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George M. Ghobrial, Michael Y. Wang, Barth A. Green, Howard B. Levene, Glen Manzano, Steven Vanni, Robert M. Starke, George Jimsheleishvili, Kenneth M. Crandall, Marina Dididze, and Allan D. Levi

of study is particularly relevant as SSIs are linked to higher costs, 2 , 9 , 12 poor patient outcomes, morbidity, and mortality. 12 , 35 Guidance in the literature for spinal surgeons is limited regarding the ideal preoperative skin antisepsis. Dissimilar study populations, SSI definitions, surgical procedures, and anatomical locations containing different bacterial flora all contribute to the variability in surgeon preference. 29 Respondents to one nationwide survey of 98 US academic neurosurgery programs showed a preference for the use of alcohol-based skin

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Simon G. Ammanuel, Caleb S. Edwards, Andrew K. Chan, Praveen V. Mummaneni, Joseph Kidane, Enrique Vargas, Sarah D’Souza, Amy D. Nichols, Sujatha Sankaran, Adib A. Abla, Manish K. Aghi, Edward F. Chang, Shawn L. Hervey-Jumper, Sandeep Kunwar, Paul S. Larson, Michael T. Lawton, Philip A. Starr, Philip V. Theodosopoulos, Mitchel S. Berger, and Michael W. McDermott

replacement before and after implementation of a skin antisepsis protocol that used 2% CHG cloths and found a reduction in SSIs after CHG cloths were used. 8 Furthermore, a previous study examined the implementation of a CHG shower protocol prior to spine surgery and found a significant reduction in SSI rates. 5 On the contrary, other evidence suggests that CHG cleansing may have limited utility in preventing SSIs. A Cochrane review of randomized controlled trials scrutinized the effect of CHG antiseptic preparation on SSI rates after surgery. 9 This review concluded

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D. Ryan Ormond and Costas G. Hadjipanayis

fractura Cranii, the second after Hippocrates' work. 5–8 Carpi was motivated to write this text shortly after treating a serious head injury in Lorenzo dé Medici. He had a dream in which a capped man with golden-winged sandals encouraged him to write a treatise on head injuries. 35 The next few centuries witnessed great advances in anatomical knowledge, but until further developments in the areas of cerebral localization, anesthesia, hemostasis, and antisepsis occurred, neurosurgery remained in its infancy. Anesthesia, Antisepsis, and Hemostasis Major advances

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Discovering neurosurgery: new frontiers

The 2011 AANS Presidential Address

James T. Rutka

stop an epidemic based on a scientifically sound theory of disease. F ig . 16. Modern-day replica of the Broad Street Pump in London, which became nefarious for its role in the spread of the cholera epidemic of 1854. Dr. John Snow is credited with halting the epidemic by removing the Broad Street Pump handle, which limited access to a highly contaminated water supply. ©Robert David Siegel, M.D., Ph.D., Stanford University. The transmission of disease by the ingestion of contaminated water or food sources foreshadowed the discovery of antisepsis by Joseph

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Howard H. Kaufman

✓ At the time of the American Civil War (1861–1865), a great deal was known about closed head injury and gunshot wounds to the head. Compression was differentiated from concussion, but localization of lesions was not precise. Ether and especially chloroform were used to provide anesthesia. Failure to understand how to prevent infection discouraged physicians from aggressive surgery. Manuals written to educate inexperienced doctors at the onset of the war provide an overview of the advice given by senior surgeons.

The Union experiences in the treatment of head injury in the Civil War were discussed in the three surgical volumes of The Medical and Surgical History of the War of the Rebellion. Wounds were divided into incised and puncture wounds, blunt injuries, and gunshot wounds, which were analyzed separately. Because the patients were not stratified by severity of injury and because there was no neuroimaging, it is difficult to understand the clinical problems and the effectiveness of surgery. Almost immediately after the war, increased knowledge about cerebral localization and the development of antisepsis (and then asepsis) permitted the development of modern neurosurgery.

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Paul T. Akins, John Belko, Amit Banerjee, Kern Guppy, David Herbert, Tamara Slipchenko, Christi DeLemos, and Mark Hawk

Object

The emergence of methicillin-resistant Staphylococcus aureus (MRSA) has posed a challenge in the treatment of neurosurgical patients. The authors investigated the impact of MRSA colonization and infection in the neurosurgical population at a community-based, tertiary care referral center.

Methods

Hospitalized patients under the care of the Kaiser Permanente inpatient neurosurgery service were prospectively entered into a database. In Phase I of the study, 492 consecutive patients were followed. Per hospital policy, the 260 patients from this group who were admitted to the intensive care unit (ICU) underwent screening for MRSA based on nasal swab cultures and a review of their medical history for prior MRSA infections. These patients were designated as either MRSA positive (17 patients, 6.5% of screened patients) or MRSA negative (243 patients). The 232 patients admitted to non-ICU nursing units did not undergo MRSA screening and were designated as unscreened. In Phase II of the study, the authors reviewed 1005 neurosurgical admissions and completed a detailed chart review in 62 MRSA-positive patients (6.2%). Eleven patients received nonoperative treatment. Five patients presented with community-acquired neurosurgical infections, and the causative organism was MRSA in 3 cases. Forty-six patients underwent 55 procedures, and the authors reviewed their perioperative management.

Results

In Phase I of the study, the authors found that for the MRSA-positive, MRSA-negative, and unscreened groups, the rates of postoperative neurosurgical wound infections caused by all pathogens were 23.5, 4.1, and 1.3%, respectively. For MRSA wound infections, the rates were 23.5, 0.8, and 0%, respectively. In Phase II, patients with MRSA were noted to have the following clinical features: male sex in 63%, a malignancy in 39.1%, diabetes in 34.8%, prior MRSA infection in 21.7%, immunosuppressed state in 17.4%, and a traumatic injury in 15.2%. The rate of postoperative neurosurgical wound infection in patients who received MRSA-specific prophylactic antibiotic therapy (usually vancomycin) was 7.4% (27 procedures) compared with 32.1% (28 procedures) in patients who received the standard treatment (usually cefazolin) (p = 0.04). Wound care for ICU patients was standardized for postoperative Days 0–7 with chlorhexidine cleaning at bandage changes at 3-day intervals. Wound cultures from neurosurgical site infections in patients with prior MRSA colonization or infection grew MRSA in 7 of 11 patients.

Conclusions

Neurosurgical patients identified with MRSA colonization or a prior history of MRSA infections benefit from specific perioperative care, including prophylactic antibiotics active against MRSA (such as vancomycin) and postoperative wound care with coverings and chlorhexidine antisepsis to reduce MRSA wound colonization.

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Marc R. Mayberg

Infections have plagued surgeons for all recorded history and remain a significant problem today. Historical documents including the Edwin Smith papyrus (circa 1600 BC) 1 and writings of Hippocrates (circa 450 BC) 3 describe principles of wound management and antisepsis to prevent infection. Although Galen proposed the concept of pus bonum et laudabile (that is, that “good and commendable pus” was favorable in wound healing), 3 modern surgeons remain flummoxed by the appearance of pus, despite all the measures undertaken to prevent surgical infection

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Ménière's Disease

A Centennial Historical Note

Lycurgus M. Davey and William J. German

's scientific writings, which he described as being as sharp and precise as his rhetoric was digressive and complicated. The four papers on his eponymic disease were written in 1861. He died of influenzal pneumonia, February 7, 1862. The medical world of 1861 was preparing for full blossom. Anesthesia was fifteen years old but bacteriology had been born only a year ago and antisepsis was still six years away. The foundations for cerebral localization were begun nineteen years earlier but were still fragmentary. Neurology was wiggling in its cradle, with Romberg (Berlin

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Ahmed Kashkoush, Nitin Agarwal, Ashley Ayres, Victoria Novak, Yue-Fang Chang, and Robert M. Friedlander

surgery. 40 In a well-designed crossover study including 4387 consecutive patients, that study showed equivalent 30-day SSIs between hand antisepsis techniques. Several studies, like ours, have examined the effect of antisepsis protocols in specific surgical departments and have demonstrated similar results. In a study of 3600 pediatric urology patients, Weight et al. showed equivalent postoperative wound infection rates between hand-rubbing and conventional hand-scrubbing protocols, although that study was limited by a notably small incidence of SSIs (5 of 3600 cases

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James Tait Goodrich

, which were later codified by the Islamic scholars. Instrument design remained rather crude, with most craniectomy methods based on the “hammer and chisel” technique. 35 In Europe the surgeon was basically an itinerant “barber-surgeon” traveling from town to town and offering whatever skills he had. Minimal anesthesia was available, mostly just alcohol and opium. Antisepsis—other than the occasional application of wine to the wound—was unheard of. Medieval neurosurgical techniques could best be described as cruel and brutal ( Fig. 5 ). F ig . 5. The “hammer