Seventh Cervical Nerve (C7) Transection for Spastic Arm Paralysis After Cerebral Injury

BACKGROUND

Spastic limb paralysis because of cerebral injury can cause long-term disability. Its treatment varies from conservative to operative; however, the optimum treatment is yet to be found.

OBJECTIVE

To test the hypothesis that patients with spastic arm paralysis who receive C7 nerve transection to their paralyzed side might have reduction in spasticity, pain, and improvement in arm function.

METHODS

Four patients with spastic hemiparesis that had ceased to improve after 1 year of rehabilitation, having pain and poor function, were included. All 4 patients underwent C7 nerve transection plus rehabilitation. The outcome was assessed at 1, 3, and 6 months by the Fugl-Meyer upper extremity scale for motor recovery, by the Modified Ashworth Scale score for spasticity, and by the visual analogue score for pain. Functional use of the limb was also assessed by performance of activities such as dressing, tying shoe laces, wringing a towel, and operating a mobile phone.

RESULTS

At the end of 6 months, there was a significant improvement in mean Fugl Meyer score, reduction in Modified Ashworth score, and Visual Analogue scale for pain. At the beginning of the study, none of the patients could perform any day-to-day activities; however, at the end of 6 months, 3/4 of the patients could perform at least 1 activity.

CONCLUSION

C7 neurectomy leads to improved motor function, reduction of spasticity and pain, and improvement in function in patients with spastic arm paralysis because of cerebral injury.

A Novel Brain Retractor for Endoscopic Evacuation of Chronic Subdural Hematoma

Background

Endoscopic chronic subdural hematoma (CSDH) evacuation is a safe and effective alternative to the conventional burr hole technique. Although a rigid endoscope has the advantage of good visualization, there are risks of brain damage due to limited space to accommodate the scope and frequent lens soiling.

Objective

This technical note describes a novel brain retractor to overcome the limitations of rigid endoscopy.

Methods

The novel brain retractor (by senior author) was made by dividing a silicon tube longitudinally into two halves, and tapered for easy introduction in the operative cavity. Sutures were placed at the outer end of the retractor to prevent migration and to assist in angulation.

Results

The novel retractor along with endoscopic assistance was used in 362 CSDH procedures. Endoscopy combined with this retractor provided additional help in complete removal of hematoma in organized/solid clots, septa, bridging vessels, and rapid expansion of brain in 83, 23, 21, and 24 patients, respectively (n = 151, 44%). Although there were three deaths (due to poor preoperative status), and two recurrences, there were no retractor-induced complications.

Conclusions

The novel brain retractor assists endoscope in proper visualization of complete hematoma cavity by gentle and dynamic brain retraction, helps in thorough irrigation of hematoma cavity, protects the brain, and prevents lens soiling. It allows easy insertion of the endoscope and instruments using bimanual technique even in patients with a small width of hematoma cavity.

Epilepsy-Related Injuries in Children: An Institution-Based Study

BACKGROUND

Epilepsy carries a lifetime risk of seizure-related accidents. The risk varies according to the socioeconomic profile of a place. Sufficient data is lacking for epilepsy-related accidents in the pediatric population.

OBJECTIVE

We aimed to identify the proportion of pediatric epileptic patients who met with accidents and their associated factors.

METHODS

A prospective study was done. Patients of less than 18 years with epilepsy of more than 1-year duration were included and were given a questionnaire modified for the pediatric population. The demography of accidents during seizures and drugs taken were recorded.

RESULTS

135 epileptic children were included. 70.4% of patients suffered seizure-related accidents ranging from 1-10 accidents in their epilepsy duration. Falls (83.15%) were the most common, 25.26% of them required hospitalization. Accidents due to missing of drug dosage were observed in 23% patients.

CONCLUSION

Seizure-related accidents are common in the pediatric population, and may lead to major accidents. Better epilepsy management with extra care for high-risk epilepsy patients may decrease their incidents.

Cadaveric study to assess the feasibility of S1 neurectomy and contralateral S1 transfer for spastic hemiparesis

Purpose

Acquired brain injury causing spasticity, pain and loss of function is a major cause of disability and lower quality of life. Sacral 1 (S1) neurectomy claims promising outcomes in spastic hemiparesis. This cadaveric study was conducted to study the surgical anatomy, surgical approach and feasibility of S1 neurectomy and contralateral S1 (cS1) transfer.

Methods

This study was conducted over a period of 10 months and 10 cadavers (age 18-60 years, 7 male and 3 female) were included in the study. 2 cadavers underwent endoscopic S1 neurectomy and 8 cadavers underwent open S1 neurectomy. Mean S1 root length and diameter were recorded using Schirmer tear strips and Vernier calliper. Feasibility of transfer was also assessed by measuring the length of donor nerve and distance between distal ends to proximal end of recipient nerve.

Results

Mean thickness of right S1 root was 4.02 ± 1.5 mm and left S1 was 3.89 ± 1.18 mm. Mean length of right S1 root was 24.9 ± 4.56 mm and left S1 was 23.6 ± 2.86 mm. Endoscopically dissected length of S1 was much less as compared to open technique.

Conclusion

S1 neurectomy is simple procedure to reduce spasticity in lower limb without any permanent deficit. It can be done by open as well as with endoscopic approach while for contralateral S1 transfer open approach need to be used.

95 DOCUMENTATION OF URINARY CATHETER INDICATION AND INSERTION PROCEDURE FOR MEDICAL INPATIENTS AT A UNIVERSITY TEACHING HOSPITAL

Background

Approximately 25% of inpatients have urinary catheters at some point during their hospital stay; over half are deemed inappropriate. This is significant as catheter-associated urinary tract infections (CAUTI) increase morbidity, mortality and length of hospitalisation. Lack of medical documentation and clinician awareness of catheters have been identified as risk factors for inappropriate catheterisation. The aim of this audit was to assess inpatient urinary catheter use among medical inpatients to determine if the indication and insertion procedure were clearly documented.

Methods

The audit was conducted over one day and included all medical inpatients aged 18 years and above. Emergency Department and High Dependency patients were excluded. Data was collected using standardised data collection sheets and involved a review of medical/nursing notes. Data was benchmarked against Health Service Executive guidelines.

Results

27 of 132 medical inpatients (20%) had a urinary catheter in situ on the day of audit. 37% (n = 10) had long-term urinary catheters in situ prior to admission and are not considered further. Of the remaining 63% (n = 17), 9 were female (53%), 8 were male (47%), and the average age was 75 years. Indication was documented in nursing notes for 76% and in medical notes for 53%. Indications included monitoring urinary output (29%), urinary retention (24%), sepsis (18%), comfort (6%) and haematuria (6%). Catheter insertion procedure was documented in nursing notes for 59% and in medical notes for 12%.

Conclusion

One fifth of medical inpatients had urinary catheters on the day of audit. 63% of these patients did not have a catheter prior to admission. Overall medical documentation of catheter indication and insertion procedure is poor. Better documentation would likely improve clinician awareness of their patient’s catheters and prompt earlier review of appropriateness. Education sessions, insertion proforma stickers and catheter review reminder systems are suggested to improve documentation.

Endoscopic Third Ventriculostomy - A Review

BACKGROUND

Endoscopic third ventriculostomy (ETV) has become a proven modality for treating obstructive and selected cases of communicating hydrocephalus.

OBJECTIVE

This review aims to summarize the indications, preoperative workup, surgical technique, results, postoperative care, complications, advantages, and limitations of an ETV.

MATERIALS AND METHODS

A thorough review of PubMed and Google Scholar was performed. This review is based on the relevant articles and authors' experience.

RESULTS

ETV is indicated in obstructive hydrocephalus and selected cases of communicating hydrocephalus. Studying preoperative imaging is critical, and a detailed assessment of interthalamic adhesions, the thickness of floor, arteries or membranes below the third ventricle floor, and prepontine cistern width is essential. Blunt perforation in a thin floor, while bipolar cautery at low settings and water jet dissection are preferred in a thick floor. The appearance of stoma pulsations and intraoperative ventriculostomography reassure stoma and basal cistern patency. The intraoperative decision for shunt, external ventricular drainage, or Ommaya reservoir can be taken. Magnetic resonance ventriculography and cine phase-contrast magnetic resonance imaging can determine stoma patency. Good postoperative care with repeated cerebrospinal fluid drainage enhances outcomes in selected cases. Though the complications mostly occur in an early postoperative phase, delayed lethal ones may happen. Watching live surgeries, assisting expert surgeons, and practicing on cadavers and models can shorten the learning curve.

CONCLUSION

ETV is an excellent technique for managing obstructive and selected cases of communicating hydrocephalus. Good case selection, methodical technique, and proper training under experts are vital.

Mature tertiary lymphoid structures in lung adenocarcinoma are associated with better progression free survival

Introduction/Objective

The presence of inducible lymphoid structures known as tertiary lymphoid structures in the tumor microenvironment has been shown to correlate with positive clinical outcome. However, the maturation states of lymphoid aggregates in lung adenocarcinoma are not completely understood.

Methods/Case Report

Seventy tumor samples from 69 patients diagnosed with lung adenocarcinoma (Stages I to III) between 2013 and 2015 were included in the study. The presence and maturation states of the lymphoid structures within the tumors were evaluated by conventional and 26 samples were further analyzed by multiplexed immunohistochemistry of formalin fixed paraffin embedded tissues and then quantified. Mature lymphoid follicles containing germinal centers were identified by the presence of CD21+ and BCL-6+ cells in an organized configuration within tight clusters of T and B cells.

Results (if a Case Study enter NA)

Samples with fully mature lymphoid structures (germinal centers) had larger tumors and higher disease stage. The number of mature lymphoid structures correlated with the total number of lymphoid aggregates present in the tumor microenvironment. Additionally, tumor samples with ≥10 mature lymphoid structures had more primary follicles. While there was no difference in overall survival, progression free survival was significantly longer in patients who had ≥10 mature lymphoid structures in comparison with patients who had <10 mature structures.

Conclusion

In conclusion, a spectrum of lymphoid aggregates in different stages of maturation are present in lung adenocarcinoma. An increase in the number of mature lymphoid structures may be associated with progression free survival in patients with lung adenocarcinoma.

Awake focussed craniotomy for oedematous/large brain lesions

Aim: Awake craniotomy has been proven to be safe and effective. It has generally been used for non-edematous conditions. If done in edematous states, large craniotomies are advised. Here, we report the combined use of techniques of awake anaesthesia and focussed craniotomy for dealing with large/edematous brain lesions. Materials and Methods: This was a prospective single-centre study from May to October 2019. Included were adult cooperative patients presenting with edematous brain lesions. A completely awake cycle was used using ring scalp block, Dexmedetomidine loading, and maintenance infusion, and use of Midazolam and Fentanyl. The dural flap was lifted limited to the lesion, and sometimes in stages to tackle the bulging brain. Data was collected for resection volume, pain scores using visual analogue scale (VAS) during the surgery, seizures, complications, new deficits, blood loss, duration of surgery, ICU, and postoperative hospital stay. Results: Fifteen patients underwent the procedure. Pathologies were high-grade gliomas (7), low-grade gliomas (3), tuberculoma (2), metastasis (1), ependymoma (1), and meningioma (1). Fourteen patients underwent total, and one underwent subtotal excision. Brain bulge could be handled with the staged opening of the dura and intratumoral decompression. No patient required postoperative ventilatory support. Intraoperative pain scores ranged from 2-3. The duration of surgery ranged from 60-280min. Blood loss ranged from 75-300ml. Postoperative stay varied from 3-20 days. There were two intraoperative seizures (managed), two CSF leaks, and two infections. Two patients developed transitory motor deficits. Conclusion: Awake focussed craniotomy was found safe and effective for large/edematous brain lesions in appropriately selected patients.

Odderon Exchange from Elastic Scattering Differences between pp and pp[over ¯] Data at 1.96 TeV and from pp Forward Scattering Measurements

We describe an analysis comparing the pp[over ¯] elastic cross section as measured by the D0 Collaboration at a center-of-mass energy of 1.96 TeV to that in pp collisions as measured by the TOTEM Collaboration at 2.76, 7, 8, and 13 TeV using a model-independent approach. The TOTEM cross sections, extrapolated to a center-of-mass energy of sqrt[s]=1.96  TeV, are compared with the D0 measurement in the region of the diffractive minimum and the second maximum of the pp cross section. The two data sets disagree at the 3.4σ level and thus provide evidence for the t-channel exchange of a colorless, C-odd gluonic compound, also known as the odderon. We combine these results with a TOTEM analysis of the same C-odd exchange based on the total cross section and the ratio of the real to imaginary parts of the forward elastic strong interaction scattering amplitude in pp scattering for which the significance is between 3.4σ and 4.6σ. The combined significance is larger than 5σ and is interpreted as the first observation of the exchange of a colorless, C-odd gluonic compound.

Endoscopic Anterior Cervical Discectomy (Disc Preserving)

Background and Introduction

Endoscopic anterior cervical approach has several advantages compared to conventional anterior cervical discectomy and fusion (ACDF).

Objective

This video demonstrates a step-by-step procedure for endoscopic anterior cervical discectomy.

Procedure

The patient is placed supine with the neck extended. A standard anterior cervical approach using about 3 cm skin incision is made and under "Easy Go" (Karl Storz, Tuttlingen, Germany) endoscopic vision, the uncinate process and uncus are drilled. Only a small portion of the normal disc, posterior longitudinal ligament (PLL), and compressing disc is removed. The closure is done in a standard manner.

Results

In 240 patients, the average postoperative reduction in disc height, operating time, and blood loss were 1.1 ± 0.2 mm, 110 ± 17 min, and 30 ± 11 mL, respectively. The average postoperative VAS score and Nurick grading improved significantly. There were no permanent complications or any mortality.

Conclusion

Endoscopic technique is an effective and safe alternative to ACDF after attaining the learning curve.

Comparison of Peripheral Neurectomy vs. Medical Treatment for Migraine: A Randomized Controlled Trial

Background

Migraine is a common form of primary neurologic headache. Many patients are chronic migraineurs and suffer from a significant disability and adverse effects of drugs. There are various surgical options available to treat migraines, including peripheral neurectomies.

Objective

To study the surgical and functional outcomes of migraine surgeries using peripheral neurectomies and compare them with conservatively treated patients.

Materials and Methods

Migraine patients who had a unilateral onset pain were given local bupivacaine block at the suspected trigger site, and those who were relieved were given the option for surgery. In the operative group, the peripheral nerve of the trigger site was lysed under local anesthesia. The conservative group was continued with the standard treatment. Evaluations with a baseline and 6 months visual analog score (VAS), migraine headache index (MHI), migraine disability assessment test (MIDAS), and pain self-efficacy questionnaire (PSEQ) scores were done.

Results

A total of 26 patients got benefitted with the local bupivacaine block, out of which 13 underwent surgery. At baseline, the VAS, MHI, MIDAS, and PSEQ scores were similar in both the groups. The operative group had significant (P < 0.001) improvement in all these parameters 6 months after the surgery. All patients of the operative group got free from prophylactic migraine treatment; however, 11 out of 13 patients still needed occasional  use of analgesics. There was one complication of transient temporal numbness.

Conclusion

Migraine surgery using peripheral neurectomies was more effective than chronic drug treatment in appropriately selected patients.

Endoscope-controlled Access to Thalamic Tumors using Tubular Brain Retractor: An Alternative Approach to Microscopic Excision

BACKGROUND

 Surgery for thalamic lesions has been considered challenging due to their deep-seated location. Endoscopic excision of deep-seated brain tumors using tubular retractor has been shown to be safe and effective in prior studies; however, there are limited reports regarding its use for thalamic tumors. We present our experience of endoscope-controlled resection of thalamic tumors using a tubular retractor.

MATERIAL AND METHODS

 This was a prospective observational case series done at a tertiary center specialized for endoscopic neurosurgery during the period from 2010 to 2019. Surgeries were performed under the endoscopic control using a silicon tubular retractor. Lesions were approached transcortically or trans-sulcally. Data were collected for the extent of resection, amount of blood loss, operative time, need for conversion to microscopy, and complications.

RESULTS

 Twenty-one patients of thalamic masses of 14- to 60-year age underwent the surgeries. Pathologies ranged from grade I to IV gliomas. Gross total and near-total resection could be done in 42.85% of cases for each group. The average blood loss and operative time were164.04 ± 83.63 mL and 157.14 ± 28.70 minutes, respectively. Complications included a small brain contusion, two transient hemipareses, and one transient speech deficit.

CONCLUSION

 Endoscopic excision of thalamic tumors using a tubular retractor was found to be a safe and effective alternative to microscopic resection.

Colloid Cyst Presenting as Head Injury

Colloid cysts are mucous- or hyaloid-filled lesions with an outer fibrous layer. These are rare developmental and nonneoplastic malformation. They may be found incidentally, while some cases may present with intermittent headache, rapid neurologic deterioration, drop attacks, and even sudden death. Early recognition of this disease may result in lesser mortality. Here, we present a 22-year-old male with a history of fall while driving his two-wheeler. A diagnosis of colloid cyst of the third ventricle with a head injury was made. Colloid cyst presenting with a head injury is exceedingly rare with only five case reports in the literature. This report may help to support surgical intervention in an asymptomatic patient, as the cyst can predispose head injury with serious consequences. It also stresses the importance of a high degree of suspicion when there is any well-defined radiological abnormality in the region of the third ventricle. A colloid cyst may easily be confused with intracranial hemorrhage due to hyperdensity in head trauma. It can be distinguished by the presence of an accompanying traumatic lesion. The cyst usually has well-defined round margins, and the morphologic appearance and density do not change on a follow-up computed tomography (CT) scan, whereas in hemorrhage the density usually regresses with clinical improvement on serial imaging.

Teaching Glasgow Coma Scale Assessment by Videos: A Prospective Interventional Study among Surgical Residents

Objective  Glasgow Coma Scale (GCS) assessment is vital for the management of various neurological, neurosurgical, and critical care disorders. Learning GCS scoring needs good training and practice. Due to limitation of teachers, the new entrants of the clinical team find it difficult to learn and use it correctly. Training through videos is being increasingly utilized in the medical field. This study aimed to evaluate the efficiency of video teaching of GCS scoring among general surgery residents. Materials and Methods  A prospective study was done utilizing the freely available video at glasgowcomascale.org. The participants (general surgery residents, 1st-3rd year) were asked to assess and record their responses related to GCS both before and after watching the video. A blinded neurosurgeon recorded the correct responses separately. Statistical Analysis  The difference between correct responses of the residents before and after watching the video was calculated using the "chi-square test." p -Value ≤ 0.05 was taken as significant. Results  There was a significant improvement in GCS scoring by residents after watching the videos ( p < 0.05). On estimating the responses separately, all the three responses (eye, verbal, and motor) improved significantly for 1st-year residents while only the motor response improved significantly for 2nd- and 3rd-year residents. The mode subjective improvement for the 1st-, 2nd-, and 3rd-year residents was 5, 4, and 3, respectively. Conclusion  Training GCS scoring through videos is an effective way of teaching the surgery residents with maximum benefit to the junior-most ones.

Computerized Tomography-Based Morphometric Analysis of Cervical Spinal Canal in Central Indian Population

Objective  Normal cervical spine canal morphometry is critical for understanding the pathology of certain diseases and for proper preoperative planning. Computerized tomography (CT) scan can replace older conventional radiography techniques by providing more accurate morphometric measurements. This study was aimed to find out various dimensions of the cervical spinal canal of central Indian population.

Materials and Methods  A prospective study was conducted including 100 consecutive cervical spine CT scan of asymptomatic adult subjects. The anteroposterior sagittal canal diameter (SCD), transverse canal diameter (TCD), canal surface area (CSA), and Pavlov-Torg Ratio (PTR) from C2 to C7 were calculated.

Statistical Analysis  Data were entered in Microsoft Excel Sheet 2007 and statistical analysis was performed by IBM SPSS statistics 2.0 version. p -Value < 0.05 was considered as significant.

Results  Age ranged from 18 years to 77 years with mean age 39.5 years. There was no significant difference in all the dimensions (SCD, TCD, CSA) in male and female except at C2 level, where SCD, TCD, and CSA were significant larger in male. The mean SCD, TCD, and CSA is largest at C2 level (14.4 ± 1.63 mm, 21.57 ± 1.59 mm, and 156.20 ± 24.98 mm ² , respectively) and smallest at C4 level (12.77 ± 1.48 mm, 20.37 ± 1.72 mm, and 130.42 ± 21.20 mm ² ). PTR showed very little variation.

Conclusion  Normal values of cervical spinal canal could serve as a future reference. CT scan provides more accurate measurement. More studies are needed as there could be variations in dimensions in different regions in India.

Endoscopic Management of Chronic Subdural Hematoma

Background Twist drill evacuation, burr hole aspiration, mini-craniotomy, and craniotomy are some of the surgical methods to remove chronic subdural hematoma (CSDH). Endoscopic treatment was also recently found to be useful.

Methods We conducted a prospective study of 72 hematomas in 68 patients. Computed tomography was performed in all cases. Endoscopic surgery was performed in all CSDH patients.

Surgical procedure A 4-cm skin incision was performed at the most curved part of skull with the CSDH. A mini-craniotomy or enlarged burr hole was made. The inner and outer table of the burr hole margin was drilled to provide a straight trajectory to the hematoma cavity. An endoscope supported by a telescope holder was used. A modified silicone brain retractor was used in five patients. A subgaleal drain was left in all patients for 3 to 5 days.

Results There were 42 male and 26 female patients. The age ranged from 45 to 79 years (average: 69 years). All patients had a history of head trauma. Preoperative average Glasgow Coma Scale Score was 14. The procedure was effective in hematoma evacuation and a good visualization of the whole cavity in all patients. The endoscopic technique helped in complete hematoma removal in organized/solid clot, septations, and bridging vessels in 17, 2, and 2 cases, respectively. Duration of surgery ranged from 35 to 80 minutes. One death occurred. There was no recurrence, infection, fresh bleed, or injury to the brain or membrane.

Conclusion The endoscopic technique is an effective alternative technique for treating CSDH. Although the study has limitations because of the small number of patients with a short follow-up, the study indicated that thick and vascular membranes, septations, and organized and solid clots can be removed effectively using this technique.

Neurotrauma Audit at Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh

Introduction For the prevention and better management of traumatic brain and spine injury patients, it is mandatory to understand the demographic and clinical profiles of cases of a particular region. This study was aimed at describing the epidemiology, pattern, and outcomes of head and spine injury patients at a tertiary care center in central India.

Materials and Methods All the patients with head and spine injury admitted to the Department of Neurosurgery between September 1, 2018, and August 31, 2019 were included in the study. Data of all these patients were collected from the medical record section and analyzed for age, sex, mode of injury, severity of injury, management, and outcomes.

Results During the study period, 932 patients with head injury and 241 patients with spine injury were admitted to our department. Around 65% of the patients in both head and spine injury categories fell in the age group of 26 to 55 years. Approximately 80% of all neurotrauma patients were male. The most common mode of injury was road traffic accident followed by fall from height. Mortality for severe head injury was 39% and that for ASIA A (American Spinal Injury Association grade A) cervical spine injury was 65%.

Conclusion Even after aggressive treatment strategies, morbidity and mortality are very high, and the ultimate outcome depends mainly on the clinical status immediately after trauma. The data from this study can be helpful in strategy-making for the prevention and management of head and spine injury patients, especially in the central Indian population.

R0 Resection Margin, A New Quality Measure in the Era of National Bowel Screening?

Aims To determine the completeness of polyp resection (i.e. achieving an R0 margin) and its relation with Endoscopists, histopathologist, size, location and technique of polypectomy in an NSS cohort. The definition of R0 margin is complete macroscopic resection with a negative microscopic margin at polypectomy. Method NCCS (National Colon Cancer Screening) colonoscopies are offered to bowel cancer screening patients after a positive faecal immunochemical test (FIT) test in a Joint Advisory Group (JAG) accredited Gastrointestinal Endoscopy centre. We histologically evaluated the polyp margins for complete resection, which was defined as the absence of adenomatous or hyperplastic tissue in the resected polyp margins in a cohort of faecal immunochemical test positive patients. Results A total of 186 consecutive NCCS colonoscopies out of a total of 542 performed between 2013 and 2017 were included in this study. Of the polyps excised 152(27%) had a R0 margin histologically, and 30(5%) had involvement of the margin. Surprisingly in 373(67%) of polyps pathologists were unable to assess the margin. Conclusion Achieving an R0 margin should be a key performance indicator for endoscopists performing polypectomy. At the same time more studies on polyp margins are recommended.

Anatomical feasibility of anastomosing intercostal nerves (D10&D11) and subcostal nerve (D12) to S2 ventral root and lumbar plexus for management of bladder function after spinal cord injury

OBJECTIVE

The transfer of peripheral nerves originating above the level of injured spinal cord into the nerves/roots below the injury is a promising approach. It facilitates the functional recovery in lower extremity, bladder/bowel and sexual function in paraplegics. We assessed anatomical feasibility of transfer of lower intercostal nerves to S2 ventral root in human cadaver for management of neurogenic bladder dysfunction in patients with spinal cord injury.

METHODS

Study was performed in five formalin fixed cadavers. Cadavers were placed in prone position. A transverse incision was made along 11th ribs on both sides and 10th, 11th Intercostal nerves (ICN) and subcostal nerve were harvested up to maximum possible length. In four cadavers the ventral root of S2 was exposed by endoscope and in one by the standard open laminectomy. Intercostal nerves were brought down to lumbo-sacral region, S2 ventral root was cut cranially and feasibility of intercostal to S2 anastomosis was assessed.

RESULTS

The mean length of intercostal nerves was 18.4 cm for the 10th 19.5 cm for the 11th and 22.15 cm for the subcostal nerve. The length of harvested nerve and the nerve length necessary to perform sacral roots neurotization were possible in all cases by only by subcostal nerve while T11 and T10 ICN fall short of the required length.

CONCLUSION

For Spinal cord lesions located at the conus, subcostal nerve could be connected to ventral root of S2 in an attempt to restore bladder function while 10th and 11th ICN had enough length to neurotize lumbar plexus.

A rare case of giant primary orbital hydatid cyst

BACKGROUND

Primary orbital involvement is extremely rare in echinococcosis. We report a case of giant orbital hydatid cyst in a 15-year-old boy.

CASE DESCRIPTION

A 15-year-old boy presented with left-side proptosis and gradual painless vision loss. Computed tomography and magnetic resonance imaging revealed a giant multilocular cystic orbital lesion extending into subfrontal region. Surgical excision was done. Histopathology was suggestive of hydatid cyst. Postoperatively, an antiparasitic agent was administered for 3 months.

CONCLUSIONS

Hydatic cyst should be kept in differential diagnosis of orbital cystic lesions, especially in pediatric population and endemic areas.

Early Syringomyelia in Tubercular Meningitis

Tubercular meningitis (TBM) can have various complications. Sometimes syringomyelia can also occur as a late complication of tubercular meningitis. Although syrinx formation in early stage of TBM is very rare. There are only four published case reports of syringomyelia in acute stage of TBM. Here we report a patient with tubercular meningitis who developed syringomyelia in early course of illness.

Measurement of the Effective Weak Mixing Angle in pp[over ¯]→Z/γ^{*}→ℓ^{+}ℓ^{-} Events

We present a measurement of the effective weak mixing angle parameter sin^{2}θ_{eff}^{ℓ} in pp[over ¯]→Z/γ^{*}→μ^{+}μ^{-} events at a center-of-mass energy of 1.96 TeV, collected by the D0 detector at the Fermilab Tevatron Collider and corresponding to 8.6  fb^{-1} of integrated luminosity. The measured value of sin^{2}θ_{eff}^{ℓ}[μμ]=0.23016±0.00064 is further combined with the result from the D0 measurement in pp[over ¯]→Z/γ^{*}→e^{+}e^{-} events, resulting in sin^{2}θ_{eff}^{ℓ}[comb]=0.23095±0.00040. This combined result is the most precise measurement from a single experiment at a hadron collider and is the most precise determination using the coupling of the Z/γ^{*} to light quarks.

Endoscopic Vascular Decompression in Trigeminal Neuralgia

AIM

Microscope may fail to detect culprit vessel at the root entry zone or distally, especially when the suprameatal tubercle is prominent and when the compressing vessel is lying anteriorly to the trigeminal nerve without using significant brain retraction. Endoscopic techniques allow better visualization of the nerve and vascular conflict.

MATERIAL AND METHODS

A retrospective study of 178 patients of endoscopic vascular decompression without the use of microscope was done. The follow-up period ranged from 12 to 108 months (average 58 months).

RESULTS

The age of the patients ranged from 32 to 75 years. Neuralgia was in the maxillary, mandibular and both (maxillary and mandibular) divisions in 89, 72 and 16 patients, respectively. Duration of the operation and hospital stay ranged from 85 to 160 minutes and 2 to 10 days (average 2.7 days), respectively. Offending vessels could be identified in 174 patients. The superior cerebellar artery, anterior inferior cerebellar artery, single vessel, double vessel conflicts and a vessel anterior to the nerve were seen in 136, 76, 133, 41 and 31 patients, respectively. The pain was relieved in 167 patients (93.8%). Temporary complications included trigeminal dysesthesias (3.9%), cerebrospinal fluid leak (2.8%), facial paresis (3.9%), decreased hearing (1.7%) and vertigo (3.3%). Permanent hearing loss, recurrence of pain and re-surgery was observed in 1, 7 and 3 patients, respectively.

CONCLUSION

Endoscopic vascular decompression is a safe and effective technique for vascular decompression with advantages of better visualization of the entire course of the nerve and vascular conflict without brain retraction. It also helps in better detection of the completeness of surgery.

Concurrent Intramedullary and Intracranial Tuberculomass

Tuberculosis of the central nervous system (CNS) is well known. CNS involvement can occur in the form of tubercular meningitis (TBM), tuberculous vasculitis, tuberculoma and rarely brain abscess. Tubercular granulomas generally solitary and occur in the brain but they may be multiple and involve other areas such as spinal cord, epidural space and subdural space also. Tuberculoma in the spinal cord is rare. Co-occurrence of intracerebral and intramedullary spinal tuberculoma is extremely rare in children with only few cases reported till date. We are reporting one such case in children and review of literature.

Endoscopic partial corpectomy using anterior decompression for cervical myelopathy

Symptomatic ventral cervical cord compressions have been treated by anterior discectomy with fusion, anterior corpectomy and fusion, discectomy with an artificial disc, and minimally invasive techniques. There are complications associated with the fusion procedure, especially when a long segment fusion is undertaken. Partial removal of the vertebral body without fusion could help in avoiding fusion and its associated complications. We are describing the detailed surgical technique, indications, limitations, and early results of endoscopic partially corpectomy. The detailed endoscopic technique of how to remove minimal portion of the anterior and middle part of the vertebra with the removal of compressing posterior portion is described. To the best of the author's knowledge, this procedure has not been described in the literature till date. This technique has the advantages of preservation of most of the vertebral body and disc. The stability of the spine is maintained without the patient having to undergo the additional procedure of spinal fusion. There is a shorter length of hospital stay. The technique can also be used in special conditions, such as when a migrated disc behind the vertebral body or any bony compression opposite the vertebral body is encountered. It avoids injury to the longus colli muscles and damage to most of the annulus fibrosis. It preserves motion segments at the operated and adjacent segments without any significant decrease in the disc and vertebral height. A relatively short follow-up and the experience in a relatively small number of patients till now, are the limitations to the widespread use of this technique. Although long-term follow-up of this procedure in a large number of patients is not currently available, endoscopic partial corpectomy seems to be an effective and an alternative method for dealing with anteriorly located cervical compression. Long-term follow-up in a large number of patients is required to assess for the safety and effectiveness of the procedure.

Combined Forward-Backward Asymmetry Measurements in Top-Antitop Quark Production at the Tevatron

The CDF and D0 experiments at the Fermilab Tevatron have measured the asymmetry between yields of forward- and backward-produced top and antitop quarks based on their rapidity difference and the asymmetry between their decay leptons. These measurements use the full data sets collected in proton-antiproton collisions at a center-of-mass energy of sqrt[s]=1.96  TeV. We report the results of combinations of the inclusive asymmetries and their differential dependencies on relevant kinematic quantities. The combined inclusive asymmetry is A_{FB}^{tt[over ¯]}=0.128±0.025. The combined inclusive and differential asymmetries are consistent with recent standard model predictions.

Whether Superficial Abdominal Reflex is Affected by Subcostal Transverse Abdominal Incisions? A Prospective, Observational Early Experience

Introduction:

Superficial abdominal reflex (SAR) is an important part of the neurologic assessment. It is normally present and may be present or absent in various physiological as well as pathological conditions. The presence of an abdominal incision creates a dilemma in the mind of the clinician for it affecting this reflex. As there is no literature on this, we decided to study the effect of abdominal incisions on SAR.

Materials and Methods:

It was a prospective, observational study. We evaluated the patients requiring transverse subcostal incision (range 3–12 cm) both preoperatively and postoperatively, for their abdominal reflexes. Patients with preoperative normal and symmetrical abdominal reflexes were included in the study. Postoperatively, we compared the change of SAR with the preoperative status and analyzed the data.

Results:

A total of 94 patients underwent surgeries, out of which 54 patients came under inclusion criteria, comprising 36 males and 18 females. Subcostal transverse abdominal incisions were made for surgeries including both gastrointestinal and ventriculoperitoneal shunts. SAR was found unaffected by the incisions in all patients.

Conclusions:

Although the study was small, subcostal transverse abdominal incisions were not found to affect SAR.

Endoscopic Management of Arnold-Chiari Malformation Type I with or without Syringomyelia

Introduction Several different surgical techniques have been used in the treatment of patients with symptomatic Arnold-Chiari malformation type 1 (ACM-1) with or without syrinx. Endoscope-assisted decompression of the posterior fossa has been found to be safe and effective. We report our initial experience of endoscopic management of ACM-I.

Material and Methods This was a prospective study of 15 symptomatic patients. Pre- and postoperative clinical status and computed tomography and magnetic resonance imaging findings were recorded. Suboccipital bone of ∼ 3 cm distance from the foramen of magnum and posterior arch of atlas was removed. Partial splitting of the dura mater with preservation of the inner portion and the arachnoid membrane was performed. Any change in axial and sagittal length of the syrinx, tonsillar ascension, shape of the tonsil tip, appearance of cerebrospinal fluid posterior to the tonsil, and formation of the cisterna magna were recorded. Patients with atlantoaxial instability, tethered cord, associated myelomeningocele, hydrocephalus, or elevated intracranial pressure were excluded.

Results Age of patients ranged from 26 to 48 years. There were nine female patients. There were six patients with ACM-I without and nine with ACM-I with syrinx. Average pre- and postoperative Karnofsky performance score was 78 and 93, respectively. Average operative time was 130 minutes (110–190 minutes), and blood loss was 30 mL (20–180 mL). Follow-up ranged from 9 to 21 months.

Conclusion Although the study is limited by the small number of patients with a short follow-up, endoscopic decompression in selected patients of ACM-I with or without syrinx with dural splitting was a safe and effective alternative to microsurgical treatment.

Indigenous Inexpensive Practice Models for Skill Development in Neuroendoscopy

Introduction:

Neurosurgery is a branch having a tough learning curve. Residents generally get very less hands-on exposure for advanced procedures like neuroendoscopy. With the limited number of cadavers available and ethical issues associated with animal models, practice models, and simulators are becoming the able alternative. Most of these simulators are very costly. We tried to build indigenous inexpensive practice models that can help in developing most of the skills of neuroendoscopy.

Materials and Methods:

Models were built for learning hand-eye coordination, dexterity, instrument manipulation, cutting, fine dissection, keyhole concept, drilling, and simulation of laminectomy and ligamentum flavum resection. These were shown in the neuroendoscopic fellowship program conducted in authors' institute, and trainees' responses were recorded.

Results:

Both novice and experienced neuroendoscopic surgeons validated the models. There was no significant difference between their responses (P = 0.791).

Conclusion:

Indigenous innovative models can be used to learn and teach neuroendoscopic skills. The presented models were reliable, valid, eco-friendly, highly cost-effective, portable, easily made and can be kept in one's chamber for practicing.

Extent of Decompression of Lumbar Spinal Canal after Endoscopic Surgery

Introduction Endoscopic techniques are being used in lumbar disk disease and lumbar canal stenosis to decompress the spinal canal. The present study analyzed pre- and postoperative magnetic resonance imaging (MRI) measurements of the lumbar canal.

Material and Methods This was a prospective study of 30 lumbar levels. Patients < 18 years of age with unilateral compression, previous surgery at the same level, and spinal instability were excluded. Endoscopic posterior decompression was used. Pre- and postoperative MRIs of all the patients were performed. Anteroposterior (AP), transverse, interfacet diameter, canal surface area, and height and angle of the lateral recess were measured.

Results Mean ages of male and female patients were 42.1 ± 10.3 and 45.0 ± 9.9 years, respectively. Pathologies were at L4–L5, L5–S1, and L2–L3 levels in 16, 13, and 1 patient, respectively. There was significant improvement in AP diameter (4.75 ± 1.75 mm to 10.33 ± 2.11 mm), interfacet distance (12.70 ± 4.86 mm to 18.92 ± 3.53 mm), and canal surface area (76.45 ± 25.36 mm2 to 187.13 ± 41.04 mm2) after decompression. Significant improvement was noted in mean height and angle of lateral recess after surgery of both sides suggesting that effective decompression of the bilateral canal was possible using a unilateral approach. Most of the patients (90%) showed excellent and good improvement after surgery. Postoperative canal surface area and AP diameter in patients who did not have any pain after surgery or had pain requiring occasional medication was higher compared with patients who continued to complain of pain and required continuous pain medication.

Conclusion Although the number of patients was small with a short follow-up, the endoscopic technique was effective in improving AP diameter, interfacet distance, canal surface area, lateral recess height, and lateral recess angle, suggesting that an endoscopic technique using a unilateral approach is effective in bilateral decompression of neural elements.

Endoscopic posterior decompression of lumbar canal stenosis

Lumbar canal stenosis (LCS) is quite common. Surgery is indicated when patient fails to improve after conservative treatment. Endoscopic technique can be used in LCS and lateral recess stenosis. It can be performed in degenerative canal stenosis or with disc bulges. Bilateral severe bony canal stenosis and unstable spine are the contraindications. This procedure should be avoided in patients with a history of trauma. Detailed history and thorough physical examination should be performed to find out exact level of pathology responsible for symptoms. Patient’s symptoms must correlate with radiological findings. Magnetic resonance imaging is the investigation of choice because of its superior visualization of soft-tissue. Computed tomography scan does give a more accurate and detailed picture of the bony anatomy. Although the operative time and the complication rate could be more in the initial learning curve, the results of endoscopic decompression are comparable with conventional open procedures with the additional benefit of decreased complications and lower morbidity, when sufficient experience is gained. Complications in endoscopic surgery for LCS could be dural tears, hematomas and root and facet injury. This procedure is also associated with limitations such as steep learning curve and the contra lateral decompression may not be as good as ipsilateral side. Some of the limitations of this technique can be overcome by attending live operative workshop, practice on models and hands on cadaveric dissection. Conversion to an open procedure may be required when there is disorientation, management of dural tear and for control of bleeding.

Practical Aspects of Neuroendoscopic Techniques and Complication Avoidance: A Systematic Review

Although endoscopic techniques have many advantages including improved visualization and magnification, they are also associated with limitations. The objective of this review is to discuss the practical aspects that can reduce complications after endoscopic procedures, and their management. The review is based on the personal experience of more than 2000 neuroendoscopic procedures performed by the senior author. Topic search was made on PubMed using Neuroendoscopy, complications and neuroendoscopy, complication avoidance and neuroendoscopy, endoscopic neurosurgery, and minimally invasive neurosurgery. Relevant articles were selected after analyzing abstracts and/or topics. Endoscopic procedures are also associated with limitations such as obstruction in instruments manipulation, steep learning curve, blind area, difficulty in visualization, disorientation, loss of stereoscopic image and others. Neuroendoscopy is distinct from microsurgery and the surgeon has to learn endoscopic skills in addition to microsurgical techniques. Difficulties in controlling bleeding, working in a limited area, higher complication rate during the initial learning curve and longer operative time are some of the limitations. Attending live workshops, practicing on models, and hands on cadaveric workshops can reduce the learning curve. Proper case selection, multidisciplinary team approach, watching operative video, visiting other departments, observing a skillful endoscopic surgeon, lab training, and simulators can improve results and shorten the learning curve. Limitations of this review are that the search is limited to the English literature and personal experience of a single surgeon that may create some bias. Although neuroendoscopic techniques are associated with improved results in some indications, they have many limitations. Neuroendoscopic skills need to be learned to improve results.

Learning neuroendoscopy with an exoscope system (video telescopic operating monitor): Early clinical results

CONTEXT

Steep learning curve is found initially in pure endoscopic procedures. Video telescopic operating monitor (VITOM) is an advance in rigid-lens telescope systems provides an alternative method for learning basics of neuroendoscopy with the help of the familiar principle of microneurosurgery.

AIMS

The aim was to evaluate the clinical utility of VITOM as a learning tool for neuroendoscopy.

MATERIALS AND METHODS

Video telescopic operating monitor was used 39 cranial and spinal procedures and its utility as a tool for minimally invasive neurosurgery and neuroendoscopy for initial learning curve was studied.

RESULTS

Video telescopic operating monitor was used in 25 cranial and 14 spinal procedures. Image quality is comparable to endoscope and microscope. Surgeons comfort improved with VITOM. Frequent repositioning of scope holder and lack of stereopsis is initial limiting factor was compensated for with repeated procedures.

CONCLUSIONS

Video telescopic operating monitor is found useful to reduce initial learning curve of neuroendoscopy.

Evidence for a B_{s}^{0}π^{±} State

We report evidence for a narrow structure, X(5568), in the decay sequence X(5568)→B_{s}^{0}π^{±}, B_{s}^{0}→J/ψϕ, J/ψ→μ^{+}μ^{-}, ϕ→K^{+}K^{-}. This is evidence for the first instance of a hadronic state with valence quarks of four different flavors. The mass and natural width of this state are measured to be m=5567.8±2.9(stat)_{-1.9}^{+0.9}(syst)  MeV/c^{2} and Γ=21.9±6.4(stat)_{-2.5}^{+5.0}(syst)  MeV/c^{2}. If the decay is X(5568)→B_{s}^{*}π^{±}→B_{s}^{0}γπ^{±} with an unseen γ, m(X(5568)) will be shifted up by m(B_{s}^{*})-m(B_{s}^{0})∼49  MeV/c^{2}. This measurement is based on 10.4  fb^{-1} of pp[over ¯] collision data at sqrt[s]=1.96  TeV collected by the D0 experiment at the Fermilab Tevatron collider.

Endoscopic management of cerebrospinal fluid rhinorrhea

Cerebrospinal fluid (CSF) rhinorrhea occurs due to communication between the intracranial subarachnoid space and the sinonasal mucosa. It could be due to trauma, raised intracranial pressure (ICP), tumors, erosive diseases, and congenital skull defects. Some leaks could be spontaneous without any specific etiology. The potential leak sites include the cribriform plate, ethmoid, sphenoid, and frontal sinus. Glucose estimation, although non-specific, is the most popular and readily available method of diagnosis. Glucose concentration of > 30 mg/dl without any blood contamination strongly suggests presence and the absence of glucose rules out CSF in the fluid. Beta-2 transferrin test confirms the diagnosis. High-resolution computed tomography and magnetic resonance cisternography are complementary to each other and are the investigation of choice. Surgical intervention is indicated, when conservative management fails to prevent risk of meningitis. Endoscopic closure has revolutionized the management of CSF rhinorrhea due to its less morbidity and better closure rate. It is usually best suited for small defects in cribriform plate, sphenoid, and ethmoid sinus. Large defects can be repaired when sufficient experience is acquired. Most frontal sinus leaks, although difficult, can be successfully closed by modified Lothrop procedure. Factors associated with increased recurrences are middle age, obese female, raised ICP, diabetes mellitus, lateral sphenoid leaks, superior and lateral extension in frontal sinus, multiple leaks, and extensive skull base defects. Appropriate treatment for raised ICP, in addition to proper repair, should be done to prevent recurrence. Long follow-up is required before leveling successful repair as recurrences may occur very late.

The role of subgaleal suction drain placement in chronic subdural hematoma evacuation

Introduction:

There is lack of uniformity about the preferred surgical treatment, role of drain, and type of drain among various surgeons in chronic subdural hematoma (CSDH). The present study is aimed to evaluate role of subgaleal drain.

Materials and Methods:

This was a prospective study of 260 patients of CSDH treated surgically. Burr-hole irrigation with and without suction drain was done in 140 and 120 patients, respectively. Out of 120 patients without suction drain 60 each were managed by single and two burr holes. Pre- and postoperative GCS was recorded. Recurrent hematomas, CSDH secondary to tumor, due to intracranial hypotension, coagulopathy, children below 18 years, and patients treated by twist drill craniostomy or craniotomy were excluded. Subgaleal closed-system drainage with low negative pressure was used.

Results:

Age of the patients ranged from 18 to 75 years with mean age of 57 years. There were 9, 47, 204 patients in GCS of 3-8, 9-12, and 13-15, respectively. Both the groups were comparable in terms of age, etiology, gender, and neurological status. There was no difference in the mortality in both the group. The recurrence and postoperative pneumocephalus was significantly less in suction drain group as compared to without drain group. There was no infection or any other complication related to suction drainage.

Conclusion:

Subgaleal closed suction drainage was safe, simple, and effective in the management of CSDH. Recurrence rate was low in the suction drain group.

Spontaneous ventral spinal epidural hematoma in a child: A case report and review of literature

Spontaneous spinal epidural hematoma is very uncommon cause of spinal cord compression. It is extremely rare in children and is mostly located in dorsal epidural space. Ventral spontaneous spinal epidural hematoma (SSEH) is even rarer, with only four previous reports in childrens. We are reporting fifth such case in a 14 year old male child. He presented with history of sudden onset weakness and sensory loss in both lower limbs with bladder bowel involvment since 15 days. There was no history of trauma or bleeding diasthesis. On clinical examination he had spastic paraplegia. Magnetic resonance imaging (MRI) of dorsal spine was suggestive of ventral spinal epidural hematoma extending from first to sixth dorsal vertebrae. Laminectomy of fourth and fifth dorsal vertebrae and complete evacuation of hematoma was done on the same day of admission. Postoperatively the neurological status was same.

Evidence for Simultaneous Production of J/ψ and ϒ Mesons

We report evidence for the simultaneous production of J/ψ and ϒ mesons in 8.1  fb^{-1} of data collected at sqrt[s]=1.96  TeV by the D0 experiment at the Fermilab pp[over ¯] Tevatron Collider. Events with these characteristics are expected to be produced predominantly by gluon-gluon interactions. In this analysis, we extract the effective cross section characterizing the initial parton spatial distribution, σ_{eff}=2.2±0.7(stat)±0.9(syst)  mb.