Anterior retropharyngeal approach (ARPA) for high cervical spine.

BACKGROUND: One of the major challenges in operating on the spine lies in taking an anterior approach for the high cervical spine. In patients with a short neck, Klippel-Fiel syndrome or when the C3 vertebra is high in relation to the hyoid bone, it will be difficult to access the C3 body. The transoral route is a highly contaminated zone, and therefore, no instrumentation or grafts can be placed through it. METHOD: The anterior retropharyngeal approach (ARPA) for the high cervical spine. CONCLUSION: The anterior retropharyngeal approach is an excellent approach for the high cervical spine where instrumentation is needed. This route provides wide exposure of the C1-C3 region, avoiding the contaminated of the oral cavity.

C1-C2 coronal and sagittal joint angle based treatment algorithm for the need of transoral odointectomy in complex craniovertebral junction anomalies with Clinico-Radiological outcome analysis.

OBJECTIVE: Craniovertebral junction (CVJ) pathology by virtue of its complexity is a surgical challenge in the realm of neurosurgery. We analyzed the need for transoral odointectomy in view of their C1-C2 joint coronal and sagittal angle of 58 patients with complex CVJ anomalies treated surgically. The clinical and radiological outcome of the patients was assessed and a treatment algorithm is proposed. METHODS: A total of 58 cases were included in the Prospective study over the period of 2 years. Patients were evaluated clinically, investigated, and operated with reduction and rigid internal fixation with screws and rod. The clinical outcome was measured by Modified Japanese orthopedic association score(mJOA) and radiologically by conventional craniometrics indices. Paired 't' test used for statistical analysis. RESULTS: Mean age of patients: 30 years, with mean, follow up: 20.5 months. 46(80%) patients were operated by posterior and 12(20%) by combined approach (anterior transoral with posterior). Occipitocervial fixation was done in 15(25.8%) cases and C1-C2 fixation in 43(74.2%) cases. As compared to patients with low coronal angle, the patient with coronal angle >65° needed anterior decompression (87.5%) and all (100%) had Occipitocervical fixation. Clinical outcome analysis showed significant improvement in mean mJOA score (preop 11.9 Vs postop 14.6) after surgery. All craniometrics indices were significantly improved after surgery. The overall complication rate was 10% with a mortality of 1.7%. 6 months follow up completed in all patients with a 100% fusion rate. CONCLUSION: Occipitocervical fixation and anterior decompression is required in increased C1-C2 joint CA (>65°) for bony realignment and adequate decompression. Measurement of C1-C2 joint coronal and sagittal angle in complex CVJ anomalies will easily anticipate the surgeon regarding the need for anterior decompression inform of transoral odointectomy.

Fluorescein sodium fluorescence: role in stereotactic brain biopsy.

BACKGROUND: Stereotactic brain biopsy for eloquent area brain tumours is associated with complications like hemorrhage due to multiple sampling and increased operative time due to dependence on neuropathologist for frozen section assessment. In order to curb these limitations, we investigated the use of Fluorescein sodium fluorescence in confirming pathological tissue samples in stereotactic brain biopsy of gadolinium-enhancing tumours. METHODS: This prospective observational study included 23 consecutive patients who underwent stereotactic biopsy of gadolinium-contrast-enhancing brain lesions with intravenous fluorescein sodium administration. 93 specimens were obtained and examined for the presence of fluorescence using a microscope with fluorescence visualisation capability. Later the nature of the samples was confirmed on histopathology. The sensitivity and specificity of flourescein sodium fluorescence were calculated based on histopathological confirmation. RESULTS: 58 (62.3%) fluorescent and 35 (37.6%) nonfluorescent samples were obtained. All fluorescent specimens contained diagnostic tissue appropriate for tumor grading. Of 35 nonfluorescent specimens, 12 (34.3%) did not contain tumor, 11 (31.4%) contained minor hypercellularity or gliosis, and 12 (34.3%) contained tumor with a high proportion of necrosis. The sensitivity and specificity for fluorescein fluorescence were 83% and 100%, respectively. CONCLUSIONS: Fluorescein fluorescence is a handy tool to detect the pathological tissue in stereotactic brain biopsy and may improve its diagnostic accuracy and expedite the procedure.

Computed tomography evaluation of variations in positions and measurements of appendix in patients with non-appendicular symptoms: time to revise the diagnostic criteria for appendicitis.

Purpose: To estimate the frequency distribution of different anatomical positions, and to measure the diameter, wall thickness, and length of appendix in patients with non-appendicular symptoms. Material and methods: This retrospective observational study was conducted among 1,575 patients, who had undergone computed tomography (CT) scan of abdomen for various non-appendicular signs and symptoms. Frequency of distribution of different anatomic locations and measurements of various morphologic parameters were recorded. Results: The most common location of appendix was retrocecal, followed by sub-cecal, post-ileal, and pelvic locations. The mean length of appendix was 66.7 mm (range, 6.3-123 mm), and the diameter was 6.3 mm (range, 2.8-11.3 mm). Diameter of > 6 mm was noted in 48.12% patients. The mean wall thickness was 2.37 mm, ranging 1.2-4.2 mm. The most common intra-luminal content was air-mixed with hypodense or hyperdense material observed in 70.5% of cases. Conclusions: Although an appendix with diameter less than 6 mm may be considered normal, a diameter above 6 mm has an overlap between a normal and inflamed appendix. Therefore, it should be considered in association with clinical and secondary findings to avoid overdiagnosis and unnecessary appendicectomies. We strongly recommend that diameter-based CT criteria to diagnose appendicitis should be revised and standardized.

Understanding decision processes in becoming a fee-for-hire service provider: A case study on direct seeded rice in Bihar, India.

While Direct Seeded Rice (DSR) has numerous potential benefits to smallholder farmers in the Eastern Gangetic Plains of South Asia, it's out-scaling has been limited by both a lack of demand by farmers and limited supply of DSR services by machinery owners. This contrasts with the comparatively more rapid scaling of zero tillage wheat in the region. This trend is yet to be fully explored, particularly when focus has been placed almost exclusively on understanding DSR adoption though the lens of farm-level agronomic, economic and environmental performance. Given that limited DSR service provision is likely to be governed outside of these considerations, this study explores with zero tillage drill owners the decision processes they apply in deciding how to use their zero tillage drills. Respondents highlight a complex web of interrelated considerations that highlight the additional complexities of DSR as compared to existing practices. Using a novel 'Decision-making Dartboard' qualitative framework, these complexities are unpacked and a set of potential changes to the assumed theory of change for DSR scaling are identified, including considerations for selection of potential DSR service providers and responsibilities for promotion and extension of DSR to overcome the prevalent negative perceptions of DSR held broadly across the communities explored. The proposed framework and analysis process are also potentially useful for exploration of other farmer decision making processes more broadly.

A Single Standard Polyvinyl Chloride 3D Skull Model to Create the Polymethyl Methacrylate Cranioplasty Flap: A Novel and Low-Cost Technique.

BACKGROUND: Although, cranioplasty is a commonly performed neurosurgical procedure worldwide, the cost of available cranioplasty implants is a major issue in a low-income country like India. The aims of this study were to introduce a novel and low-cost technique using a single standard three-dimensional (3D) skull model to guide the polymethyl methacrylate (PMMA) cranioplasty flap production and to evaluate the functional and cosmetic outcomes. METHODS: We retrospectively evaluated 47 cases of PMMA cranioplasty in the period from February 2019 to June 2022. A single standard 3D skull model was used to make the PMMA cranioplasty flaps. The overall cost of this PMMA implant was compared with that of other available cranioplasty implants. The functional and cosmetic outcomes were evaluated postoperatively. RESULTS: The mean age of our patients was 37.17 ± 13.83 years and the age range was 17 to 63 years. The primary cause of surgery was trauma in the majority of cases (n = 31, 65.96%). The mean operative time was 78.55 ± 19.82 minutes. The cosmetic results were very satisfying in 46 of 47 (97.87%) patients and moderately satisfying in 1 (2.12%) patient. Overall, there were three (6.38%) complications. CONCLUSION: Our technique provides excellent functional and cosmetic outcomes. The overall surgical cost of these PMMA implants was lower than that of the other available cranioplasty implants. This technique is currently the most cost-effective option for cranioplasty.

Follicular carcinoma of the thyroid presenting as metastasis in the wall of an arachnoid cyst.

The brain is an uncommon site for metastases of differentiated thyroid carcinoma with the most common location being cerebral hemispheres, followed by cerebellum and pituitary gland. Metastasis in the wall of an arachnoid cyst is exceedingly rare with single case report available in the published literature. Arachnoid cyst metastasis from an extraneuraxial malignancy has not been published until. We present a unique case of thyroid carcinoma metastasizing to the wall of an intracranial arachnoid cyst and the most interesting fact is that it was the first clinical manifestation of her malignancy.

Ruptured mirror DACA aneurysm: A rare case report and review of literature.

Bilateral distal anterior cerebral artery (DACA) aneurysms also called "kissing aneurysms" or "mirror aneurysm" are extremely rare, accounting for only 0.2% of all intracranial aneurysms. There have only been a few examples of mirror DACA aneurysms reported in the literature. Here, we report a rare case of mirror DACA aneurysm in a middle aged female with its successful clipping. Patient was admitted with severe headache and altered sensorium. Computed tomography (CT) head was suggestive of anterior inter-hemispheric hematoma. Digital subtraction angiography (DSA) was done which was suggestive of two distal anterior cerebral artery aneurysms located at same anatomical position. It was treated through microsurgical clipping. Mirror image DACA aneurysms are rare occurrence. All patients with ruptured DACA aneurysms should have angiography with 3D reconstruction studies. This aids in determining the aneurysm's morphology and planning treatment accordingly.

Comparative Study of Intraoperative Fluorescein and Indocyanine Green Videoangiography for Ruptured Cerebral Aneurysms Clipping: A Single Centre Study of 30 Cases.

Aim This study assesses the application of microscope integrated videoangiography techniques in aneurysm clipping surgery using Indocyanine Green and Fluorescein fluorophores and evaluates merits and demerits of each technique. Materials and Methods Total 30 patients of cerebral aneurysmal clipping were included. Standard microsurgical procedures were done. After clipping, we administered a 25 mg bolus intravenous dose of indocyanine green with microscope focused through the INFRARED 800 camera module, followed by administration of 60 mg bolus intravenous dose of fluorescein with microscope focused through the yellow 560 module and images were assessed. Results The average aneurysm size was 17 mm. In 12 patients (40%), FL-VA allowed better assessment of perforating arteries (seven cases) or distal branches (three cases) or both (two cases), when compared with ICG-VA. In one case of MCA (M1) aneurysm, ICG-VA showed no fluorescent signal in one of the distal trunks whereas FL-VA showed normal signal. In one case of ACOM aneurysm, perforators were missed on ICG-VA but were seen on FL-VA. FL-VA was able to identify inadequate aneurysm clipping in one case. In two patients, FL-VA provided the advantage of real-time manipulation of the vessels to expose the vessels and aneurysms of interest. Fluorescein detected all the perforators that were visible under white light (68/68) whereas ICG was able to detect 56 (82.35%) perforators ( p -value< 0.05). Conclusion Intraoperative ICG and Fluorescein videoangiography recognize inadequate occlusion of aneurysm, decreased flow in branches or perforators. When various study parameters were considered such as ability to assess small size perforators, branching vessels, adequacy of aneurysmal clipping, and useful information on repeat imaging, FL-VA was found superior to ICG-VA.

Intraventricular migration of fourth ventricular neurocysticercosis: an unusual complication during endoscopic surgery.

A boy in his middle childhood presented with intermittent episodes of headache with vomiting for 6 months. Plain CT of the head and MRI of the brain revealed fourth ventricular cysticercal cyst with acute obstructive hydrocephalus. Endoscopic excision of the cyst was done along with endoscopic third ventriculostomy and septostomy with external ventricular drain placement. Although we were able to decompress the cysticercal cyst, unfortunately, the cyst got slipped from the grasper leaving the grasped cyst wall in the tooth of the grasper. Through this case report, we want to highlight that such a complication could also happen during neuroendoscopic cysticercal cyst removal and how we dealt with it. Our patient was discharged neurologically intact and was symptom free on follow-up.

Use of a Single Standard Skull Model for Preparation of PMMA-Based Cranioplasty Flap: A Novel Low-Cost Technique.

AIM: To introduce a novel, low-cost technique for cranioplasty using a single standard polyvinyl chloride plastic skull model as a guide for cranioplasty flap development; to observe and to compare the functional and cosmetic outcomes. MATERIAL AND METHODS: We conducted an observational, retrospective, cohort study that included 20 patients who underwent cranioplasty at the Department of Neurosurgery, RMLIMS, Lucknow from September 2020 to September 2021. The patients were evaluated based on postoperative cosmesis and symptomatic relief. RESULTS: A total of 20 patients were included in this study. All procedures were performed without any intraoperative or long-term complications noted on follow-up. None of the patients required reoperation. We observed no evidence of bleeding, infection, or poor scar formation. The patients and their families were satisfied with the cosmetic results of the procedure. CONCLUSION: Our technique provided excellent functional outcomes, cosmetic appearance, and improved clinical symptoms. This technique is currently the most cost-effective alternative available.

Exposure to High Dosage of Gold Nanoparticles Accelerates Growth Rate by Modulating Ribosomal Protein Expression.

Gold nanoparticles (AuNPs) have been utilized in various biomedical applications including diagnostics and drug delivery. However, the cellular and metabolic responses of cells to these particles remain poorly characterized. In this study, we used bacteria (Escherichia coli and Bacillus subtilis) and a fungus (Saccharomyces cerevisiae) as model organisms to investigate the cellular and metabolic effects of exposure to different concentrations of citrate-capped spherical AuNPs with diameters of 5 and 10 nm. In different growth media, the synthesized AuNPs displayed stability and microorganisms exhibited uniform levels of uptake. Exposure to a high concentration of AuNPs (1012 particles) resulted in a reduced cell division time and a 2-fold increase in cell density in both bacteria and fungus. The exposed cells exhibited a decrease in average cell size and an increase in the expression of FtsZ protein (cell division marker), further supporting an accelerated growth rate. Notably, exposure to such a high concentration of AuNPs did not induce DNA damage, envelope stress, or a general stress response in bacteria. Differential whole proteome analysis revealed modulation of ribosomal protein expression upon exposure to AuNPs in both E. coli and S. cerevisiae. Interestingly, the accelerated growth observed upon exposure to AuNPs was sensitive to sub-minimum inhibitory concentration (sub-MIC) concentration of drugs that specifically target ribosome assembly and recycling. Based upon these findings, we hypothesize that exposure to high concentrations of AuNPs induces stress on the translation machinery. This leads to an increase in the protein synthesis rate by modulating ribosome assembly, which results in the rapid proliferation of cells.

C2 Superior Facetal Osteotomy: A Novel Technique in Complex Craniovertebral Junction Surgery for C1 Lateral Mass Screw Placement.

Complex craniovertebral junction (CVJ) defects account for a considerable proportion of CVJ diseases. Given the heavily assimilated C1, an unfavorable C1-C2 joint orientation, an overriding C2 superior facet, a low-hanging occiput, and an abnormal vertebral artery course with a high-riding vertebral artery, placement of C1 lateral mass screws might be difficult. To address this, a novel technique for placing C1 lateral mass screws that avoid vertebral artery injury, low-hanging occiput, and overriding C2 superior facet was developed in this study. This approach enables firm fixation of C1-C2 even in difficult situations where the placement of the C1 lateral mass is challenging.

Multiple Site Dissimilarities of Herbaceous Species Due to Coal Fly Ash Dumping Based Soil Heavy Metal Toxication.

The present study analyzes the determinants and patterns of the regional, local, and differential plant diversity of two different sites with similar climatic but varied edaphic factors. This research was undertaken to study the plant diversity and population structure as a consequence of variation in the soil quality between two biotopes: Guru Ghasidas Vishwavidyalaya in Koni (site-I) and National Thermal Power Corporation in Sipat (site-II). The soil of site-I was found to be fertile and showed rich vegetation. On the other hand, the soil of site II was found to be contaminated with heavy metals, which impacts the flora of the region. The ecology of both sites was studied, and their quantitative and qualitative aspects were compared and contrasted. The abundance, density, and richness of the plants in site II were fairly lower than in site-I, which was confirmed by utilizing Simpson's and Shannon's diversity indices. Many of the species collected from site II were heavy metal accumulators and could also serve as indicators of heavy metal toxicity.

Absent posterior element of axis vertebra with myelopathy treated with C2, C3, and C4 arthrodesis: A case report and review of literature.

A congenital abnormality of the posterior element of the axis (C2) vertebra is extremely unusual, with just a few occurrences documented in the literature. The majority of individuals have no symptoms and are discovered by chance on plain radiography for neck discomfort, radiculopathy, or trauma. We describe a case of a 13-year-old boy who was born without the posterior element of the C2 vertebrae, resulting in C2-C3 spinal instability and compressive myelopathy.

Recurrent glioblastoma in elderly: Options and decision for the treatment.

Background: Glioblastoma (GBM) is the most common primary malignant brain tumor in adult. Its incidence increases with age and nearly half of the all newly diagnosed GBM cases are older than 65 years. Management of GBM in elderly is challenging and recurrence poses further challenge. This article aims to review the literature, evaluate the various options, and to decide the treatment plan in elderly cases with GBM recurrence. Methods: A systemic search was performed with the phrase "recurrent GBM (rGBM) in elderly and management" as a search term in PubMed central, Medline, and Embase databases to identify all the articles published on the subject till February 2022. The review included peer-reviewed original articles, review articles, clinical trials, and keywords in title and abstract. Results: Out of 473 articles searched, 15 studies followed our inclusion criteria and were included in this review. In 15 studies, ten were original and five were review articles. The minimum age group included in these studies was ≥65 years. Out of 15 studies, eight studies had described the role of resurgery, four chemotherapy, three resurgery and/or chemotherapy, and only one study on role of reradiotherapy in patients with rGBM. Out of eight studies described the role of resurgery, six have mentioned improved survival and two have no survival advantage of resurgery in cases of rGBM. Conclusion: Resurgery is the main treatment option in selected elderly rGBM cases in good performance status. In patients with poor performance status, chemotherapy has better post progression survival than best supportive care.

Risk Factor Assessment and Outcomes of Intra Procedural Rupture of Intracranial Aneurysm During Endovascular Treatment: A Race Against Time.

AIM: To identify the risk factors for aneurysmal intra-procedural rupture (IPR) of intracranial aneurysms suring endovascular treatment, and to discuss its management and outcomes. MATERIAL AND METHODS: A total of 106 patients with cerebral aneurysm who have undergone endovascular treatment (EVT) were included in this study, with a mean follow-up period of 17.2 months. Risk factors for IPR, such as the aneurysm?s location, size and morphology, etc. were evaluated, and the chi-squared test was used for statistical analysis. Clinical outcomes were assessed using the modified Rankin scale (mRS) at 15 months. RESULTS: Among all 106 patients who have undergone EVT, five (4.7%) had aneurysmal IPR as well as ruptured aneurysms with subarachnoid haemorrhage (SAH). Among those five patients, primary coiling was performed in three cases and balloon/stentassisted coiling was performed in two cases, with complete occlusion of the aneurysmal sac achieved in four (4/5) patients. Clinical follow-up with the mRS scores of the patients revealed mortality in one patient (20%), favourable outcomes in three patients (60%) and unfavourable outcomes in one patient (20%). CONCLUSION: Aneurysmal IPR is considered a rare but important complication of endovascular coiling that is associated with poor clinical outcomes. Several risk factors are significantly associated with IPR, such as small-sized aneurysm ( < 3.5 mm), presence of bleb and parent vessel tortuosity. Acom location, irregular shape and past episode of SAH also increase the risk of IPR, but such association was found to be statistically insignificant in our study. Although IPR is considered a devastating complication, good clinical outcomes can be achieved with early detection and proper management using rapid aneurysmal coil packing and occlusion.

Valorisation of hazardous medical waste using steam injected plasma gasifier: a parametric study on the modelling and multi-objective optimisation by integrating Aspen plus with RSM.

The COVID-19 Pandemic has a detrimental effect on the environment related to the exponential rise in medical waste (MW). Extraction of energy from the toxic MW with the latest gasification technology instead of conventional incineration is of utmost importance to promote sustainable development. This present study investigates the processing of MW for the generation of enriched hydrogen syngas using steam injected plasma gasifier. Modelling of Plasma gasifier was performed in Aspen Plus and Model validation was done with the experimental result and, a good agreement was attained. Sensitivity analysis was implemented on MW in which the influence of gasification temperature, equivalence ratio (ER), and Steam/Biomass (S/B) on the producer gas (PG) composition, gas yield, H2/CO ratio, cold gas efficiency (CGE), and the higher heating value (HHV) was calculated. Furthermore, Response surface methodology (RSM) has been incorporated for the multi-objective optimisation of the variable gasification parameters. R2 values obtained from ANOVA for H2, CGE, and HHV are 98.62%, 99.10%, and 98.9% respectively. Using the response optimiser, the optimum values of H2, CGE, and HHV were found to be 0.43 (mole frac), 89.95%, and 7.49 MJ/Nm3 for temperature at 1560.60°C, equivalence ratio 0.1, and S/B 0.99, respectively. The observed coefficient of desirability was about 0.97.

C1 lateral mass reduction screws for treating atlantoaxial dislocations: Bringing ease by modification.

Objective: The C1-C2 fixation technique revolutionized the management of complex craniovertebral junction (CVJ) anomalies. Presently used polyaxial screw and rod systems have inadvertent technical difficulties in rod fitting and reduction of atlantoaxial dislocations (AAD) requiring forceful joint handling. The purpose of this study is to analyze the use of a specially designed "reduction screw" in C1 lateral mass in C1-C2 fixation for treating AAD with or without basilar invagination (BI). Study Design: This is a retrospective cohort study in which long lateral mass reduction screws were used for C1-C2 fixation. Materials and Methods: Eighteen patients diagnosed with congenital AAD with or without BI treated with C1-C2 fixations using C1 reduction lateral mass were included in the study. The outcome was measured clinically by the modified Japanese Orthopedic Association score and radiologically by conventional craniometric indices. Results: Among all cases included in the study, 72% (13/18) are males and 18% (5/18) are females with average age at presentation of 33.5 years. Among 18 cases of AAD, 84% (15/18) of patients have BI, 22% (4/18) have Chiari Type 1 malformation, and one patient has Klipple-Feil syndrome. Symptomatic improvement is noted in all patients following surgery. Adequate reduction of AAD with normalization of radiological indices was also achieved in all 18 (100%) patients. Conclusion: C1 lateral mass reduction screw in C1-C2 fixation helps in reduction of AAD and BI (Type A) even in difficult cases of CVJ anomalies with intraoperative technical ease, reduced operative time, no need for special instruments or complex maneuvers, and avoiding potential neurological injury.