A Novel Low Recurrence Surgical Approach for Medulloblastoma Excision: A Study of 58 cases.

AIM: Telovelar and transvermian approaches for medulloblastoma excision have high complication and recurrence rates. This study aims to describe a novel surgical approach to decrease such rates. MATERIAL AND METHODS: A retrospective review was performed. The novel technique was performed in similar conditions for all patients. It involves early intra-operative identification of the superior part of the floor of the fourth ventricle, so that the inferior part of the tumour can be viewed directly and excised thoroughly. Importance was given to the pattern of tumour growth and CSF flow dynamics. RESULTS: A total of 58 patients underwent this surgery between February-2006 and May-2016. Mean age was 13.2 years (Range - 6 months to 55 years). Follow-up ranged from 1 to 11 years. 49 patients (84.4%) who were under the age of 3 years were administered craniospinal radiation as well as chemotherapy, while 9 patients (15.6%) over the age of 3 years were administered only chemotherapy. Total excision could be performed in 50 cases (86.2%) and subtotal excision ( 90% excision) in 8 cases (13.8%). The tumour recurred in only 1 patient (1.72%). The complications included akinetic mutism (8.6%), meningitis (8.6%), 6th and 7th nerve paresis/palsy (5.17%), and chest infection (3.44%). Death occurred in 2 patients (3.44%), causes of death were unrelated to surgery. CONCLUSION: This study highlights the possible benefits of this novel approach to medulloblastoma excision by decreasing recurrence and complication rates and increasing rates of total excision. However, studies with large cohorts need to be performed to evaluate its efficacy.

Atlantoaxial Fixation as Treatment of Trigeminal Neuralgia in a Patient Having Basilar Invagination.

BACKGROUND: Trigeminal neuralgia can rarely be identified in association with basilar invagination. The presented case report observes that the treatment of basilar invagination by atlantoaxial fixation can result in lasting relief from trigeminal neuralgia. CASE DESCRIPTION: We report a case of a 36-year-old male patient who presented with the primary symptom of trigeminal neuralgia for a period of 2 years. Investigations revealed the presence of basilar invagination and an ectatic vertebral artery loop in the vicinity of the trigeminal nerve. The patient underwent atlantoaxial fixation on the basis of the concept that atlantoaxial instability is the nodal point of pathogenesis of basilar invagination. Atlantoaxial fixation resulted in complete and lasting relief from symptom of trigeminal neuralgia. CONCLUSIONS: The pathogenesis of trigeminal neuralgia and its relationship with atlantoaxial instability is speculated.

Revision for Failed Craniovertebral Junction Stabilization: A Report of 30 Treated Cases.

OBJECTIVE: To analyze the probable causes of failed craniovertebral junction stabilization procedures, and to evaluate the advantages of the Goel technique in revision surgery and the positive factors that lead to reduction of the instability and achieve ultimate arthrodesis. METHODS: During the period from January 2010 to June 2018, we treated 30 cases where previous attempt at craniovertebral stabilization with various fixation techniques had failed and the patients presented with progressively worsening neurologic deficits. All patients were re-operated by lateral mass fixation techniques described by the senior author. The technique involved opening of the atlantoaxial joint, denuding the articular cartilage, introduction of bone graft within the articular cavity, and plate and screw fixation. No bone decompression was done. RESULTS: Fixation of multiple subaxial spinal segments (n = 9), inclusion of occipital bone in the fixation construct (n = 21), and dependence on metal stabilization rather than bone fusion (n = 19) appear to be important causes of implant failure. All patients improved in clinical symptoms after revision surgery. Postoperative images of all patients demonstrated significant reduction of the atlantoaxial dislocation and craniovertebral junction realignment. During the average follow-up period of 32 months, all reoperated patients continued to show clinical recovery. No further surgery was necessary. CONCLUSIONS: Although relatively difficult, when indicated, reoperation and direct stabilization of the atlantoaxial joint can result in significant and enduring clinical recovery.

Central or Axial Atlantoaxial Dislocation as a Cause of Cervical Myelopathy: A Report of Outcome of 5 Cases Treated by Atlantoaxial Stabilization.

OBJECTIVE: The implications of diagnosis and treatment of central or axial atlantoaxial dislocation (CAAD) as a cause of symptoms of cervical myelopathy are evaluated. METHODS: This is a report of a series of 5 patients who presented with the primary symptoms of spasticity and motor weakness and paresthesias in all the limbs. There was no evidence of any significant compression of the dural tube or neural structures at the craniovertebral junction. There was no craniovertebral junction instability when assessed by classically described radiologic parameters. CAAD was diagnosed based on our recently discussed parameter of facetal alignment, corroborative clinical and radiologic evidence, and direct observation of atlantoaxial instability by manual manipulation of the bones of the region. All patients underwent atlantoaxial fixation. RESULTS: There was remarkable improvement in the clinical symptoms in the immediate postoperative period and during the follow-up period of 12-24 months (average, 16 months). All patients have continued to have progressive clinical recovery. Clinical assessments were done using Goel clinical evaluation scale, Japanese Orthopedic Association score, and visual analog scale. CONCLUSIONS: Identification and treatment of CAAD can have a significant management impact on patients where the cause of spastic quadriparesis is otherwise undiagnosed.

Facetal Fixation Arthrodesis as Treatment of Cervical Radiculopathy.

OBJECTIVE: We assessed the efficacy of "only fixation" as treatment for cervical radiculopathy. METHODS: From 2012 to December 2017, 21 patients who had presented with primary symptoms related to cervical radiculopathy, including radiating pain, tingling paresthesia, numbness, weakness, and wasting were treated by facetal stabilization surgery aimed at achieving segmental arthrodesis. No decompression by removal of bone, disc material, or osteophyte was performed. The age of the patients ranged from 27 to 59 years. Of the 21 patients, 19 were men and 2 were women. The imaging findings showed a herniated disc in 4, a disc bulge in 12, and osteophyte-related foraminal stenosis in 5 patients. Transarticular screw fixation was deployed for surgery. The levels of cervical fixation were guided by the clinical and radiological information and determined by direct observation of the facet morphology and stability by manual manipulation of the bones in the region. RESULTS: All the patients experienced "remarkable" relief of the presenting radicular symptoms in the "immediate" postoperative period. The visual analog scale and neck disability index scores were used to assess the patients before and after surgical treatment. During the follow-up period, which ranged from 6 to 64 months, all the patients continued to experience satisfactory symptomatic relief. CONCLUSIONS: Instability of the spinal segment is the nodal point of pathogenesis and the primary cause of symptoms related to degenerative spondylotic radiculopathy. The treatment is spinal stabilization. No direct bone or soft tissue decompression is necessary.

Lumbar radiculopathy: Outcome analysis following treatment by only fixation - A report of an early experience of 44 cases.

OBJECTIVE: An alternative novel form of surgical treatment for patients having prolapsed or bulging intervertebral disc, with or without associated osteophyte, related lumbar radiculopathy by "only fixation" or internal orthosis and aiming for segmental arthrodesis is presented. MATERIALS AND METHODS: During the period July 2014-October 2018, 44 patients presenting with symptoms of lumbar radiculopathy and diagnosed to have bulging, prolapsed or herniated lumbar intervertebral disc with or without associated osteophytes were treated by only spinal stabilization without resorting to any kind of bone, ligaments, osteophyte, or disc resection. RESULTS: All patients had "immediate" postoperative relief from radicular symptoms. The Visual Analog Scale and the Oswestry Disability Index scores were used to assess the patient both before and after the surgical treatment. During the follow-up period that ranged from 10 to 60 months (average: 35 months), there was no recurrence of symptoms. Complete or significant resorption of the herniated disc was seen in 29 cases on follow-up radiological assessment. CONCLUSIONS: Spinal segmental fixation without any manipulation of the herniated disc or osteophyte and without any kind of bone or soft-tissue decompression is a safe, effective, and rational method of treatment of lumbar radiculopathy related to intervertebral disc herniation.

Gossypiboma: An Unusual Presentation as Perforation and Intraluminal Migration.

Gossypiboma is a mass formed around cotton material acting as foreign body in visceral cavity. In our study, we present a case of gossypiboma following open cholecystectomy. A surgical sponge left in the peritoneal cavity following cholecystectomy, caused inflammatory reaction, perforation and intraluminal migration. It is a relatively rare presentation. This patient underwent emergency laparotomy with Billroth II anastomosis and sponge removal.