Use of Two Novel Dyes to Enhance Visualization of Cut Ends of the Vessel in Microvascular Anastomosis-An Experimental Study of 45 Rats

BACKGROUND

Good visualization is a prerequisite for performing microvascular anastomosis. The most commonly used dye, methylene blue, has several limitations: it is washed off quickly and stains all the vessel layers. The objective of our study is to use 2 new novel dyes for improving visualization.

METHODS

After ethical committee approval, 2 Dyes (2% cresyl violet, 1% eosin) were studied in 3 groups, 20 rats in each group and 5 rats in the combined group. End-to-side anastomosis was performed in the classic fashion in 45 rats. After venotomy, the dye was applied to the raw surface of the vessels and subsequently, anastomosis was performed. The improvement in visualization was judged by 3 blinded experts and nonexperts in 4 groups on a scale of 1-10. Scores were statistically analyzed. After 2 weeks, animals were re-explored to check the delayed patency, and segments were harvested for histopathologic analysis.

RESULTS

The immediate and delayed patency rates were 100% (45/45) and 97% (33/34), respectively. In statistical analysis, the combined group (P = 0.005)was judged statistically significant because of the contrast in color. All the layers were stained by both dyes, staining lasted until the end of the surgery. Visibility of the cut ends was better in cresyl violet. All histopathologic findings suggested normal changes at the anastomotic site.

CONCLUSIONS

This study showed that the use of these 2 dyes was not only feasible but highly efficacious. Even though all the layers were stained by both the dyes, the visibility of the cut ends was better. In both dyes, staining lasted until the end of surgery. To the best of our knowledge, this is the first study that has used these 2 novel dyes to improve visualization in microvascular anastomosis in an experimental setting.

Monomelic Amyotrophy/Hirayama Disease: Surgical Outcome in a Large Cohort of Indian Patients

BACKGROUND

Hirayama disease (HD) is a cervical compressive myelopathy. Anterior cervical discectomy and fusion (ACDF) is identified as the best surgical approach. We evaluated surgical outcomes and factors influencing ACDF in HD.

METHODS

Between 2015 and 2019, 126 patients with HD underwent ACDF. Contrast magnetic resonance imaging of the cervical spine in full flexion was performed. Clinical examination and preoperative/postoperative assessment of hand function using Fugl-Meyer assessment, Jebsen-Taylor hand function test, and handheld dynamometry were performed at 3-monthly intervals for 1 year. Surgical outcomes were assessed as per the Odom criteria and Hirayama outcome questionnaire.

RESULTS

Age at onset and duration of illness were 12-31 years (mean, 18 ± 2.7) and 1-96 months (32.7 ± 24.4), respectively. All patients had progressive weakness and wasting of the affected limb. Cord atrophy was seen in 97.1%, with epidural detachment and engorgement of the posterior epidural venous plexus in all. All patients underwent ACDF. Of these patients, 54% had an excellent/good outcome and 39% had a satisfactory outcome as per the Odom scale at last follow-up (mean, 44.9 ± 16.5 months) after surgery. Handheld dynamometry showed improvement from preoperative values to 1 year follow-up. Duration of illness and age at onset had a negative correlation and the preoperative Fugl-Meyer score had a positive correlation with improvement.

CONCLUSIONS

ACDF resulted in remarkable improvement or stabilization in neurologic deficits in many patients with HD. Because motor disability ensues over time, early surgical intervention during the progressive phase is advocated.

Histopathological Validation of Microvascular Anastomosis using Two-Throw Reef Knots - An Experimental Study

Background

Knot configuration is an important but relatively neglected topic in microvascular anastomosis literature.

Objective

To study the differences between end-to-end microvascular anastomosis performed with two-throw reef knots as compared to traditional three-throw knots in a rat femoral artery model at the histological level.

Material and Methods

Sprague Dawley rats underwent end-to-end microvascular anastomosis of the right femoral artery (one-way-up method). The rats were divided into two groups: two-throw reef knots versus traditional three-throw knots. The patency was checked by the standard empty refill method. After 2 weeks, the rats underwent re-exploration. An anastomotic segment was sent for histological analysis. Histological alterations including luminal patency and changes in Tunica intima, Tunica media, and Tunica adventitia were compared between the two groups.

Results

Twenty-nine rats were operated on by the senior author (17 by three-throw and 12 by two-throw reef knots). In the two-throw reef knot group versus the traditional three-throw knot group, the immediate patency rates were 100% versus 82.4%, and the delayed patency rates were 90.9% versus 62.5%, respectively. The histopathological patency rates were concordant with delayed patency rates. Subintimal proliferation and fibrosis were comparable in both groups. Adventitial granulomas were noted in all, irrespective of the knotting technique. Tunica media preservation rates for the two-throw reef knot versus the traditional three-throw knot group were 63.6% versus 0%. Five rats were operated by the beginner in the field, all by two-throw reef knots (to assess the safety of this new method in the hands of a beginner).

Conclusion

Microvascular anastomosis performed with two-throw reef knots appears not only feasible but better in terms of anastomosis patency. Histological superiority in terms of Tunica media preservation further validates the technique.

Neuroanatomical zones of human traumatic brain injury reveal significant differences in protein profile and protein oxidation: Implications for secondary injury events

Traumatic brain injury (TBI) causes significant neurological deficits and long-term degenerative changes. Primary injury in TBI entails distinct neuroanatomical zones, i.e., contusion (Ct) and pericontusion (PC). Their dynamic expansion could contribute to unpredictable neurological deterioration in patients. Molecular characterization of these zones compared with away from contusion (AC) zone is invaluable for TBI management. Using proteomics-based approach, we were able to distinguish Ct, PC and AC zones in human TBI brains. Ct was associated with structural changes (blood-brain barrier (BBB) disruption, neuroinflammation, axonal injury, demyelination and ferroptosis), while PC was associated with initial events of secondary injury (glutamate excitotoxicity, glial activation, accumulation of cytoskeleton proteins, oxidative stress, endocytosis) and AC displayed mitochondrial dysfunction that could contribute to secondary injury events and trigger long-term degenerative changes. Phosphoproteome analysis in these zones revealed that certain differentially phosphorylated proteins synergistically contribute to the injury events along with the differentially expressed proteins. Non-synaptic mitochondria (ns-mito) was associated with relatively more differentially expressed proteins (DEPs) compared to synaptosomes (Syn), while the latter displayed increased protein oxidation including tryptophan (Trp) oxidation. Proteomic analysis of immunocaptured complex I (CI) from Syn revealed increased Trp oxidation in Ct > PC > AC (vs. control). Oxidized W272 in the ND1 subunit of CI, revealed local conformational changes in ND1 and the neighboring subunits, as indicated by molecular dynamics simulation (MDS). Taken together, neuroanatomical zones in TBI show distinct protein profile and protein oxidation representing different primary and secondary injury events with potential implications for TBI pathology and neurological status of the patients.

Correction: Comprehensive Normative Data for Objective Vestibular Tests

[This corrects the article DOI: 10.7759/cureus.40080.].

Factors predicting recurrence in benign spinal nerve sheath tumors: A retrospective study of 457 patients from a single institution

BACKGROUND

Benign Nerve sheath tumors (NST) comprise almost one-third of primary spinal tumours. The majority are sporadic. They have low rates of recurrence but an occasional recurrence may need re-surgery. The present study was designed to identify the variables that can predict the risk of their recurrence.

METHODS

A retrospective chart review was done including all the histologically proven benign spinal NSTs operated between 2001 and 2019 in our institute. Demographic, operative and postoperative follow-up data were recorded. Recurrence was defined as local reappearance after definite surgical excision or symptomatic increase in size of a residual tumour on follow-up imaging studies. Statistical analysis was done to determine the significant variables associated with local recurrence.

RESULTS

457 patients with a median age of 38 years operated for 459 NSTs qualified for the study. The most frequent location of occurrence of tumours was found to be Low Cervical level (C3-C7 levels). Majority of Schwannoma were located intradurally while Neurofibroma were dumb-bell shaped and extradural. Most of the tumours had solid consistency. Post operatively, 7.7% patients developed complications. 7.8% tumours developed local recurrence after median period of 12 months. The patients developing recurrence were younger compared to nonrecurring tumors. On univariate analysis, male gender, Low cervical and Cervicothoracic junction location were associated with higher recurrence. On multivariate analysis, location at Cervicothoracic junction reached significance.

CONCLUSION

Overall recurrence risk among all NST was 7.8% with a median progression free survival of 36 months. The location of tumour at cervicothoracic location was the significant risk factors for recurrence of tumour in our study.

Comprehensive Normative Data for Objective Vestibular Tests

INTRODUCTION

 Vestibular dysfunction is a debilitating disorder frequently encountered in neurological and otological settings. The vestibular system is a complex network between peripheral and central mechanisms. This innate complexity of the vestibular system necessitates objective test procedures for evidence-based diagnostic formulations and intervention. Objective tests aid in the evaluation of both peripheral and central vestibular pathologies. Establishing and availability of comprehensive normative data for these objective tests is crucial for clinicians and researchers alike.

MATERIALS AND METHODS

This is a prospective study involving 120 participants (both males and females) aged between 18 and 55 years. All participants were right-handed individuals and had no significant medical history. On pre-set protocols, cVEMP (cervical vestibular evoked myogenic potential), oVEMP (ocular vestibular evoked myogenic potential), vHIT (video head impulse test), and VNG (videonystagmography) were done.

RESULTS

While all participants (n=120) underwent cVEMP, oVEMP, vHIT, saccade, smooth pursuit, and optokinetic tests, only 109 participants consented to the caloric test. Each test's mean, standard deviation, median, quartile, and third quartiles have been recorded. A right-left comparison yielded no significant difference on cVEMP, oVEMP, caloric test, smooth pursuit, and optokinetic test. However, few vHIT and saccade parameters did reveal significant differences.

DISCUSSION

This study presents comprehensive normative data for cVEMP, oVEMP, vHIT, caloric test on VNG, and oculomotor tests (smooth pursuit, saccade, optokinetic) on VNG. The test results were in concordance with previously published data. The significant difference between the right and left sides in vHIT may be because of the monocular goggles used for the testing.

CONCLUSION

This study brings out the normative data for various vestibular tests on individuals aged between 18-55 years. This information could aid both clinicians and researchers working in the field of vestibular science.

The Use of Retraction Sutures in End-to-Side Microvascular Anastomosis - A Novel Technical Innovation in Experimental Rat Femoral Model with Successful Use in STA-MCA Bypass in Moya-Moya Disease

BACKGROUND

A narrow working space, small diameters, and the tendency to collapse with clamps make cerebral microvascular anastomosis challenging. A retraction suture (RS) is a novel technique to keep the recipient vessel lumen open during the bypass.

OBJECTIVE

To provide a step-by-step overview of RS for end-to-side (ES) microvascular anastomosis on rat femoral vessels and successful use for STA-MCA bypass in Moya Moya disease (MMD) patients.

METHODS

A prospective experimental study with approval from the Institutional Animal Ethics Committee. Femoral vessels ES anastomoses were performed on Sprague Daley rats. The rat model used three types of RS (Adventitial, Luminal, and Flap-retraction sutures). An ES-interrupted anastomosis was done. The rats were observed for an average period of 16.18±5.65 days; the patency was assessed by re-exploration. The immediate patency on the STA-MCA bypasses was confirmed with intra-operative indocyanine green (ICG) angiography and micro-doppler; delayed patency with MRI and DSA after 3-6 months.

RESULTS

In the rat model, 45 anastomoses were performed, 15 each using the three subtypes. The immediate patency was 100%. Delayed patency was 42/43 (97.67%), and two rats died during observation. In the clinical series, 59 STA-MCA bypasses were done in 44 patients (average age -18.14±11.09 years) using RS. The follow-up imaging was available for 41/59 patients. Both immediate and delayed patency (41/41 at six months) was 100%.

CONCLUSION

The RS allows continuous visualization of the vessel lumen, reduces the handling of intimal edges, and avoids incorporating the back wall in sutures; thus improving anastomosis patency.

Microneurosurgical Anatomic Study of the Horizontal Fissure of the Cerebellum

OBJECTIVE

The horizontal fissure of the cerebellum, which is the largest and most prominent fissure, has received less interest from anatomists and neurosurgeons. Hence, the current study aims to provide comprehensive detail about the horizontal fissure and its anatomic and surgical relationship with deeper structures such as the dentate nucleus and middle cerebellar peduncle for the benefit of the neurosurgeon.

METHODS

Ten whole formalin-fixed human cadaveric cerebellar hemispheres were obtained from human cadavers donated to the institution. Different parameters of the horizontal fissure were studied, such as length, depth (medial end, lateral end, and middle), sulcal and gyral variations (superficial and deep), and its close relationship, especially at depth, with the dentate nucleus and middle cerebellar peduncle.

RESULTS

The total length of the horizontal fissure on the right and the left side was 64.3 ± 7.9 mm (range, 53-77 mm) and 65.6 ± 8.01 mm (range, 53-79 mm), respectively. The medial third of the horizontal fissure, with the fewest vessels, was the most suitable place to puncture or start the dissection of the horizontal fissure. The surface projection of the center of the posterior border of the dentate nucleus lies within 20-21 mm on either side of the posterior midline along the horizontal fissure and is only approximately 4 mm deep from the horizontal fissure.

CONCLUSIONS

The anatomic measurements and relationships provided in this description of the horizontal fissure will serve as a tool for surgery selection and planning, as well as an aid to improve microneurosurgical techniques, with the final goal being better patient outcomes.

Measure of Central Vestibular Compensation: A Review

The central vestibular compensation reduces vestibular symptoms and helps individuals improve balance affected by vestibular dysfunction. The video head impulse test provides an opportunity to study central vestibular compensation objectively. This study aims to methodically present existing information about the video head impulse test as a measure to evaluate central vestibular compensation in patients with unilateral vestibular dysfunction. Literature review comprised 12 research articles selected based on pre-set criteria and timeline (January 2010 to June 2020). The findings indicate that the appropriate video head impulse test measures to evaluate central vestibular compensation after the occurrence of temporary unilateral vestibular dysfunction are the improvement in vestibulo-ocular reflex gain. And, for permanent unilateral vestibular dysfunction are reduction in catch-up saccades percentage, velocity, amplitude, latency, and Perez and Rey score.

Pathological Spectrum of Vascular Malformations of the Central Nervous System: A Single Institution Experience of a Decade

Background Vascular malformations (VMs) of the central nervous system comprise a variety of lesions that could affect the arteries, veins, or capillaries.

Materials and Methods We analyzed the histopathological features of all the VMs diagnosed at our centre over a decade.

Results Intracranial VM included arteriovenous malformation (AVM) (53%), cerebral cavernous malformations (CCMs) (45%), capillary telangiectasia (2%), venous angioma (0.5%), and arteriovenous fistula (AVF) (0.5%). In spinal VMs, capillary telangiectasia (40%) were the most common, followed by cavernomas (34%), AVF (16%), and AVMs and venous angiomas (5%). Clinical presentation varied from focal deficit to features of raised intracranial tension.

Conclusion Imaging and histopathology plays an important role in the diagnosis and management of VMs. Histopathological examination is essential for characterization of the VMs, which influences the prognosis.

Access to pain medicines and follow-up consultation after radiofrequency ablation for trigeminal neuralgia during the COVID-19 pandemic

Background:

In the recent coronavirus disease 2019 (COVID-19) pandemic, follow-up of patients with trigeminal neuralgia post radio-frequency ablation (RFA) of the Gasserian ganglion was restricted because of closure of pain clinic services (PCSs) at our institution, travel restrictions, and fear of contracting COVID-19 infection by hospital visit. Periodic follow-ups are a must in this group of patients. Because the access to pain medications and consultations remained restricted, we tried identifying the factors predisposing to these difficulties in patients.

Methods:

We had contacted patients telephonically, who underwent RFA at our institution in the past 5 years as the PCS had not re-started to follow up with in-person consultation. Demographics, socio-economic factors, clinical factors, literacy status, distance to the health care system, and current health status were noted. Collected data were analyzed descriptively, and correlations were calculated between the predictors for difficulty in follow-up to access the medications and consultations.

Results:

Out of 121 patients who underwent RFA in the past 5 years, 73 were accessible on phone. Of these, 42.46% (31/73) patients had difficulty in accessing either medications or consultation. The literacy status of the patient was the strongest predictor (0.044) with a negative correlation (-1.216). Difficulty in accessing PCS was associated with a poor health status (p-0.032) and higher pain scores (0.066).

Conclusion:

Along with the clinical factors, we have to overlook other factors in predicting difficulty to access PCS in trigeminal neuralgia patients post the RFA status. Difficulty in access to pain medicines and/or consultations was associated with a poor health status and higher pain scores.

Vertebral artery dissection in acute cervical spine trauma

Objective:

The aim of this study was to study mechanism, risk factors, and prognosis of patients with vertebral artery dissection (VAD) from acute cervical spine trauma (CST).

Methods:

A total of 149 consecutive patients were chosen from 2014 to 2019 from our institute data base, and their records were retrospectively studied. Morphology of fracture and subluxation were studied in detail with respect to the presence or absence of VAD.

Results:

Patients were divided in subsets of axial spine injury and subaxial spine injury. Subgroup and group analysis was performed and computerized tomography angiogram, MR angiogram and T1/T2 axial scans were studied to identify VAD, an incidence of 14.1% was found. Patients having infarcts in posterior circulation were also identified.

Conclusion:

There is a significant contribution of biomechanics of CST and evolution of VAD. This is an important consideration to prevent significant morbidity and mortality. Hence, a diagnostic algorithm which can be applied in any hospital setup is the need of the hour.

Abusive head trauma in India: imaging raises the curtain

The purpose of the study was to identify children at our institute who possibly suffered abusive head trauma (AHT). A retrospective study of CT imaging of children between one month to three years of age between January 2013 and May 2021 was carried out at a dedicated neurocentre in Southern India. We identified 48 cases of possible AHT. The demographics, clinical features at presentation, imaging and fundus findings were analyzed. Imaging revealed subdural hemorrhage (SDH) in 42 and sub dural effusion (SDE) in 5 cases, one case had only hypoxia. The location of SDH was studied as was hypoxia underlying SDH, global hypoxia and ischemia. Cases of subarachnoid hemorrhage (SAH), parenchymal hematoma & intraventricular hemorrhage (IVH) were also noted. Skeletal survey, chest X-ray and CT spine were reviewed. AHT needs to be paid attention to in the Indian scenario. An extensive work up is required to substantiate the claim and to work on prevention & management of these cases subsequently.

Complex Chiari Malformation: Proposal of a New Set of Diagnostic Criteria and Outcomes After fusion Surgery

BACKGROUND

The proposal of C1-C2 fusion as a better treatment option compared with foramen magnum decompression (FMD) for the treatment of Chiari 1 malformations has led to controversy. Although FMD is a time-tested treatment option, a group of patients exists who will benefit from C1-C2 fusion. We have proposed an objective system for defining complex Chiari malformations and studied the outcomes of fusion with decompression versus decompression alone for these patients.

METHODS

A total of 26 patients with complex Chiari malformations were identified using our criteria (any 4 of 7 clinicoradiological parameters). Of the 26 patients, 13 had undergone C1-C2 fusion with FMD and 13 had undergone FMD alone. They had also undergone pre- and postoperative clinicoradiological evaluations, and the outcomes were assessed using the Chicago Chiari outcome score.

RESULTS

Of the 13 patients in the fusion group, 12 (92.3%) showed improvement compared with only 6 of 13 patients (46.2%) in the nonfusion group using the Chicago Chiari outcome score, a statistically significant difference (P = 0.036, χ² test). The mean hospital length of stay was longer for the fusion group (6.15 ± 1.46 days) than for the nonfusion group (4.38 ± 2.22 days; P = 0.02).

CONCLUSIONS

We have proposed a novel set of criteria for defining complex Chiari malformations. Fusion with decompression provided better outcomes than decompression alone.

Toe-First Technique for End to Side Microvascular Anastomosis

BACKGROUND

The use of the classic 2-ends anchoring technique is common in end-to side (ES) microvascular anastomosis. The literature on the toe-first (TF) technique is limited. In the current study we present the successful outcomes with the TF technique in ES anastomoses in rat femoral vessels model.

METHODS

ES microvascular anastomosis with the tf technique was performed in the femoral vessels of 10 Sprague Dawley rats. Two-throw reef knot interrupted sutures were used in all cases. Individual parameters during the procedure were recorded for analysis. The immediate and delayed (cut open technique after 2 weeks) patencies were confirmed. An illustrative case showing the use of this technique in superficial temporal artery to middle cerebral artery bypass in a pediatric moyamoya disease case is included.

RESULTS

The average suturing time was 40.14 ± 5.30 minutes, the procedures were completed with an average of 14.57 ± 1.90 sutures. The average time per suture was 2.78 ± 0.43 minutes. The immediate patency was 100% (10 of 10 cases). Two rats died of unknown cause in the observation period. The delayed patency was 100% in the remaining 8 cases (average observation: 29.6 days).

CONCLUSIONS

The TF interrupted suture technique of ES microvascular anastomosis with 2-throw reef knots is feasible with excellent immediate and delayed patency rates. The distinct advantages of the TF are the continuous visualization of the recipient lumen during anastomoses, avoiding back-wall bites, and the ability to correct any discrepancy in the recipient-donor lumens during the procedure.

Spinal dysraphism illustrated; Embroyology revisited

Spinal cord development occurs through three consecutive periods of gastrulation, primary nerulation and secondary neurulation. Aberration in these stages causes abnormalities of the spine and spinal cord, collectively referred as spinal dysraphism. They can be broadly classified as anomalies of gastrulation (disorders of notochord formation and of integration); anomalies of primary neurulation (premature dysjunction and nondysjunction); combined anomalies of gastrulation and primary neurulation and anomalies of secondary neurulation. Correlation with clinical and embryological data and common imaging findings provides an organized approach in their diagnosis.

Anterior Odontoid Screw Fixation for C2 Fractures: Surgical Nuances, Complications, and Factors Affecting Fracture Union

OBJECTIVE

Type II odontoid fractures are the commonest C2 fractures. The management of dens fractures remains controversial with various radiological and fracture morphological factors affecting the approach and outcomes.

METHODS

All cases of anterior odontoid screw fixation between 2010 and 2020 were retrospectively analyzed. Patients' clinical, radiological (type of fracture, orientation, displacement, and diastasis), operative (single vs. double screw) and follow-up records were documented. The postoperative imaging findings were classified into grades I (excellent), II (good), and III (poor) based on the anatomical alignment with the screw. Follow-up cervical computed tomography was reviewed for fracture union.

RESULTS

A total of 49 patients with a mean age of 37.3 ± 13.8 years were included in the study. The average time from injury to surgery was 23.1 ± 22.2 days. The bicortical screw purchase and superoposterior odontoid tip breach significantly affected the postoperative alignment (P = 0.035 each). Fracture union was noted in 41 (83.7%) patients. The horizontal fracture displacement ≥2.5 mm (P = 0.02) and poor postoperative fracture alignment (P < 0.001) resulted in worse fracture union rates. Transient dysphagia was the commonest complication (n = 12), whereas screw breakout (n = 2) and pullout (n = 2) were other hardware-related complications. One patient underwent re-exploration for screw readjustment and 2 underwent posterior instrumentation.

CONCLUSIONS

Anterior odontoid screw fixation is technically straightforward, less morbid, and preserves biomechanical cervical mobility, when compared with the posterior instrumentation. With careful patient selection, meticulous surgical planning, and intraoperative image-guided screw insertion, good fracture union outcomes can be obtained. In the current study, we were able to achieve stable fracture union in 83.7% patients.

Histopathology of Microvascular Anastomosis—Comparison of Patent and Nonpatent Anastomosis: An Experimental Study

Objective To compare the histopathology of patent and nonpatent microvascular anastomosis using rat femoral artery end-to-end anastomosis model.

Materials and Methods In 15 Sprague–Dawley rats, end-to-end anastomosis was performed on the right femoral artery. The classical method was used in four cases and one-way up method in 11 cases. The animals were sacrificed after 2 weeks and the anastomosis was subjected to histopathology. The pathological changes in patent and nonpatent cases were compared.

Results The immediate patency rate and delayed patency (after 2 weeks) rate was 86.7% and 66.7%, respectively. The mean follow-up was 3 months. At sacrifice, 5/15 anastomosis were not patent. Marked subintimal thickening was noted in ⅘ (80%) of the nonpatent group, which was absent in the patent group. Severe loss or fibrosis of tunica media and marked adventitial inflammation were noted in all nonpatent cases (5/5, 100%). As much as ⅘ of the nonpatent cases had poor or indeterminate apposition; in contrast, good apposition was seen in 6/10 (60%) of the patent group. The mean clamp time and mean suturing time were significantly longer in the nonpatent group (69.2 minutes and 53.8 minutes, respectively) as compared with the patent group (48.8 minutes and 31.8 minutes, respectively). A single case that was initially nonpatent was found to have recanalized at 6 months.

Conclusion Minimal intimal injury and reaction, minimal thinning of tunica media, mild-to-moderate adventitial changes, good apposition, and equidistant sutures were associated with a successful microvascular anastomosis. Short duration of vessel clamping time and suturing comes with experience and dedicated practice in a skills laboratory.

Fiber Microdissection Technique for Demonstrating the Deep Cerebellar Nuclei and Cerebellar Peduncles

BACKGROUND

The cerebellum is one of the most primitive and complex parts of the human brain. The fiber microdissection technique can be extremely useful for neurosurgeons to understand the topographical organization of the cerebellum's important contents, such as the deep cerebellar nuclei and the cerebellar peduncles, and their relationship with the brain stem.

OBJECTIVE

To dissect the deep cerebellar nuclei and the cerebellar peduncles using the fiber microdissection technique.

METHODS

Under the operating microscope, 5 previously frozen, formalin-fixed human cerebellums and brain stems were dissected from the superior surface, and 5 were dissected from the inferior surface. Each stage of the process is described. The primary dissection tools were handmade, thin, wooden spatulas with tips of various sizes, toothpicks, and a fine regulated suction.

RESULTS

In 15 simplified dissection steps (6 for the superior surface and 9 for the inferior surface), the deep cerebellar nuclei (dentate, interpositus, and fastigial) and the cerebellar peduncles (inferior, middle, and superior) are delineated. Their anatomical relationships with each other and other neighboring structures are demonstrated.

CONCLUSION

The anatomy of the deep cerebellar nuclei and the cerebellar peduncles are clearly defined and understood through the use of the fiber microdissection technique. These stepwise dissections will guide the neurosurgeon in acquiring a topographical understanding of these complex and deep structures of the cerebellum. This knowledge, along with radiological information, can help in planning the most appropriate surgical strategy for various lesions of the cerebellum.

End-to-Side Microvascular Anastomosis on Rat Femoral Vessels Using Only 2-Throw Knot Interrupted Sututres - Evaluation of Feasibility and Patency Rates on Rat Femoral Vessels Model

BACKGROUND

The use of a 3-throw knot for anastomosis by microvascular neurosurgeons is the usual standard. There is an inherent belief that the third throw adds extra security to the knot; however, the third throw can make the knot heavy and unbalanced and can exert undue extra pressure on the opposing walls of the small-caliber intracranial vessels. This study evaluated the feasibility and efficiency of 2-throw reef knot interrupted sutures for an end-to-side microvascular anastomosis.

METHODS

A prospective observational study of end-to-side anastomosis using a femoral artery-to-vein model was performed in 30 Sprague-Dawley rats. All anastomoses were done using 2-throw reef knot interrupted sutures. Ten procedures each were done by the heel-first, toe-first, and classic 2-ends techniques. Individual parameters were recorded for analysis. The delayed patency was confirmed by reexploration after a mean duration of 19.82 ± 8.12 days.

RESULTS

The overall patency rates were 100% in the immediate period and 96.43% (27 of 28) in the delayed period. The average clamping time, average suturing time, and the average time per suture were 65.48 ± 16.93 minutes, 40.94 ± 11.22 minutes, and 3.18 ± 1.10 minutes, respectively. Two rats died in the postoperative period.

CONCLUSIONS

The end-to-side microvascular anastomosis with 2-throw reef knots is feasible, with excellent immediate and delayed patency rates.

Case Report: Chronic Fungal Meningitis Masquerading as Tubercular Meningitis

Phaeohyphomycosis causes a wide spectrum of systemic manifestations and can affect even the immunocompetent hosts. Involvement of the central nervous system is rare. A 48-year-old farmer presented with chronic headache, fever, and impaired vision and hearing. Serial MRIs of the brain showed enhancing exudates in the basal cisterns, and lesions in the sella and perichiasmatic and cerebellopontine angle regions along with enhancement of the cranial nerves and leptomeninges. Cerebrospinal fluid (CSF) showed lymphocytic pleocytosis with elevated protein and decreased glucose on multiple occasions. Clinical, imaging, and CSF abnormalities persisted despite treatment with antitubercular drugs and steroids for 2 years. Biopsy of the dura mater at the cervicomedullary junction revealed necrotizing granulomatous lesions, neutrophilic abscesses, and giant cells containing slender, pauci-septate, pigmented fungal hyphae. Fungal culture showed growth of Fonsecaea pedrosoi, which is classically known to cause brain abscesses. Here, we report the diagnostic odyssey in a patient with chronic meningitis from a region endemic for tuberculosis and describe the challenges in establishing the accurate diagnosis. Lack of therapeutic response to an adequate trial of empirical antitubercular therapy warrants search for alternative causes, including fungal meningitis. We highlight the uncommon manifestation of F. pedrosoi with chronic meningitis as well as the protracted clinical course despite not receiving antifungal therapy.

Multimodal Intraoperative Monitoring During Microsurgical Treatment of Spinal Dural Arteriovenous Fistula

We report here a case to illustrate the potential intraoperative multimodal monitoring options available for safe ligation of spinal dural arteriovenous fistula (DAVF). The success of microsurgical treatment depends on the correct identification of the arterial feeder and monitoring the functional integrity of the corticospinal tract.

Microcystic Meningiomas: MRI-Pathologic Correlation

BACKGROUND AND PURPOSE

Microcystic meningiomas (MM) are a distinctive, rare subtype of Grade I meningiomas with limited radiological descriptions. We intend to identify unique imaging phenotypes and seek radiopathological correlations.

METHODS

Retrospective analysis of histopathologically proven MM was undertaken. Clinicodemographic profiles, imaging, and histopathological characteristics were recorded. Spearman rank correlations among radiological and pathological attributes were performed.

RESULTS

Twenty-eight cases were analyzed (mean age = 45.5 years; M:F = 1:1.54; mean volume = 50.1 mL; supratentorial n = 27). Most lesions were markedly T2 hyperintense (higher than peritumoral brain edema-a unique finding) (89.3%) and showed invariable diffusion restriction, severe peritumoral brain edema (edema index >2 in 64.3%), a "storiform" pattern on T2-weighted images (T2WI) (75%), reticular pattern on postcontrast T1 (78.6%)/diffusion-weighted images (DWI) (65.4%), hyperperfusion, T1 hypointensity (84.6%), and absence of blooming on susceptibility-weighted image (80.9%). Storiform/reticular morphology correlated with large cysts on histopathology (ρ = .56; P = .005753).  Lesion dimension positively correlated with reticular morphology on imaging (ρ = .59; P = .001173), higher flow voids (ρ = .65; P = .00027), and greater microcystic changes on histopathology (ρ = .51; P = .006778). Peritumoral brain edema was higher for lesions demonstrating greater angiomatous component (ρ = .46; P = .014451).

CONCLUSIONS

We have elucidated varied neuroimaging features and highlighted pathological substrates of crucial imaging findings of MM. MM ought to be considered as an imaging possibility in an extra-axial lesion with a marked hypodensity on noncontrast computed tomography, markedly T2-hyperintense/T1-hypointense signal, and a storiform/reticular pattern on T2W/GdT1w//DWI.

Predicting the Ideal Ventricular Freehand Pass Trajectory Using Osirix Software and the Role of Occipital Shape Variations

BACKGROUND

Cannulation of lateral ventricles via a posterior approach is a common neurosurgical procedure. It is often believed that a single entry and fiducial point applies to all. No importance is given to skull shape variations, which can lead to wrong shunt positions and revisions.

OBJECTIVE

A virtual-reality study was conducted to find the ideal entry point, ideal forehead fiducial point, and ideal angulation of the ventricular catheter and variations in these with changes in skull shapes.

METHODS

Fifty human cadaveric skulls were used to measure anteroposterior (AP) diameter and width and to classify shape of skulls into 4 types. Hydrocephalus (100 cases) and normal magnetic resonance images (50 cases) were studied from a PACS (Picture Archiving and Communication System) database. An Osirix DICOM Viewer (3.9.4) was used to reconstruct the images and estimate the ideal, 90°, and midline shunt trajectory and correlate the same with AP/width ratios and skull shapes.

RESULTS

Contrary to popular practice, the vertical distance from the inion for ideal trajectory placement was <6 cm and >4 cm in all shapes and ratio groups for hydrocephalus and nonhydrocephalus cases, respectively. As the AP/width ratio increases, the fiducial needs to be placed at a higher distance from the nasion and the distance of the entry point also increased from the inion. A rounder or more dolichocephalic skull dictates a 90° approach to be better, especially as the first pass.

CONCLUSIONS

No magical external entry point uniformly applicable for all cases exists. Hence, there is a need to classify skulls according to shapes/ratios and to use a tailored approach for a freehand pass to cannulate the ventricles.

Myelopathy in Two Brothers with Respiratory Chain Disorder-Severe Complex 1 Deficiency with Atlantoaxial Dislocation and Long Spinal Arachnoid Cyst: A New Unreported Association

Billion of years ago bacteria is believed to have entered a eukaryotic cell and converted to mitochondria. The respiratory chain present in it supplies ATP to all cells and therefore the diseases can have any phenotype. Diagnosis may be difficult to confirm by the conventional methods including genetics. Two brothers born to consanguineous parents had global delay, mild visual impairment and drooping of eyelids since birth in the elder child and dysmorphism in the second one. Both had progressive myelopathy due to retroflexed odontoid ,large arachnoid cyst and tethered cord. Muscle biopsy with special stain was normal but respiratory chain assay revealed severe complex 1 deficiency.Elder child underwent surgical decompression of the arachnoid cyst with duroplasty with significant improvement.Atlanto axial dislocation and large arachnoid cyst as cause of myelopathy is not reported in literature in patients with respiratory chain disorders to the best of our knowledge.

Hypoglossal Nerve Palsy in Case of Spontaneous Atlantooccipital Dislocation-Rare Clinical Finding in Rare Clinical Entity and its Complete Recovery After Corrective Surgery

Spontaneous atlantooccipital dislocation is a rare clinical entity. Patients may present with neck pain and restriction of movements. Rarely does a patient present with hypoglossal nerve palsy. We report 1 such case, whose 12th nerve palsy promptly recovered after corrective surgery.

Surgical Management and Outcomes of Aneurysms of Posterior Inferior Cerebellar Artery: Location-Based Approaches with Review of Literature

Background  Posterior inferior cerebellar artery (PICA) is a tortuous, variable, and uncommon site for aneurysms. Surgical management of PICA aneurysms involves careful selection of approach based on the location of the aneurysm and meticulous dissection of the neurovascular structures and perforators.

Materials and Methods  We did a retrospective review of all the PICA aneurysms operated at our institute in the past 10 years along with the site, presentation, and approach used for the same. Preoperative World Federation of Neurosurgical Society scores and follow-up modified Rankin scores (mRS) were also evaluated. During the same period, data for intervention cases of PICA aneurysm were also collected with follow-ups for a comparative analysis.

Results  A total of 20 patients with 21 PICA aneurysms were reviewed. All the reviewed cases presented with subarachnoid hemorrhage, and the most common location was the lateral medullary segment and vertebral artery (VA)–PICA junction. Midline approaches were used for distal PICA cases, with far-lateral approach reserved for anterior medullary/VA–PICA junction. No lower cranial nerve palsies were recorded at follow-up. Four cases needed cerebrospinal fluid diversion and two developed cerebellar infarcts. All cases were mRS 0 to 2 at follow-up.

Conclusion  Our series compares well with some of the larger surgical series of PICA aneurysms. This may be due to early referral patterns and early surgery (<24 hours) policy at our institution. Anatomical knowledge of PICA anatomy and sound perioperative management are keys to good outcomes in these cases.

Microvascular Anastomosis Using Only 2-Throw Reef-Knots: A Technical Note

In macrosurgery creating a knot with at least three throws is an established practice. The potential disadvantages of this practice in microsurgery include the following: the direction of the cut ends interfere with the suture line, unbalanced nature of knot disturbs the apposition of delicate vessel ends and the excessive knot weight. A reef knot with only 2 throws may thus be a better alternative. We have described our technique of end to end anastomosis with 2-throw reef knots in a rat femoral artery model using one way up method. Judging from the surgical outcome the practice of two throw reef knot seems feasible and appealing.

Craniovertebral Junction Arachnoiditis: An Unusual Sequelae to Tuberculous Meningitis

Adhesive arachnoiditis at the craniovertebral junction should be suspected in patients with a history of meningitis having delayed onset gradually progressive tetra paresis. Patients can present after an asymptomatic interval of 2 to 20 years. Cardiac gated cine magnetic resonance imaging is useful for its diagnosis. Posterior fossa decompression with upper cervical laminectomy and adhesiolysis appears to be a reasonable treatment for the same. We illustrate two patients who presented to us with gradually progressive spastic tetra paresis; both had prior history of cured tuberculous meningitis.

Hirayama disease/cervical flexion-induced myelopathy progressing to spastic paraparesis: A report on three cases with literature review

Hirayama disease (HD)/cervical flexion-induced myelopathy (CFIM) is a lower motor neuron disease conventionally affecting a single upper extremity. We describe three men progressing after a long stable period to develop severe spastic paraparesis and bladder disturbances as a protracted implication of HD. The age at onset was 20, 24, and 15 years, while the age at presentation was 27, 41, and 57 years, respectively. The second phase of disease progression occurred after 4, 13, and 28 years of stationary period. All had CFIM with characteristic magnetic resonance imaging features as observed during progressive stages. The anterior dural shift extended variably from C4 to D4 levels with a median value of 5 mm and was maximum at C6 to C7 levels, pushing the cord anteriorly causing compression. This study emphasizes the need to recognize this unusual subgroup of HD and mandates long-term follow-up with timely intervention in arresting the progression/improving the deficits.

Response of Syrinx Associated with Chiari I Malformation to Posterior Fossa Decompression with or without Duraplasty and Correlation with Functional Outcome: A Prospective Study of 22 Patients

Background

The aim of the study is to correlate the surgical outcome with radiological changes in patients with Chiari I malformation (CMI) with syrinx. We also compared long-term functional and radiographic outcome in CM1 patients treated with posterior fossa decompression (PFD) with or without duroplasty.

Patients and Methods

From December 2013 to October 2015, 22 patients who underwent surgery with the diagnosis of CMI and syrinx were included in the study. Measurements were performed on preoperative and postoperative magnetic resonance (MR) scans using the same software. All patients underwent PFD with or without duroplasty. Clinical results were evaluated on the basis of the Chicago Chiari Outcome Scale (CCOS). We assessed the degree of resolution of syrinx and outcome of Chiari decompression with PFD versus PFD with duroplasty. Mean duration of follow-up was 12.4 ± 5.37 months (range: 6-24 months).

Results

Out of 19 patients in whom syrinx diameter decreased on postoperative MR imaging, 17 (89.5%) improved based on CCOS and 2 (10.5%) were unchanged while out of three patients in whom syrinx worsened, 2 (66.7%) improved and 1 (33.3%) was unchanged (P = 0.37). The cord diameter was found to have decreased in 12 patients and of these 11 (91.7%) improved. The cord diameter increased in 10 patients, but 8 (80%) improved (P = 0.57). The mean changes in syrinx, cord, and syrinx/cord ratio were studied in both groups with and without duroplasty, were not statistically significant. In this study, radiological parameters failed to predict functional outcome.

Conclusions

The outcome does not correlate with change in any of the syrinx-related factors. Surgical decompression with or without duroplasty does not have a statistically significant relationship in the degree of syrinx resolution. Surgical decompression without duroplasty provides the benefits of surgical decompression while avoiding the complications of intradural techniques.

Pediatric thoracolumbar spinal injuries: The etiology and clinical spectrum of an uncommon entity in childhood

BACKGROUND

Pediatric thoracolumbar (TL) spinal injuries are uncommon entities with an incidence of 5-34% of all pediatric spinal injuries. There is a scarcity of studies done on the pediatric population in the developing countries like India. This study aims to review our experience with TL spine injuries in children over a 12-year period.

MATERIALS AND METHODS

We retrospectively reviewed the epidemiology, risk factors, mechanisms, patterns of injury and management of pediatric TL injuries in our population.

RESULTS

There were 90 children with TL spine injuries comprising 2% of all the spine injuries treated in our institute. The mean age was 15.9 ± 3.2 years (range: 2-18 years) with a male predominance (3:1). The most common mode of injury was fall from height. 64/90 (71.1%) children sustained injury due to fall from height, 18/90 (20%) children sustained injury following motor vehicle accident and rest of the children sustained injury due to the fall of a heavy object over the neck. Most of the patients (27.8%) sustained Grade A injury. Lumbar spine was the most common spinal level injured (53.3%), and fractures were the most common type of injury (93.3%). Surgical fixation was performed in 18/90 (20%) children. Follow-up was available for 21 children of which 13 (62%) were ambulant at follow-up.

CONCLUSION

TL injuries are rare and are most common in children older than 10 years and mainly involve the lumbar region. When indicated, surgical fusion of the involved vertebrae is safe and effective.

Per-operative glue embolization with surgical decompression: A multimodality treatment for aggressive vertebral haemangioma

OBJECTIVE

The aim of this study is to share our experience in per-operative embolization of aggressive vertebral haemangioma and to compare the surgical outcome with existing modalities of management.

BACKGROUND

Vertebral haemangioma accounts for 12% of benign lesions of the vertebral column detected incidentally. Rarely they may enlarge, cause pain and neurological deficit because of spinal cord compression, vertebral body or arch expansion, or pathological fracture. Treatment options for symptomatic vertebral haemangioma include pre-operative transarterial embolization, surgical excision, radiotherapy, and percutaneous injection of alcohol or methyl methacrylate. We present our experience of per-operative glue embolization for aggressive (Enneking stage 3) vertebral haemangiomas.

MATERIALS AND METHODS

We describe five patients with symptomatic vertebral haemangioma at the dorsal level who underwent per-operative glue embolization. After initial laminectomy, a tumorogram was obtained under fluoroscopic guidance through direct contrast injection via spinal needle inserted through the pedicles of vertebra at the involved level. Varied concentration of glue was injected via the same spinal needle. All patients underwent surgical decompression of the intraspinal epidural component in the same sitting along with posterior spinal stabilization of the adjacent levels in two patients.

RESULTS

In all five patients, complete embolization of the tumour was possible per-operatively through the transpedicular approach along with adjunctive surgical decompression, and the blood loss was significantly less. Clinical follow-up of these patients at 12-48 months showed reduction in size of the epidural component, relief of cord compression, and significant improvement in their neurological deficits with no recurrence.

CONCLUSION

We conclude that per-operative embolization is a safe and efficacious adjunctive procedure with surgical decompression with or without spinal stabilization for the treatment of symptomatic vertebral haemangiomas.

Inverted (Buried) Reef Knot in Microsurgery - A Technical Note

In side to side anastomosis and end to end (one way up) microvascular anastomosis, the back wall of the vessel is sutured first with inverted/buried knots. A common mistake made by surgeons during this step is the formation of a granny knot. In inverted suturing, cut ends of granny knot points inside the vessel lumen and interfere with the suture line. This additional Intraluminal thread may promote foreign body reaction and may act as a nidus for thrombus formation. Hence, this subtle mistake in knot formation may cause immediate and/or delayed anastomosis failure. The purpose of the study was to describe principles of inverted/buried reef knot formation. We describe in detail the methodology to form an inverted reef knot in microsurgery using paracords and a glove model.

Cervical Spine Osteoblastoma with an Aneurysmal Bone Cyst in a 2-Year-Old Child: A Case Report

Osteoblastomas and aneurysmal bone cysts are uncommon benign tumors of the spine. Their presentation can vary between diffuse pain, restriction of neck movements, torticollis, radiculopathy, and myelopathy. Complete excision is the best treatment to achieve a cure, but recurrence is not uncommon. A combination of the two conditions in the pediatric population is extremely rare. To the best of the authors' knowledge, only 2 cases of such a combination in the cervical spine have been reported in the literature. We report the case of a 2-year-old child having a right C4 lateral mass osteoblastoma with an aneurysmal bone cyst. The child underwent complete surgical excision of the lesion with fusion.

Can the position of the vertebral artery be predicted on a lateral view X-ray of the craniovertebral junction? A radiological anatomy study

Background

The most feared complication while inserting C2 screws is vertebral artery injury. This article proposes predicting the position of the vertebral artery on a true lateral X-ray of the axis vertebra from the background information acquired from the computed tomography (CT) scan utilizing fluoroscopy.

Methods

Spiral CT scans of 33 C2 vertebrae were performed utilizing a 16-slice CT scanner lateral X-rays of C2 were then obtained before and after painting the vertebral artery grooves with barium. The space available for transarticular and C2 pedicle screw insertion above the vertebral artery groove in the isthmus was then calculated as a ratio for both X-rays and CT scans.

Results

There was no statistically significant difference between the (mean) ratios calculated by CT scan and X-rays regarding the space available for transarticular and C2 pedicle screw insertion (left side: 0.3894 vs 0.3897; right side: 0.3892 vs 0.3925; P > 0.05). The Kappa test revealed that CT scan and X-ray findings were in agreement in majority of the bones (left side: n = 24, 72.7%, right side: n = 22, 73.3%; P < 0.05).

Conclusion

A thorough understanding of a true lateral view X-ray based on background information extracted from three dimensional CT scans helps predict the highest point of the vertebral artery groove. This proves useful for placement of C2 transarticular and pedicle screws during regular "open" and "minimally invasive" spine surgery.

Adult intramedullary epidermoid cyst without spinal dysraphism: A case report

Background:

Intramedullary epidermoid cyst (IEC), typically associated with spinal dysraphism, is rare, with fewer than 80 such cases reported in the literature. Here we present an adult with an IEC without spinal dysraphism.

Case Description:

A 41-year-old female presented with the gradual onset of a progressive spastic paraparesis attributed to a magnetic resonance imaging (MRI)-documented D8-9 intramedullary lesion. Following microsurgical excision of the IEC, she fully recovered.

Conclusion:

IECs are rare lesions, typically found in conjunction with spinal dysraphism. Utilizing MRI studies to document the lesion location, gross total microsurgical excision is the procedure of choice. Early excision of these benign lesions maximizes functional recovery.

Anatomical Variations of the Temporomesial Structures in Normal Adult Brain - A Cadaveric Study

BACKGROUND

Despite significant evolutional, functional, and clinical interest, the anatomical variations of the temporomesial structures in cadaveric samples have received little attention. This study was undertaken to document the anatomical variations observed in the temporal lobe of human brain with emphasis on the structures present in temporomesial region.

MATERIALS AND METHODS

Using 26 postmortem cadaveric cerebral hemispheres (13 right and 13 left hemispheres), several neurosurgically significant mesial structures were studied by blunt dissection under the operating microscope. The observed surface-based qualitative variations and right-left asymmetries were tabulated under well-defined, moderately defined, and ill-defined classification.

RESULTS

Among the areas, uncus (100%), limen insulae (88.4%), rhinal sulcus and hippocampus (81%), intralimbic gyrus (77%), Heschl's gyrus (73%), gyrus ambiens, semilunar gyrus, sulcus semiannularis, and calcar avis (69.2%) were well defined, and band of Giacomini (38.4%) was found to be distinctly ill-defined areas in the list. Further, our analysis confirmed the presence of consistent left-greater-than-right asymmetry in all the areas of interest in temporal region under well-defined category. Rightward asymmetry was noticed in moderately defined and ill-defined classification. However, no asymmetry was detected in the uncal region. P value for all the obtained results was >0.05.

CONCLUSION

Our study offers a preliminary anatomic foundation toward the better understanding of temporal lobe structures. These variations may prove valuable to neurosurgeons when designing the appropriate and least traumatic surgical approaches in operating the temporomesial lesions.

Use of intraoperative X-ray to differentiate between reducible versus irreducible atlantoaxial dislocation

Background

The treatment and classification of atlantoaxial dislocations (AADs) remain controversial. Here, we utilized intraoperative X-ray to differentiate between reducible and irreducible AADs.

Methods

Five patients were diagnosed as having irreducible AAD on dynamic and post-traction X-rays. Under general anesthesia, they were placed prone in a neutral position utilizing skeletal traction. The X-rays and motor evoked potential (MEP), were then monitored before, during, and after placing a thumb on the C2 spinous process and pushing it anteriorly to attain reduction.

Results

The intraoperative X-ray confirmed reducibility of AAD in four patients; they subsequently underwent a C1-C2 posterior fusion, which maintained that reduction. For the one patient with an irreducible AAD (despite thumb maneuver), an anterior release was required first to attain reduction, followed by posterior C1-C2 fusion.

Conclusion

Here, we divided irreducible AAD into two categories: a) reducible-utilizing a thumb maneuver to compress/push the C2 spinous process forward with the patient positioned prone and b) irreducible-those who cannot be reduced with this technique. A posterior only approach was sufficient for those with "reducible" AAD, whereas those who could not be reduced required an anterior release followed by posterior fusion.

Functional Outcome for Chiari Malformation Using a Novel Scoring System

Background The authors report functional outcomes comparing various surgical techniques, using a Chiari-specific assessment tool. They also intend to externally validate the performance of the CCOS by comparing with gestalt outcome.

Methods Total cohort comprised 73 surgically treated patients, and patients were divided into two groups: patients who were operated upon at the authors’ institute and those who were evaluated at their institute but underwent surgery elsewhere due to various reasons. Functional outcome was evaluated on the basis of the Chicago Chiari outcome scale (CCOS) and gestalt outcome scale. Mean duration of follow-up was 10.23 ± 5.8 months.

Results In the authors’ cohort of 73 patients, 76.70% (n = 56) were improved, 23.30% (n = 17) were unchanged, and none of them deteriorated. The median CCOS was 14 ± 1.34 (range: 11–16). There was no statistical difference in outcome between the different operative groups (foramen magnum decompression, duraplasty, tonsillar resection “other”). The CCOS value of 14 has excellent sensitivity (0.95) and good specificity (0.746) for identifying patients with good gestalt outcome.

Conclusion The authors found a clear correlation between higher CCOS score and gestalt outcome. There was no statistical difference in outcome between the different operative groups.

Posterior epidural migration of lumbar disc: Will the real "disc" please stand up?

Background:

Posterior epidural lumbar disc fragment migration is rare and most commonly occurs at the L3-L4 level where it may contribute to cauda equina compression.

Case Description:

Here, we report three cases of epidural migration of a lumbar disc, two of which led to bladder dysfunction/cauda equina compression. Early decompression (e.g., laminectomy) and aggressive postoperative physiotherapy led to significant postoperative improvement in all three patients.

Conclusion:

Migration of large sequestrated lumbar disc herniations leading to cauda equina compression should be recognized early and promptly treated with decompressive laminectomies to achieve the best postoperative outcomes.