OpenUCT :: Browsing by Department "Division of Neurosurgery"

Browsing by Department "Division of Neurosurgery"

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Open Access
Adult neoplastic spinal cord compression
(2000) Pillay, Robin; Peter, J C
Spinal cord compression ( SCC ) constitutes a neurological emergency, and if left untreated, can result in permanent irreversible neurological dysfunction. Disabilities can range from mild weakness to complete quadriplegia with the inherent associated mental, physical and emotional suffering .The burden of cost to the individual and community is enormous.
Open Access
Advantages of delayed ventriculoperitoneal shunting in post haemorrhagic hydrocephalus seen in low birth weight infants
(1999) Taylor, Allan Grant; Peter, Jonathan C
INTRODUCTION: The incidence of intraventricular hemorrhage (IVH) in very low birth weight infants is between 25 and 50%. Approximately 13-60% of these patients will develop progressive post hemorrhagic hydrocephalus (PHH) and of these 22- 70% will require CSF diversion. The most common therapeutic intervention is insertion of a ventriculoperitoneal shunt but there is considerable controversy surrounding the timing of the operation. Most authors promote early surgery to prevent secondary injury from hydrocephalus but it was our impression that this was associated with a higher incidence of shunt complications. METHOD: The incidence of shunt complications in 36 patients shunted for PHH were retrospectively reviewed. Patients were treated at Red Cross Children's Hospital over an 8 year period. RESULTS: Nine (25%) of the 36 patients required shunt revision for obstruction, seven required revision during the initial admission. Shunt infection occurred in 4 patients (11 %) all during the initial hospital admission. Four patients died, one from a shunt related complication. There was a clear relationship between the timing of surgery and the incidence of complications (chi square test p,0.01 ). Nineteen patients underwent surgery before 5 weeks of age and 9 developed early shunt complications. Of those shunted after 5 weeks none had an early complication. Groups were matched for weight and grade of IVH. DISCUSSION: A possible explanation for these results is that shunt complications are related to the quantity of blood present in the CSF at the time of shunting. A short delay before intervention is recommended in an effort to reduce the morbidity of shunt complications.
Open Access
Bacterial intracranial aneurysms
(1990) Aspoas, A R
Open Access
Barbiturate treatment in experimental transient focal cerebral ischaemia
(1982) Kieck, Charles Frederick
When the research, which forms the basis of this thesis was started in 1979, the theoretically attractive situation of transient focal cerebral ischaemia simulating a cerebral vessel occlusion followed by re-vascularization, had not been specifically investigated with barbiturate treatment. Cerebral infarction is progressive and evolves over hours, proceeding from ischaemia and functional loss to cell death. Sundt et al (1969), Crowell et al (1970), Hayakawa and Waltz (1975). Complete recovery is possible if re-vascularization is instituted in time. This time interval depends on the regional cerebral bloodflow during the period of the vessel occlusion and this bloodflow is provided by the collateral circulation. Thus, whether infarction results and the extent of it, becomes a factor of the period of ischaemia and the collateral circulation present. Dujovny et al (1976), Morawetz et al (1978), Ojeman et al (1979), Kieck and Crowell (1979), Jones et al (1981). This ischaemic period may vary tremendously from less than an hour to as much as 5 hours and occlusion times of up to an hour can be tolerated without infarction at very low regional cerebral bloodflow levels. Morawetz et al (1978), Kieck and Crowell (1979), Jones et al (1981). In the clinical situation there would be an obligatory delay from the onset of ischaemia to the institution of barbiturate treatment and completion of re-vascularization. Treatment during this period would thus be a major contribution if it could afford protection so as to allow restitution of cerebral bloodflow before irreversible infarction took place. The South African Vervet monkey was chosen for the investigation of the effect of barbiturate treatment on transient focal cerebral ischaemia in a model simulating the clinical event. In this experiment pentobarbital therapy would be delayed for 1 hour to provide for the expected delay that would occur from the onset of ischaemia to the institution of treatment. Similarly, ischaemia was to last 4 hours to allow for a minimum time interval necessary to complete the re-vascularization. It was also borne in mind that many stroke patients would be older people; the barbiturate dose of 30mg/kg would be such as to induce prolonged coma but not major cardiovascular disturbances with a fall in blood pressure and/or cardiac arrest.
Open Access
Biomarkers of neurological tissue injury and inflammation in paediatric tuberculous meningitis
(2014) Rohlwink, Ursula Karin; Figaji, Anthony
[Background] Tuberculous meningitis (TBM) in children has high mortality and neurological morbidity rates. The assessment of disease severity and prognostication are difficult because several factors influence initial presentation, and advanced tools for these are lacking. Biomarkers of neurological injury could help to assess severity and to prognosticate, but have not been assessed in paediatric TBM. This study examined serum and cerebrospinal fluid (CSF) biomarkers of neurological injury in paediatric TBM in association with clinical and physiological data, radiology, inflammatory markers, and outcome. [ Methods ] Serum and CSF (ventricular and lumbar) samples were taken on admission and over 3 weeks in children with probable TBM and hydrocephalus. These were analysed with ELISA for neuromarkers S100B, neuron-specific enolase (NSE) and glial fibrillary acidic protein (GFAP), and with Luminex multianalyte array assay for a panel of inflammatory markers. Results were compared with 2 controls groups. Computerized tomography was done on admission and magnetic resonance imaging (brain, spine and magnetic resonance angiography) at 3 weeks. Brain oxygenation was monitored invasively and non-invasively in selected patients. Clinical and neurodevelopmental outcomes were assessed at 6 months. Data were analysed with various statistical tools, including principal component analysis. [ Results ] Data were collected from 44 children. Of these, 16% died and 36% had disability (25% mildmoderate, 11% severe). S100B, NSE, GFAP and inflammatory markers were elevated in CSF on admission and for up to 3 weeks, but not in serum. Elevated neuromarkers were significantly associated with poor outcome and increased over time in patients who died, although combined inflammatory biomarkers decreased. Cerebral infarcts occurred in 66% of patients and were associated with neuromarker elevation. Novel findings on spinal MRI were the high frequency of asymptomatic disease. Cerebral vascular pathology was documented frequently on imaging but did not predict infarcts. Low brain oxygenation was common and in keeping with physiological events and outcome. [ Conclusion ] CSF neuro- and inflammatory markers are elevated in TBM. Neuromarkers were prognostic of clinical and radiological outcome and an increasing trend suggested ongoing injury. This does not appear to be related to ongoing inflammation as measured by cytokines but may reflect the ongoing secondary injury processes initiated by inflammation.
Open Access
Blushing and gaze avoidance in social anxiety disorder : a structural neuroanatomical investigation
(2014) Van der Merwe, Nicolina Thandiwe; Stein, Dan J; Malcolm-Smith, Susan; Brooks, Samantha J
Background: Social anxiety disorder (SAD) is a common psychiatric condition characterised by fear and avoidance of social situations. Lifetime prevalence is 5-16% and co-morbidity with other mood and substance abuse disorders is common. Symptoms including cognitive, behavioural and physiological components vary between individuals. Of these, blushing and gaze fear and avoidance are regarded as cardinal symptoms. First line treatment of SAD involves SSRIs and cognitive behavioural therapy, while surgery may also be considered for excessive blushing. Blushing and gaze avoidance are thought to have an evolutionary adaptive advantage, promoting the display of submissive behaviour and appeasement in threatening situations. MRI research has demonstrated differences on functional and structural neuroimaging between patients with SAD and healthy controls (HCs). However, little is known about the neurocircuitry underlying gaze fear and avoidance or increased blushing propensity or how the severity of these traits correlate with the neuroimaging differences found in SAD. In this research, I explored the neuroanatomy of blushing propensity and gaze fear and avoidance in the context of SAD. Methods: 18 SAD patients and 18 HCs underwent structural MRI scans and self-report scales were administered to assess their symptom severity, blushing propensity and gaze fear and avoidance. Structural data was analysed using voxel-based morphometry (VBM). Regression and contrast analyses were used to correlate blushing propensity and gaze anxiety and avoidance symptoms with brain volumes, controlling for total grey matter volume, age and level of education. Results: Anxiety, blushing propensity and gaze fear and avoidance symptoms were all significantly higher in SAD patients (p<0.001). Brainstem volumes were increased for higher blushing scores a (p<0.01), while the volumes of left inferior parietal lobe b (p=0.04) and left occipital cortex a (p<0.01) were decreased. With increased gaze fear and avoidance, there were associated decreases in the right posterior cingulate cortex a (p<0.01), right occipital lobe b (p=0.03) and right fusiform gyrus a (p<0.01). Increased blushing and gaze symptom severity considered together, was associated with increased brainstem volume a (p<0.01) and decreased pons/cerebellum b (p=0.001), right cerebellum b (p=0.009), left cerebellum c (p<0.001) and left inferior parietal lobe a (p<0.1), volumes. Contrast analysis of SAD and HC brain volumes revealed a greater grey matter volume in HCs in the regions of left occipital cortex (p<0.01), left anterior cingulate (p<0.01) and right inferior parietal lobe (p<0.01) when compared to SAD patients. Increased symptom severity in SAD was significantly associated with higher volumes in the left premotor cortex (p<0.01), right hippocampus (p<0.01), left orbitofrontal cortex (p<0.01) and right superior temporal cortex (p<0.01). Possible areas for of interest for volume differences between SAD and HCs include total grey matter volume (d =0.83), left and right anterior cingulate cortex (d =0.68 and d =0.65), and left and right dorsolateral prefrontal cortex (d =0.55 and d =0.54), yet these differences were not significantly different. (a uncorrected peak levels b uncorrected cluster level, c corrected cluster level). Conclusion: Differences in brain volumes pertaining to blushing and gaze fear and avoidance in SAD patients may be a contributing factor or a consequence of these core symptoms, and a potential biomarker for SAD. Future studies could build on this preliminary research with increased sample sizes, and determine the possible effects of reduced symptom severity and treatment options on brain structure and function. Most importantly, an investigation of the genetic underpinnings and functional neural correlates of blushing and gaze avoidance behaviour may enhance our understanding of the complex aetiology of these cardinal SAD symptoms, thereby improving our understanding of SAD as a psychiatric disorder and facilitating better patient care and management.
Open Access
Brain arteriovenous malformations presenting with haemorrhage
(2012) Mjoli, Ntethelelo; Taylor, Allan; Feuvre, David Le
Includes bibliographical references.
Open Access
The Cape Town Stereotactic pointer clinical development and Applications
(2009) Fieggen, Anthony Graham; Peter, Emeritus Jonathan C
This dissertation describes the development and clinical use of a novel stereotactic neurosurgical system, the Cape Town Stereotactic Pointer (CTSP). This system has four main components; a halo containing three fiducials also serves as the platform for a tripod pointing device which is set with the aid of a 3D phantom or a printed setting diagram, and software which enables transformation of imaging space into patient space. Laboratory tests indicated an application accuracy of 1.9 +/- 0.6mm using the 3D phantom to set the tripod. From the first clinical application, the system underwent a series of iterations which could broadly be divided into four successive phases of refinement. This took place over a six year period, encompassing one hundred patients who underwent 115 stereotactic procedures. Indications for surgery included biopsy (62.6%), aspiration (15.7%) and cannulation (21.7%) and the surgical objective was realized in 101/109 cases (92.7%). Given the fact that six of the eight failures represented errors of surgical judgment that could not be ascribed to the device, and each of two system errors resulted in a significant modification to the system, the CTSP demonstrated a satisfactory level of accuracy in the clinical setting. This was accomplished at an acceptable complication rate, with one death five days after surgery attributable to a stereotactic procedure (mortality 0.9%) and major morbidity in two cases (1.7%); thirteen patients experienced minor complications, all of which proved to be transient (11.3%). A simple protocol for use of the CTSP evolved over the course of this study, making it easier for neurosurgeons from varying backgrounds to introduce stereotaxis into their practice with the help of this system. In addition to satisfactory levels of clinical reliability and safety, the system was versatile and also well tolerated by patients. It is hoped that the CTSP provides a costeffective alternative for neurosurgeons working in under-resourced settings. Sixty units of the production version of the CTSP have been sold and the system is now in use in ten countries.
Open Access
Cerebral autoregulation in children with traumatic brain injury: Comparing the autoregulatory index (ARI) to pressure reactivity index (PRx) and their associations with cerebral physiological parameters
(2017) Patel, Maryam; Figaji, Anthony; Enslin, Johannes M N
As an important hemodynamic mechanism, pressure autoregulation protects the brain against inappropriate fluctuations in cerebral blood flow subject to changing cerebral perfusion pressures. In acute neurological illnesses, including traumatic brain injury in children, impaired autoregulation is associated with a worse prognosis. It also has important clinical implications for managing blood pressure and intracranial pressure. Two common methods of measuring pressure autoregulation reported in the adult literature have been rarely reported in children. This pilot study aimed to examine the relationship between two autoregulatory indices, namely PRx (pressure reactivity index) and ARI (autoregulatory index) in children with severe TBI. The study also examined their relationship with the response of clinically relevant variables such as intracranial pressure (ICP), brain oxygenation (PbtO2) and local cerebral blood flow (loCBF) to dynamic testing. The study is a retrospective cohort study of prospectively collected data conducted at the Red Cross Children Hospital. We analyzed the results of 18 patients in 28 tests of autoregulation to determine the static state of autoregulation by calculating the autoregulatory index (ARI). These tests were done by controlled elevation of blood pressure to evaluate changes in transcranial Doppler-derived flow velocity of the middle cerebral artery. Concomitant recordings were made of ICP, PbtO2, and loCBF. Secondly, we also calculated the PRx as a moving correlation co-efficient between slow changes in blood pressure and ICP. Two time epochs of PRx were examined in relation to the static tests: 1 hour before and after the test, and 12 hours before and after the test. The results included 28 tests done for ARI and 27 calculations for PRx epochs; all tests had ICP and PbtO2 data and 23 had loCBF. PRx and ARI showed no significant relationship between them. However, there was a significant relationship between ARI and ΔICP (p=0.04), i.e. when autoregulation was weak the change in ICP with a change in blood pressure was greater; and between PRx and ΔPbtO2 (p=0.04). There was a trend in correlation analysis between loCBF and PRx but not in the linear mixed effects model In conclusion, the study showed no correlation between the two autoregulatory indices, PRx and ARI, probably because they assess different aspects of autoregulation. However, significant relationships exist between ARI and ΔICP as well as PRx and ΔPbtO2, which generate interesting hypotheses about autoregulation and have clinical implications. Both autoregulatory indices have benefits and limitations. Further studies on such relationships, taking into consideration a larger sample group, inclusion of unstable patients, and utilization of the same range in BP for calculating the indices, are recommended.
Open Access
Decompressive craniectomy in children with traumatic brain injury
(2005) Figaji, Anthony Aaron; Peter, Jonathan C; Fieggen, A Graham
Although the conventional role of the operation was that of a salvage procedure when medical therapy failed in the treatment of raised intracranial pressure (ICP), two important concepts have emerged in the recent literature that appear to challenge that approach. In addition to the lack of evidence supporting benefit from current forms of treament, evidence from diverse studies that use data from magnetic resonance images, cerebral owygenation and cerebral blood flow measurements have highlighted potential adverse effects that may occur with these therapies.
Open Access
The effect of light on a rat model of depression
(2014) Mtintsilana, Asanda; Russell, Vivienne A; Dimatelis, Jacqueline J
Background: Depression is a debilitating mood disorder, negatively affecting an individual’s health and well-being. Despite this, the aetiology of depression remains poorly understood. Consistently, depression treatments are far from satisfactory due to limited efficacy and adverse side effects often associated with them, suggesting a need to improve the current animal models of depression in order to understand the basic mechanisms of the disorder. In an attempt to elucidate the pathophysiology of depression, a rodent model of depression (maternal separation, MS) is used to study the neurobiological mechanisms implicated in depression. However, MS alone produces inconsistent findings and often additional stressors are used to exaggerate the effects of MS. To create a more robust model of MS, MS rats were exposed to chronic constant light (CCL). However, contradictory findings have been reported with CCL. Aims: This study aimed to explore the effects of additional CCL in an MS model by measuring glutamate and potassium-stimulated [3H]DA release in the nucleus accumbens (NAc), testing the effects of CCL on serotonin (5-HT) levels in the hypothalamus and prefrontal cortex (PFC) and measuring ì-opioid receptor (MOR-1) levels in the NAc and orexin receptor (OXR-1 and OXR-2) levels in the PFC. Methods: In order to achieve these aims four experimental groups were chosen, out of which two groups; non-maternally separated (NMS) rats and maternally separated (MS) rats were exposed to CCL for 3 weeks during adolescence and the remaining two groups; NMS and MS rats were not subjected to CCL. At postnatal day 80 (adulthood), rats were decapitated and brain tissue collected for analysis of glutamate- and potassium-stimulated [3H]DA release in the NAc using in vitro superfusion. Serotonin levels in the hypothalamus and PFC were determined using Enzyme-Linked ImmunoSorbent Assay (ELISA). Western blot analysis was used to measure MOR-1 levels in the NAc, OXR-1 and OXR-2 in the PFC. Results: MS caused a significant decrease in glutamate-stimulated [3H]DA release in the NAc. In the NAc shell, CCL exposure revealed a trend towards a decrease in [3H]DA release in response to both glutamate- and potassiumstimulation. Moreover, in the hypothalamus NMS and MS rats subjected to CCL had significantly increased 5-HT levels compared to NMS and MS rats without xvii CCL exposure. In the PFC CCL had a significant effect on 5-HT levels and it was revealed that NMS CCL rats had decreased 5-HT levels compared to NMS rats. Similarly, MS CCL rats had significantly decreased 5-HT levels compared to NMS. MS and CCL did not have any significant effect on MOR-1 protein levels in the NAc. On the other hand, MS rats had increased OXR-1 and OXR-2 proteins levels in the PFC compared to NMS and MS CCL rats. Conclusion: MS decreased glutamate-stimulated [3H]DA release in the NAc. Serotonin levels in the hypothalamus and PFC were altered by the effects of MS and CCL. Furthermore, MS exposure increased OXR-1 and OXR-2 protein levels in the PFC. However, MS and CCL did not alter MOR-1 protein levels in the NAc. Therefore, this study has demonstrated that CCL exaggerated the effects of MS and created a more robust model of MS.
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Effect of maternal separation on stress-related proteins measured in a 6-hydroxydopamine rat model of Parkinson’s disease
(2014) Tomes, Hayley Sarah; Russell, Vivienne A; Lang, Dirk
The developing central nervous system is especially vulnerable and research has implicated early life stress (ELS) as a potentiating factor to cell death in a rat model of Parkinson’s disease (PD). PD is a movement disorder resulting from the selective degeneration of dopamine neurons in the substantia nigra pars compacta (SNc). Dopamine neurons have been shown to exhibit mitochondrial dysfunction, oxidative stress and misfolded protein aggregation in patients with PD. Since ELS has been shown to negatively affect the nigrostriatal pathway and mitochondrial function, developmental stress may create a vulnerable microenvironment which results in a greater rate of cell death during the development of PD. Many proteins play a role in establishing a positive microenvironment that is neuroprotective, and may be good candidates for the mechanism by which ELS potentiates neurodegeneration in the PD rat model. This study aimed to investigate whether the finding that ELS increases neuronal susceptibility to 6-hydroxydopamine(6-OHDA)-induced degeneration of dopamine neurons occurs through dysregulation of the oxidative stress-related heat shock protein (HSP)25, or plasticity-related proteins, chondroitin sulphate proteoglycans (CSPGs) or Nogo-A.
Open Access
The effects of early developmental stress and exercise intervention on neurodegeneration in a rat model of Parkinson's disease
(2010) Warton, Fleur L; Russell, Vivienne A
Early developmental stress has been shown to produce numerous deleterious effects, e.g. the later development of affective disorders, and this has been related to chronic enhanced hypothalamic-pituitary-adrenal axis activity. Animal studies have shown that maternally separated rats exhibit increased anxiety- and depression-like behaviour in adulthood, although other evidence shows hyperactivity and impulsivity in such cases. Given that stress has these behavioural effects, it is of interest to determine whether early developmental stress might enhance the toxicity of a later unrelated neural insult. The 6-hydroxydopamine (6-OHDA) model of Parkinson's disease involves the selective unilateral lesion of nigrostriatal dopamine neurons. In this group of studies it was hypothesized that maternal separation might enhance the toxic effects of 6-OHDA.
Open Access
Endoscopic repair of cerebrospinal fluid leaks
(2018) Mohammed, Ben Husien; Semple, Patrick Lyle; Lubbe, Darlene
Developmental Venous Anomalies are a normal variant that may be associated with other cerebral vascular malformation they have bean previously referred to Venous angiomas. DVAs are the most frequently encountered cerebral vascular malformation and their incidence is reported to be high as 2.6%. DVAs are classified into two types based on draining veins. Either deep or superficial. Those that drain into subependymal veins are classified as deep and those that drain into cortical pial veins are classified as superficial. The trans-cerebral veins join either the deep or superficial venous systems by crossing a varying length of the brain parenchyma. Controversy surrounds their exact clinical significance, as DVAs are rarely symptomatic. The symptoms displayed by a patient can be related to a lesion that is associated with DVAs, such as a cavernoma. Study Aim: To describe the patients presenting to a single unit over a 10-year period with symptoms attributable to a DVA. Results: Out of 19 patients in the database with the diagnosis of DVA, 10 were identified where the clinical presentation was directly related to the DVA. Seven of the patients presented with haemorrhage, 6 had parenchymal bleeds and one was intraventricular. Two patients had neurological deficit, 1 was transient and one was progressive. One patient had sudden severe headache with no evidence of haemorrhage on CT scan. The age range was from 14 to 55 with a mean of 32,7 years. Four patients were male and 6 were female. Of the patients that presented with haemorrhage only one had a fistula, three other patients with haemorrhage had evidence on DSA of stenosis of the large collector vein, In the remaining 3 patients no reason for the bleed could be detected. One patient presented with left hemianopia that resolved after several hours, DSA showed minimal caput medusa with delayed filling of the collector vein. The other patient that presented with progressive neurological deficit in the form of progressive leg spasticity and dysarthria, Angiography showed a large collecting vein that drains in the jugular bulb was stenosed. The last patient that presented with sudden sever headaches, with no haemorrhage identified on CT scan, On DSA there was early filling of the DVA veins compared to other cerebral veins and two prominent posterior communicating thalamoperforating vessels were seen. Conclusion: Developmental venous anomalies are the commonest vascular malformation, and are rarely symptomatic unless associated with a cavernoma. In patients that have symptoms linked to DVAs (Haemorrhage, neurological deficit, sudden sever headaches) overall they have a good outcome, and the deficit related to a DVA tend to improve overtime, except for one patient that we had in our group, the DVA draining the pons and the cerebellar hemisphere had a tight outflow stenosis, that lead to progressive neurological deficit. In general, the majority of DVAs that are symptomatic do well.
Open Access
Endovascular cerebral aneurysm treatment : Long-term outcomes
(2008) Le Feuvre, David; Taylor, Allan
Endovascular treatment was confirmed by the International Subarachnoid aneurysm Trial1 as the treatment of choice for intracranial “berry” aneurysms. The durability of coiling and the relevance of stable neck remnants next needed to be addressed. Methods We retrospectively assessed the follow-up angiograms of patients, who presented with subarachnoid haemorrhages or IIIrd nerve palsies and had berry aneurysms treated endovascularly between 2002 and 2003, Patients were phoned to assess their wellbeing and to see whether they were back at work or not. Angiograms were assessed to ascertain percentage of aneurysm coiled at initial procedure and then stability was assessed by percentage change in the residual on later angiograms. Results Over a 1-year period 75 patients were treated endovascularly. 100% occlusion was attainable in 52% at the initial procedure and although the number of patients who attended their 3-month and 1year follow-up angiograms were 40 and 34 respectively there was a trend toward progressive thrombosis to 65% and then 82% respectively. In only 1 of the neck remnants was there growth at the 3-month angiogram. One patient bled having missed his 3-month follow-up angiogram. Although only 40% of the patients were contactable at 4 years there was no re-bleeds amongst them. Conclusion Coiling is durable as shown by our results over a 4 year period and while neck remnants may be observed any growth should be viewed as unstable and treated either endovascularly or surgically if required.
Open Access
Endovascular cerebral aneurysm treatment : one year radiological and 4-year clinical outcomes
(2008) Le Feuvre, David Edmond John; Taylor, A
Includes bibliographical references.
Open Access
The endovascular treatment of traumatic cranio-cervical vascular injuries
(2013) Ssenyonga, Peter Kato; Taylor, Allan; Feuvre, David Le
Includes abstract. Includes bibliographical references.
Open Access
Functioning, disability, health and quality of life in adults with cerebral palsy more than 25 years after selective dorsal rhizotomy: a long-term follow-up study during adulthood
(2019) Veerbeek, Berendina Egbertine; Langerak, Nelleke; Lamberts, Robert; Fieggen, Graham
Cerebral palsy (CP) is the most common cause of physical disability in childhood. Today, most children with CP survive into adulthood with life expectancies similar to typically developing (TD) adults. One of the biggest challenges during the lifespan of individuals with CP is healthy aging; to prevent or minimize the secondary effects of CP on the musculoskeletal system (e.g. bone deformities due to spasticity) as well as to improve functional status and quality of life. There is currently no treatment that is able to cure the brain damage which causes CP, but a variety of options exist to address spasticity, the most prevalent primary condition which is estimated to be present in 80% of people with CP. One of these options is the neurosurgical procedure of Selective Dorsal Rhizotomy (SDR) which entails selective sectioning of dorsal rootlets in the lumbosacral area, diminishing spasticity through reducing muscle tone. SDR gained increasing acceptance following the work of Peacock and Arens in the 1980s, and although a large number of studies have demonstrated the benefits of this procedure, they largely comprise relatively short-term follow-up assessments in children and adolescents. There is thus a need for long-term follow-up studies focussed on all facets of daily living (International Classification of Function, Disability and Health (ICF) model domains: body structure and function, activity and participation) and quality of life in adults with CP who underwent SDR in their childhood. The aim of this doctoral thesis was to address this need, and provide information that might help guide parents, caregivers and clinicians in their clinical decision-making process for a child with CP. This aim was addressed through three key investigations. First, the status of adults with CP and spastic diplegia - related to all domains of the ICF-model and health-related quality of life - was determined more than 25 years after SDR. Second, changes in gait pattern, spinal deformities and level of activities and participation in adults with CP were determined nine years after a similar assessment. Third, associations between results in the different ICFmodel domains along with personal and environmental context factors. This PhD thesis forms part of a longitudinal investigation tracking the health and wellness of adults with CP. The former studies were performed in 2008 and consequently a recent follow-up was conducted in 2017 in the same CP cohort. All participants underwent SDR according to the Peacock method (strict selection criteria were adhered) at Red Cross War Memorial Children’s Hospital in Cape Town, South Africa, between 1981 and 1991. This PhD thesis is based on four studies, with the first being a cross-sectional study conducted in 2017 (Chapter 2) and the other three are nine-year follow-up studies (comparing findings in 2017 with studies conducted in 2008 (Chapter 3 - 5). Each study included a matched TD group, except for the spine study (Chapter 4). Participants were observed and assessed for functioning, health, disability and quality of life based on a physical examination, gait analysis, functional mobility tests, spine radiographs and several questionnaires. With respect to the ICF-model Body structure and function domain, adults with CP showed sustained reduction in muscle tone and minimal signs of spasticity in their gait pattern, with no increased prevalence of scoliosis, hyperkyphosis or hyperlordosis, and did not experience limitation of daily activities due to pain. Some challenges were found regarding ROM, muscle strength, selectivity and back pain but they were comparable with what would be expected in adults with CP who did not undergo SDR. Concerning, the Activity domain, the majority of the cohort was independent in functional mobility and the accomplishment of daily activities with no increased risk for falls. They were as satisfied with accomplishing daily activities as the TD adults, though as might be expected, they were found to be less content with their level of mobility. Regarding Participation domain, the adults with CP greater than 25 years post-SDR were independent and satisfied with their attainment of social roles. Most were married or had a relationship, lived independently (with or without partner), finished higher education and were engaged in paid employment. The perceived health-related quality of life was similar to that of TD adults in most of the health concepts (physical role functioning, bodily pain, general health, vitality, social functioning, emotional role functioning and mental health), except for physical functioning. No increased prevalence of anxiety and depression was found, which was in line with the reported mental health findings of the health-related quality of life questionnaire. This suggests that while adults with CP have on-going physical challenges following SDR, this might not directly impact their mental health and levels of anxiety and depression. The majority of the cohort viewed the SDR they had undergone as worthwhile due to mobility and functional walking gains. Importantly, no changes were found over the nine-year interval in overall gait, functional mobility, spinal deformities, pain and level of accomplishment and satisfaction in daily activities and social participation. This indicates stability of function which is remarkable since functional decline might be expected in adults with CP while aging. However, correlations were found between functional mobility and daily activities and social participation as well as between functional mobility and strength. This highlights the possible importance of resistance training and maintaining walking ability to enable daily activities and social participation and prevent functional deterioration in the future.
Open Access
HIV-associated neurocognitive disorders biomarkers and the response to antiretroviral therapy
(2012) Cross, Helen Margot; Combrinck, MI
This study aimed to determine whether highly active antiretroviral therapy (HAART) improved cognitive function in HIV positive people in South Africa, and whether this effect differed according to the CNS penetration-effectiveness (CPE) of the regimen used. I also investigated potential HIV-Associated Neurocognitive Disorders (HAND) biomarkers (serum neopterin, osteopontin and neurofilament H) to determine their relationship to the severity of cognitive impairment at baseline in HAART-naïve patients, and whether initial levels of these biomarkers related to the change in cognitive function a year later.
Open Access
Hyperextension injury of the cervical spine with central cord syndrome
(2013) Thompson, Crispin; Welsh, David
Includes abstract. Includes bibliographical references.