The Hawthorne Effect: Quality and Outcomes in Neurosurgery.

Measure something, and it gets better-this is what is called as the Hawthorne effect (also known as the observer effect). The Hawthorne factory experiments in 1920s were remarkable industrial data collection and analysis exercises that lead to Edwards Deming's quality revolution. The Harvard Medical Practice Study (1991), Leape's "Error in Medicine" (1994), and the Bristol pediatric cardiac report (2001) are among many documents that have revealed the huge gap between best practices and actual medical practice. Alarmed by the poor standards of quality at the most respected institutions, the medical fraternity therefore began visiting facilities in different fields and observing their quality assessment processes. The next leap for neurosurgery is to realize that it is unacceptable to treat patients with no regard for the standard of clinical outcomes. The traditional neurosurgery residency training has long ignored the most important issues of self-assessment, reappraisal, relearning, and measurement of skill and surgical outcomes. However, the experience taken from disparate fields, especially cardiac surgery, may encourage research and progress in measurement and improvement of quality in neurosurgery. Like cardiac surgeons, neurosurgeons must examine and analyze the results of their interventions. The concept of quality measurement is the most important single advance we can make in neurosurgery practice. Meticulous and precise measurement of outcomes will allow future progress of our specialty.

Melioidosis mimicking tuberculous vertebral osteitis: Case report and review of literature.

Whitmore's disease or melioidosis is an infectious disease caused by Burkholderia pseudomallei. The reported cases are but the tip of the iceberg. This pathogenic saprophyte is commonly found in wet soil and water. An accidental or occupational exposure (in field workers, farmers, gardeners or villagers) to B. pseudomallei contaminated soil or pooled water is the primary source of infection. Neurosurgeons need to consider this as a possible rare cause of back pain and possible neurological deterioration. A diabetic type 2 rice farmer with severe lumbago and fever, misdiagnosed as vertebral tuberculous osteitis based on his radiological findings, was confirmed to harbour Burkholderia Pseudomallei, which was diagnosed using laboratory cultures. He made a remarkable recovery with antibiotic therapy. The empiric anti-tuberculous (ATT) drugs were stopped. The rare differential diagnosis of melioidosis should be thought of in diabetic patients with a psoas abscess and vertebral osteitis, especially in rice farmers from endemic regions that includes India.

Management of pediatric intracranial meningiomas: an analysis of 31 cases and review of literature.

OBJECTIVE: The purpose of this study is to understand the epidemiology, clinical features, behavior, and the prognostic factors that influence the outcome of intracranial meningiomas in children. METHODS: Thirty-one patients with age less than 18 years who underwent surgery for intracranial meningiomas during the period of at 1988-2012 at Voluntary Health Services Hospital, Chennai, India were studied. These formed 3.7 % of the total 831 cases of intracranial meningiomas operated at the institute. RESULTS: The study group included 22 (71 %) males and 9 (29 %) females. The mean age of presentation was 15 years, with the youngest being 9 months old. Two (6 %) had evidence of neurofibromatosis type 2 (NF2). The most common symptoms at presentation were seizures in 11 (35.5 %), weakness of limbs in 11 (35.5 %), and raised intracranial pressure in 10 (32 %). Convexity meningiomas were seen in 16 (51 %) and skull base in 15(49 %). Multiple meningiomas was seen in two (6 %) of the patients and intraventricular location was found in one patient (3 %). Two (6 %) had evidence of NF2. Gross total excision was achieved in 26 (83 %) and subtotal excision in 5 (17 %). WHO grade I was found in 20 (64 %) and higher grade was seen in 11 (36 %). The mean follow-up was 46.2 months. Recurrence was seen in 20 patients (64 %). In patients with higher grade or with recurrence resurgery and radiotherapy was given. Three (9 %) had multiple recurrences. On a mean follow-up of 46.2 months, 25 patients (81 %) were neurologically intact, 5 (16 %) were having moderated disability, and 1 (3 %) patient died. CONCLUSIONS: Childhood meningiomas are uncommon lesions with a slight male predominance. They can have a varied clinical presentation. Higher grade is found more frequently compared with adults. Gross total resection is the goal and in higher grade meningiomas radiotherapy helps as a good adjuvant. Though the rate of recurrence is high, resurgery and radiotherapy gives a good outcome.

Management outcome of the transcallosal, transforaminal approach to colloid cysts of the anterior third ventricle: an analysis of 78 cases.

BACKGROUND: Colloid cysts are not common brain lesions and account for 0.2-2.0% of all brain lesions. Transcallosal, transforaminal approach is a safe route and the most direct path to excise third ventricular colloid cyst, without dependence on hydrocephalus. AIM: To assess the surgical outcome of patients with colloid cysts of the anterior third ventricle treated by the transcallosal, transforaminal approach. PATIENTS AND METHODS: Seventy-eight patients operated by the above approach over a period of 20 years were analyzed. A pre- and postoperative neurological assessment was done in all the patients. Neuro-cognitive evaluation of corpus callosum function was done in the last 20 patients. Computer tomography scan of the brain was done in all patients pre- and postoperatively. RESULTS: Clinical features of raised intracranial pressure without localizing signs were the commonest presenting feature in 52 (66.7%) patients. Hydrocephalus was present in 65 (83.3%) patients. All patients underwent the transcallosal, transforaminal approach, and total excision of the lesion was achieved in 77 patients and subtotal in 1. Four patients required a postoperative shunt for acute hydrocephalus. There was no incidence of postoperative disconnection syndrome. In two patients, there was recurrence of the lesion after 2 and 6 years, respectively. Two patients died in the postoperative period. CONCLUSION: Colloid cyst is surgically curable. Early detection and total excision of the lesion can be a permanent cure with low mortality and minimum morbidity, when compared to the natural history of the disease. The limited anterior callosotomy does not result in disconnection syndromes or behavioral disturbance.

Dr. Thanjavur Santhanakrishna Kanaka-A Pioneer and Neurosurgical Innovator.

BACKGROUND: Thanjavur Santhanakrishna Kanaka, M.B.B.S., M.S. (General Surgery), M.S. (Neurosurgery), Ph.D., and former Captain, Indian Army Medical Corps, was born on March 31, 1932. She became the first woman neurosurgeon in India and all of Asia. METHODS: This manuscript was compiled through a combination of interviews and references to other articles and some of the published manuscripts of Dr. Kanaka and her colleagues. RESULTS: Dr. Kanaka was a trailblazer for women in neurosurgery and a pioneer in functional and stereotactic neurosurgery. During her long and productive career, she authored dozens of articles reported in prestigious neurosurgical journals worldwide and helped inspire and train the next generations of neurosurgeons in India and abroad. Even after retirement, Dr. Kanaka continued to focus on serving the medical community through her Sri Santhanakrishna Padmavathi Health Care and Research Foundation in Chennai with the mission of serving underprivileged and senior citizens in the local community. In addition to her accomplishments as a practicing neurosurgeon, Dr. Kanaka's career was notable for her successful collaborations with biomedical engineers on medical device development using locally sourced materials and talent in India. CONCLUSIONS: Through her innovative thinking, compassion for her patients, and unwavering resilience, Dr. Kanaka has continued to serve as an inspiration to all pursuing a career in academic medicine and neurosurgery.

Spinal Drop Metastasis of Glioblastoma-Two Case Reports, Clinicopathologic Features, Current Modalities of Evaluation, and Treatment with a Review of the Literature.

BACKGROUND: Glioblastomas (World Health Organization grade IV) are aggressive primary neoplasms of the central nervous system. Spinal metastasis occurs supposedly in 2%-5% of patients. This percentage may be only the tip of iceberg because most succumb to the disease before clinical detection and few documented cases are reported. CASE DESCRIPTIONS: A 45-year-old man presented with history of diplopia and gait disturbance. Magnetic resonance imaging showed a left cerebellar space-occupying lesion. The histopathology was consistent with glioblastoma. The patient underwent adjuvant chemoradiation. A year later, he presented with seizures, worsening headache, neck stiffness, and low back pain. Imaging showed metastasis to the S1/S2 region of the spinal canal. A 29-year-old man presented with episodic headaches associated with nausea, vomiting, neck stiffness, and imbalance while walking. Computed tomography of the brain showed a hypodense lesion involving the left midbrain, pons, and left middle cerebellar peduncle, causing fourth ventricular pressure with obstructive hydrocephalus. A navigation-guided biopsy of the brainstem lesion confirmed the diagnosis of glioblastoma World Health Organization grade IV, isocitrate dehydrogenase 1 (R132 H) and H3K27M negative. Isocitrate dehydrogenase gene sequencing was suggested. The patient was referred for chemoradiation. During treatment, he worsened neurologically and developed axial neck and back pain. Neuraxis screening showed disseminated leptomeningeal spread, which was confirmed on dural biopsy. CONCLUSIONS: Spinal and dural metastasis should always be suspected in patients with glioblastoma with signs and symptoms not explained by primary lesion. A regular protocol with postcontrast magnetic resonance imaging before and after initial surgery is mandatory to detect spinal metastasis before it becomes clinically apparent, thereby improving the prognosis and quality of life in patients.

Cervical solitary long segment cystic Schwannoma.

Cystic neurofibromas are very rare and are of separate entity; occurrence in the cervical spine extending over a long segment intra-durally is very rare. There is a paucity of literature available on cervical cystic Schwannoma and its MRI characteristics. As the preoperative diagnosis of these tumors helps in planning the surgery for this rare tumor the imaging findings reported herein may aid in the preoperative diagnosis and management.

Invasive rhino-cerebral fungal granuloma.

BACKGROUND: Increased incidence of fungal infection has been reported globally in the recent years. Fungal infection of the central nervous system remains one of the most difficult diseases to treat and requires multi-modality intensive therapeutic strategies. MATERIALS AND METHODS: Retrospective analysis of case records of patients with confirmed skull base fungal granuloma treated at a tertiary hospital between 1988-2008. An attempt was made to stage the extent of skull base fungal granuloma based on neuroimaging, operative findings and course of the disease on serial follow-up. RESULTS: Thirty-three patients with skull base fungal granuloma were treated surgically during the study period. The mean age at presentation was 33.2 years and diabetes was a major predisposing factor. Eight patients expired in the first two months following surgical intervention due to flare-up of the disease. Eighteen patients who underwent grossly total excision had a mean progression-free survival (PFS) of 43 months and seven patients with subtotal excision had a mean PFS of 23 months. Better survival probability was noted in those patients who underwent total excision at surgery and received complete course of amphotericin. CONCLUSION: Total surgical excision with complete course of antimycotic drug therapy increases PFS. A better antimycotic drug with less toxicity and high efficacy with fungicidal property can make a difference in the outcomes of the disease.

A system of radiological criteria for grading and prognosticating temporal lobe contusions.

INTRODUCTION: Temporal contusions are common in patients with head injuries and require close monitoring due to the propensity of these patients to deteriorate rapidly and fatally. This study attempts to introduce a radiological grading system for temporal lobe contusions and analyse its prognostic value so as to better identify patients at risk of deterioration. METHODS: The study was conducted as a cross-sectional observational study from April 2011-March 2017 on 42 patients with temporal lobe contusion. Each patients was graded according to the proposed system from a minimum of four to a maximum of 13 and then further grouped in three grades - grade 1 (score = 4), grade 2 (score 5-7) and grade 3 (score > 7) - and their clinical course was closely observed. RESULTS: The minimum and maximum scores observed were four and 11 respectively. The proposed grading system has statistically significant correlation to the Glasgow Coma Scale (p-value < 0.05). All patients in grade 1 (17) could be managed conservatively, while all those in grade 3 (five) needed immediate surgical intervention. Of 20 patients in grade 2, 11 had a score of 5-6 and did not require surgery, whereas nine patients had a score of seven and of these eight required delayed surgical intervention. This correlation was statistically significant (p-value < 0.05). CONCLUSION: The proposed temporal lobe contusion grading system is a good radiological tool to predict the clinical course of patients and thereby identify patients at higher risk of delayed deterioration.

Surgical management of brainstem hydatid cyst--an unusual site.

BACKGROUND: The authors describe their surgical experience of a hydatid cyst in the brainstem, which is an unusual site. The cyst was internally decompressed and totally excised. Although the Dowling technique has been described to be the ideal method for removal of hydatid cysts, it may not be possible when the cyst is in a deep-seated, vital, and eloquent location. We report the use of internal decompression by aspiration followed by total excision as an alternative method when the cyst is located in vital areas of the brain. CASE DESCRIPTION: A 40-year-old female presented with headache, progressive right-sided weakness, double vision, and unsteadiness of gait of 1-month duration. On examination, she had left one-and-a-half syndrome, right hemiparesis of 3/5, and left cerebellar signs. Computed tomographic and MRI scans of the brain revealed a solitary, stenciled-out cystic lesion in the brainstem more toward the left side with features suggestive of hydatid cyst. A left retromastoid craniectomy followed by left middle cerebellar peduncle approach, aspiration of the cyst, and total excision of the cyst was performed. Postoperatively, the patient improved progressively and was asymptomatic with minimal left cerebellar signs at 1-year follow-up. CONCLUSION: Hydatid cyst is a benign lesion. Appropriate management is mandatory for reducing the morbidity. Although the Dowling technique with its modifications is appropriate for cerebral parenchymal surfacing or superficial hydatid cysts, in deep-seated cysts located in eloquent and vital areas such as the brainstem, management by internal decompression by aspiration followed by extirpation of the cyst wall, protecting the surrounding cisterns and CSF spaces, is an alternative option.

Suboccipital segment of the vertebral artery: a cadaveric study.

OBJECTIVE: To study the course, relationships, branches and possible anomalies of the vertebral artery in the suboccipital region in adult Indian cadavers. MATERIALS AND METHODS: Twenty-one suboccipital segment vertebral artery specimens from embalmed, Indian adult cadavers were dissected and studied. Dissection was performed using microsurgical instruments and was carried out from the skin up to the vertebral artery in layers. The course, relationships and the branches of the vertebral artery were studied and measurements were taken using Vernier calipers. The readings obtained were corroborated with the measurements derived from the digital images using a computer. OBSERVATIONS: All the vertebral arteries had a tortuous course and were covered with rich venous plexuses. None of the specimens had an anomalous course. The artery was divided into a vertical segment (Vv) between C2 and C1 vertebra and a horizontal segment (Vh) from the C1 transverse foramina to its dural entry. The mean diameter of the artery was 4.8 mm. The shortest distance of Vv segment from the dural tube was 16.1 mm, and the distance from the C2 ganglion was 7.2 mm. The average length of the Vv segment was 15 mm and the average length of the Vh segment was 35.6 mm. The average of the shortest distance between the vertebral artery and the midline was 13.4 mm. CONCLUSION: The vertebral artery has a tortuous course and is prone to accidental iatrogenic injury, which can result in devastating neurological sequelae depending on contralateral vertebral artery flow. A thorough anatomical knowledge of this segment is essential for the surgeon who intends to operate in this area.

Forty years of clinical excellence at the Dr A Lakshmipathi Neurosurgical Centre and Post-Graduate Institute of Neurological Surgery, Voluntary Health Services (VHS) Hospital.

The Achanta Lakshmipathi Neurosurgical Center (ALNC) and Post Graduate Institute of Neurological Surgery is a private teaching neurosurgical institution located in the VHS (Voluntary Health Services) Hospital Chennai. It has been a leader and trendsetter among the private academic neurosurgical training institutions, and because of its unique legacy, has influenced the progress of Neurosurgery in India. The center was the second neurosurgical Institute to be created by Prof. B Ramamurthi and has trained neurosurgeons in the unique ALNC school of Neurosurgery. The Institute has grown to become a centre of excellence in microsurgery, and spinal surgery and has become a training centre for neurosurgery since 1985. The unique humanitarian aspects of the Voluntary Health Services Hospital helped in bringing the best of Neurosurgery to all strata of society. Forty years after its inception, the ALNC continues its delivery of excellence in clinical neurosurgery and academics.

Concomitant cervical and lumbar intradural intramedullary lipoma.

BACKGROUND: Lipomas of the spinal cord are often a component of spinal dysraphic states. Nondysraphic intramedullary spinal cord lipomas are rare, and concomitant isolated cervical and lumbar intradural intramedullary lipomata are very rare. One patient with concomitant isolated nondysraphic cervical and lumbar spinal cord lipomata has been reported and management options discussed. CASE DESCRIPTION: A young girl presented with insidious-onset diffuse neck pain and early myelopathic signs. Conventional radiographs were normal. Magnetic resonance imaging of the whole neuraxis revealed concomitant cervical and lumbar intradural intramedullary lipoma. Subtotal resection of the lesion was performed at both levels, after which the patient improved symptomatically and was ambulant independently. CONCLUSION: Concomitant intradural lipomas at 2 different locations unassociated with a dysraphic state is very rare. Magnetic resonance imaging with fat suppression study is the investigation of choice. Adequate decompression with subtotal removal is the treatment of choice.

Aneurysmal bone cyst of the lumbar spine.

An aneurysmal bone cyst (ABC) is a benign, locally proliferative vascular disorder of non-neoplastic osseous lesions in children and young adults. Seventy-five percent of ABCs occur before the age of 20 years. They comprise 1.4% of all primary bone tumors, and commonly occur in the long bones. Spinal ABCs are much rarer. We present to you one such rare case of ABC involving the lumbar spine which was successfully treated with surgery. The clinical pathological and radiological features are described. The treatment options available are discussed.

Complication avoidance in transcallosal transforaminal approach to colloid cysts of the anterior third ventriclen: An analysis of 80 cases.

OBJECT: The objective of the present study is to analyze the complications and their avoidance in a series of 80 patients operated by transcallosal transforaminal approach to colloid cysts of the anterior third ventricle. MATERIALS AND METHODS: The surgical outcome and complications of 80 patients operated by transcallosal transforaminal approach for colloid cysts in the anterior third ventricle was analyzed. A detailed pre- and post-operative neurological assessment was done in all patients. Neurocognitive assessment of corpus callosal function was done in the last 22 cases. CT scan of the brain was done in all patients, before and after surgery. RESULTS: All patients underwent transcallosal transforaminal approach. Total excision of the lesion was achieved in 79 patients and subtotal in one. The complications encountered were postoperative seizures in six, acute hydrocephalus in four, venous cortical infarct in four, transient hemiparesis in four, transient memory impairment, especially for immediate recall in nine, mutism in one, subdural hematoma in one, meningitis in three, and tension pneumocephalus in one patient. There were two mortalities. There was no incidence of postoperative disconnection syndrome. CONCLUSION: Colloid cyst is surgically curable. With good knowledge of the regional anatomy and meticulous microsurgical techniques, there is a low mortality and minimum morbidity, when compared to the natural history of the disease. With increasing experience, most of the complications are avoidable. The limited anterior callosotomy does not result in disconnection syndromes.

Isolated skull base primary Ewing's sarcoma: an extremely rare location.

A 16-year-old boy presented with history of headache and blurring of distant vision. He had UMN facial paresis and papilledema. Imaging revealed a heterogenous space occupying lesion in the middle cranial fossa base with mass effect and midline shift and non homogenous contrast enhancement with erosion of the petrous bone. He underwent gross total excision of the lesion. Histopathology and immunohistochemistry were suggestive of skull base Ewing's sarcoma. Bone scan was done to rule out primary involvement of other extracranial location. We have discussed the epidemiology, presentation, management and prognosis of such cases.

Delayed anterior cervical plate dislodgement with pharyngeal wall perforation and oral extrusion of cervical plate screw after 8 years: A very rare complication.

We report a patient with congenital anomaly of cervical spine, who presented with clinical features suggestive of cervical compressive spondylotic myelopathy. He underwent C3 median corpectomy, graft placement, and stabilization from C2 to C4 vertebral bodies. Postoperative period was uneventful and he improved in his symptoms. Eight years later, he presented with a difficulty in swallowing and occasional regurgitation of feeds of 2 months duration and oral extrusion of screw while having food. On oral examination, there was a defect in the posterior pharyngeal wall through which the upper end of plate with intact self-locking screw and socket of missed fixation screw was seen. This was confirmed on X-ray cervical spine. He underwent removal of the plate system and was fed through nasogastric tube and managed with appropriate antibiotics. This case is presented to report a very rare complication of anterior cervical plate fixation in the form of very late-onset dislodgement, migration of anterior cervical plate, and oral extrusion of screw through perforated posterior pharyngeal wall.