the cut-off value for PMI and the population was then stratified into 2 groups; sarcopenic if PMI was less than 1.22 and non-sarcopenic if the PMI value was more than or equal to 1.22. Multivariable linear regression was used for LOS, while multivariate logistic regression was used for complications. RESULTS:57 patients were included with a mean length of stay of 17.8 days (SD 25.1) and the total number of patients with complications were 20 (35.1 %). Mean LOS was significantly higher in the sarcopenic group compared to the non-sarcopenic group. Univariate analysis confirmed the association of lower psoas muscle index corresponding with longer lengths of stay and this was corroborated in a multivariable linear regression model. There were no significant associations between PMI and postoperative complications. CONCLUSIONS:Lower PMI values were significantly associated with a longer LOS. PMI may be warranted for risk stratifying Asian spinal tumour patients undergoing surgery.

Purpose Acute traumatic central cord syndrome (ATCCS) accounts for up to 70% of incomplete spinal cord injuries, and modern improvements in surgical and anaesthetic techniques have given surgeons more treatment options for the ATCCS patient. We present a literature review of ATCCS, with the aim of elucidating the best treatment option for the varying ATCCS patient characteristics and profiles. We aim to synthesise the available literature into a simple-to-use format to aid in the decision-making process. Methods The MEDLINE, EMBASE, CENTRAL, Web of Science and CINAHL databases were searched for relevant studies and improvement in functional outcomes were calculated. To allow for direct comparison of functional outcomes, we chose to focus solely on studies which utilised the ASIA motor score and improvements in ASIA motor score. Results A total of 16 studies were included for review. There were a total of 749 patients, of which 564 were treated surgically and 185 were treated conservatively. There was a significantly higher average motor recovery percentage amongst surgically-treated patients as compared to conservatively treated patients (76.1% vs. 66.1%, p value = 0.04). There was no significant difference between the ASIA motor recovery percentage of patients treated with early surgery and delayed surgery (69.9 vs. 77.2, p value = 0.31). Delayed surgery after a trial of conservative management is also an appropriate treatment strategy for certain patients, and the presence of multiple comorbidities portend poor outcomes. We propose a score-based approach to decision making in ATCCS, by allocating a numerical score for the patient’s clinical neurological condition, imaging findings on CT or MRI, history of cervical spondylosis and comorbidity profile. Conclusions An individualised approach to each ATCCS patient, considering their unique characteristics will lead to the best outcomes, and the use of a simple scoring system, can aid clinicians in choosing the best treatment for ATCCS patients.

External ventricular drainage (EVD) is carried out in many neurosurgical conditions for the diversion of cerebrospinal fluid. These EVD systems can, however, malfunction with potentially lethal consequences. Air bubbles within the EVD can result in air locking of the system with subsequent blockage of drainage, with blood clots and debris being the other causes. There are both non-invasive and invasive methods of rectifying such blockages, with invasive procedures having its associated risks. This is especially so for EVD revisions, with each surgery increasing the risk of ventriculitis. We describe a case of bilateral air locked EVD managed successfully with a novel non-invasive 'pressure differential efflux technique'. This method exploits the pressure gradient established by adjusting each EVD to a different height to evacuate the pneumoventricle. In addition, we present a sequential approach to the management of EVD malfunction, based on the current literature and our institutional protocol.

Background: Primary intracranial malignant melanoma (PIMM) is an uncommon brain malignancy that is often diagnosed after excluding melanoma brain metastases.It is often life-limiting with early relapse and portends a poor prognosis.Given its rarity, there are no well-defined standard treatments.Case Description: Here we described a middle-aged lady who has an underlying nevus of Ota and presents with new onset vision changes and unilateral headaches.The initial radiological diagnosis was thought to be a sphenoid wing meningioma but during the operation a blackish dural based tumour was noted with pigmented overlying dura.Gross total resection of visualized tumour was attempted.Further work-up performed uncovered a PIMM.A post-operative MRI brain scan was performed that showed possible residual disease.The patient was then treated with adjuvant hypofractionated stereotactic radiotherapy after a multi-disciplinary discussion; 7-month post-surgery she remained well with no evidence of relapse.There were also further improvements in visual symptoms.Conclusions: Given the rarity of this disease, there is little consensus for further management of such patients beyond surgery.We thus present a literature overview mainly based on reported case series of PIMM and melanoma brain metastases that have guided our management as well as to share our experience that may collectively help the future management of similar patients.

Introduction Aneurysmal subarachnoid haemorrhage (aSAH) is a condition with significant morbidity and mortality. Traditional markers of aSAH have established their utility in the prediction of aSAH outcomes while frailty markers have been validated in other surgical specialties. We aimed to compare the predictive value of frailty indices and markers of sarcopaenia and osteopaenia, against the traditional markers for aSAH outcomes. Methods An observational study in a tertiary neurosurgical unit on 51 consecutive patients with ruptured aSAH was performed. The best performing marker in predicting the modified Rankin scale (mRS) on discharge was selected and an appropriate threshold for the definition of frail and non-frail was derived. We compared various frailty indices (modified frailty index 11, and 5, and the National Surgical Quality Improvement Program score [NSQIP]) and markers of sarcopaenia and osteopaenia (temporalis [TMT] and zygoma thickness), against traditional markers (age, World Federation of Neurological Surgery and modified Fisher scale [MFS]) for aSAH outcomes. Univariable and multivariable analysis was then performed for various inpatient and long-term outcomes. Results TMT was the best performing marker in our cohort with an AUC of 0.82, Somers’ D statistic of 0.63 and Tau statistic 0.25. Of the frailty scores, the NSQIP performed the best (AUC 0.69), at levels comparable to traditional markers of aSAH, such as MFS (AUC 0.68). The threshold of 5.5 mm in TMT thickness was found to have a specificity of 0.93, sensitivity of 0.51, positive predictive value of 0.95 and negative predictive value of 0.42. After multivariate analysis, patients with TMT ≥ 5.5 mm (defined as non-frail), were less likely to experience delayed cerebral ischaemia (OR 0.11 [0.01 – 0.93], p = 0.042), any complications (OR 0.20 [0.06 – 0.069], p = 0.011), and had a larger proportion of favourable mRS on discharge (95.0% vs. 58.1%, p = 0.024) and at 3-months (95.0% vs. 64.5%, p = 0.048). However, the gap between unfavourable and favourable mRS was insignificant at the comparison of 1-year outcomes. Conclusion TMT, as a marker of sarcopaenia, correlated well with the presenting status, and outcomes of aSAH. Frailty, as defined by NSQIP, performed at levels equivalent to aSAH scores of clinical relevance, suggesting that, in patients presenting with acute brain injury, both non-neurological and neurological factors were complementary in the determination of eventual clinical outcomes. Further validation of these markers, in addition to exploration of other relevant frailty indices, may help to better prognosticate aSAH outcomes and allow for a precision medicine approach to decision making and optimization of best outcomes.

The novel coronavirus disease (COVID-19), has become the most critical global health challenge in recent history. With SARS-CoV-2 infection, there was an unexpectedly high and specific prevalence of olfactory and taste disorders (OTDs). These high rates of hyposmia and hypogeusia, initially reported as up to 89% in European case series, led to the global inclusion of loss of taste and/or smell as a distinctive feature of COVID-19. However, there is emerging evidence that there are striking differences in the rates of OTDs in East Asian countries where the disease first emerged, as compared to Western countries (15.8 vs. 60.9%, p-value < 0.01). This may be driven by either variations in SARS-CoV-2 subtypes presenting to different global populations or genotypic differences in hosts which alter the predisposition of these different populations to the neuroinvasiveness of SARS-CoV-2. We also found that rates of OTDs were significantly higher in objective testing for OTDs as compared to subjective testing (73.6 vs. 60.8%, p-value = 0.03), which is the methodology employed by most studies. Concurrently, it has also become evident that racial minorities across geographically disparate world populations suffer from disproportionately higher rates of COVID-19 infection and mortality. In this mini review, we aim to delineate and explore the varying rates of olfactory and taste disorders amongst COVID-19 patients, by focusing on their underlying geographical, testing, ethnic and socioeconomic differences. We examine the current literature for evidence of differences in the olfactory and gustatory manifestations of COVID-19 and discuss current pathophysiological hypotheses for such differences.

Objective: Multimorbidity burden across disease cohorts and variations in clinico-radiographic presentations within normal pressure hydrocephalus (NPH) confound its diagnosis, and the assessment of its amenability to interventions. We hypothesized that novel imaging techniques such as 3-directional linear morphological indices could help in distinguishing between hydrocephalus vs. non-hydrocephalus and correlate with responsiveness to external lumbar drainage (CSF responsiveness) within NPH subtypes. Methodology: Twenty-one participants with NPH were recruited and age-matched to 21 patients with Alzheimer's Disease (AD) and 21 healthy controls (HC) selected from the Alzheimer's Disease Neuroimaging Initiative (ADNI) database. Patients with NPH underwent testing via the NPH programme with external lumbar drainage (ELD); pre- and post-ELD MRI scans were obtained. The modified Frailty Index (mFI-11) was used to stratify the NPH cohort, including Classic and Complex subtypes, by their comorbidity and frailty risks. The quantitative imaging network tool 3D Slicer was used to derive traditional 2-dimensional (2d) linear measures; Evans Index (EI), Bicaudate Index (BCI) and Callosal Angle (CA), along with novel 3-directional (3d) linear measures; z-Evans Index and Brain per Ventricle Ratio (BVR). 3-Dimensional (3D) ventricular volumetry was performed as an independent correlate of ventriculomegaly to CSF responsiveness. Results: Mean age for study participants was 71.14 ± 6.3 years (18, 85.7% males). The majority (15/21, 71.4%) of participants with NPH comprised the Complex subtype (overlay from vascular risk burden and AD); 12/21 (57.1%) were Non-Responders to ELD. Frailty alone was insufficient in distinguishing between NPH subtypes. By contrast, 3d linear measures distinguished NPH from both AD and HC cohorts, but also correlated to CSF responsiveness. The z-Evans Index was the most sensitive volumetric measure of CSF responsiveness (p = 0.012). Changes in 3d morphological indices across timepoints distinguished between Responders vs. Non-Responders to lumbar testing. There was a significant reduction of indices, only in Non-Responders and across multiple measures (z-Evans Index; p = 0.001, BVR at PC; p = 0.024). This was due to a significant decrease in ventricular measurement (p = 0.005) that correlated to independent 3D volumetry (p = 0.008). Conclusion. In the context of multimorbidity burden, frailty risks and overlay from neurodegenerative disease, 3d morphological indices demonstrated utility in distinguishing hydrocephalus vs. non-hydrocephalus and degree of CSF responsiveness. Further work may support the characterization of patients with Complex NPH who would best benefit from the risks of interventions.

Abstract Background Triage trauma scores are utilised to determine patient disposition, interventions and prognostication in the care of trauma patients. Heart rate variability (HRV) and heart rate complexity (HRC) reflect the autonomic nervous system and are derived from electrocardiogram (ECG) analysis. In this study, we aimed to develop a model incorporating HRV and HRC, to predict the need for life-saving interventions (LSI) in trauma patients, within 24 h of emergency department presentation. Methods We included adult trauma patients (≥ 18 years of age) presenting at the emergency department of Singapore General Hospital between October 2014 and October 2015. We excluded patients who had non-sinus rhythms and larger proportions of artefacts and/or ectopics in ECG analysis. We obtained patient demographics, laboratory results, vital signs and outcomes from electronic health records. We conducted univariate and multivariate analyses for predictive model building. Results Two hundred and twenty-five patients met inclusion criteria, in which 49 patients required LSIs. The LSI group had a higher proportion of deaths (10, 20.41% vs 1, 0.57%, p < 0.001). In the LSI group, the mean of detrended fluctuation analysis (DFA)-α1 (1.24 vs 1.12, p = 0.045) and the median of DFA-α2 (1.09 vs 1.00, p = 0.027) were significantly higher. Multivariate stepwise logistic regression analysis determined that a lower Glasgow Coma Scale, a higher DFA-α1 and higher DFA-α2 were independent predictors of requiring LSIs. The area under the curve (AUC) for our model (0.75, 95% confidence interval, 0.66–0.83) was higher than other scoring systems and selected vital signs. Conclusions An HRV/HRC model outperforms other triage trauma scores and selected vital signs in predicting the need for LSIs but needs to be validated in larger patient populations.

INTRODUCTIONOwing to the scarcity of randomized controlled trials to guide treatment for decompression illness (DCI), there are many unanswered questions about its management. Apart from reviews and expert opinion, surveys that report practice patterns provide information about useful management strategies. Hence, this study aimed to identify current treatment preferences for DCI amongst diving physicians in Singapore.METHODSAn anonymous web-based questionnaire was sent to known diving physicians in Singapore. The demographics of the respondents were captured. Respondents were asked about their preferred management for five different DCI scenarios.RESULTSThe response rate was 74% (17 of 23 responses). All respondents chose to recompress patients described in the five scenarios. Regarding the number of recompression sessions, "one additional session after no further improvement in signs and symptoms" was the most common end point of treatment across all the scenarios (47 of 85 responses). Analgesics would be used by five physicians, three would use lidocaine and two steroids as adjuvant therapies.CONCLUSIONSApart from the general agreement that recompression is indicated for DCI, there was no strong consensus regarding other aspects of management. This survey reinforces the need for robust RCTs to validate the existing recommendations for DCI treatment.