Anchoring the Temporalis Muscle with an Intact Fascial Layer Along the Superior Temporal Line in Pterional Craniotomy: A Technical Note.

BACKGROUND: Manipulation of the temporalis muscle during pterional and frontotemporal approaches poses major cosmetic and functional issues postoperatively. The temporalis muscle has usually been secured in its normal position using implants or by leaving a thin rim of muscle and fascia attached along the superior temporal line. In the present report, we have described a pure tissue-based method of anchoring the intact temporalis muscle precisely along the superior temporal line. METHODS: A total of 30 consecutive cases of pterional or frontotemporal craniotomy were performed by single surgeon (SKR). A subfascial dissection technique was used to expose the transition zone of the frontal pericranium with the temporalis fascia. These were then separated by sharp dissection along the superior temporal line at which the muscle is attached. The temporalis muscle and fascia were repositioned during closure, precisely at their original anatomical location by passing multiple anchoring sutures along the free edge of the muscle and fascia lying along the superior temporal line. RESULTS: Temporalis muscle reattachment was achieved in all 30 cases with good cosmesis and functional outcome without temporalis muscle-related complications at 6 months of follow-up. CONCLUSIONS: The approximation of sutures running through the free edge of the temporalis muscle with intact fascia along the superior temporal line from anteriorly to posteriorly restored the muscle and fascial layer to its original position. Avoidance of the formation of any potential dead space during surgical exposure will prevent periorbital edema and/or subgaleal collection postoperatively. The described inexpensive technique avoids implant-related complications, with good functional and aesthetic outcomes. A comparative study is needed to establish the superiority of this procedure over other techniques.

Clinical outcome following multisegmental cervical spinal fixation in patients who recovered partially following injury.

OBJECTIVE: The clinical outcome following multilevel stabilization in patients who suffered cervical spinal injury and developed severe neurological deficits and then gradually partially recovered is evaluated. The basis of the surgical concept was that cervical spinal degeneration is a result of single or multilevel spinal instability and that spinal trauma exaggerates the instability. MATERIALS AND METHODS: During the period 2015-2020, 14 patients who suffered severe cervical spinal injury and could be included in the classification of spinal cord injury without computed tomography evidence of trauma were surgically treated. There were 11 males and 3 females. The ages ranged from 45 to 67 years, average being 53 years. Cervical canal stenoses related to degenerative spinal changes were observed in all patients. All patients suffered severe neurological deficits and within few days or weeks had shown significant but incomplete neurological recovery. The identification of the levels of unstable spinal segments was done on the basis of radiological and clinical parameters and direct observation of spinal instability in adjoining spinal segments. Transarticular fixation was done by Camille's transarticular fixation technique. Using ASIA score, modified JOA score, and Goel Clinical Grading Scale, the clinical course of the patients was monitored. RESULTS: All patients showed recovery in the neurological status. Recovery started in the immediate postoperative period and the improvement progressed during the period of follow-up. CONCLUSIONS: Surgery for spinal stabilization can be indicated even in cases that improve in the neurological function.

Large lateral intraventricular tumors - Outcome of radical surgery.

This is a retrospective analysis of 145 cases of lateral intraventricular tumors that were larger than 4 cm in their maximum dimension. The aim of surgery was radical tumor resection. During the period January 2000 to December 2019, 145 cases of lateral intraventricular tumors were treated by surgery by an interhemispheric approach. There were 101 males and 44 females. The ages of the patients ranged from 2 months to 77 years (average 29 years). Histological examination of tumors identified 73 central neurocytomas, 20 choroid plexus papillomas, 23 subependymal giant cell astrocytomas (SEGA), 5 ependymomas, 21 gliomas, 2 primitive neuroectodermal tumors (PNET/embryonal tumors) and 1 atypical teratoid rhabdoid tumor (ATRT). Nineteen patients had mild to severe hemiparesis in the immediate post-operative period. Eight patients died in the postoperative period. At a follow up of 1 year 137 patients were leading active and symptom free lives. Twenty seven patients received adjuvant radiation treatment. At a follow-up of more than 3 years, 8 additional patients died of their disease. Tumor recurrence or re-growth was observed in 13 patients and 2 patients needed reoperation. Surgery on large lateral intraventricular tumors can be associated with significant postoperative morbidity and mortality. Majority of tumors in this location are relatively 'low-grade' malignant tumors and when successfully treated, the long term outcome can be gratifying.

Report of two cases with omovertebral bone and Klippel-Feil syndrome with craniovertebral junction instability.

We present a report of two patients having the association of omovertebra, Sprengel's deformity of the shoulder and Klippel-Feil abnormality with craniovertebral junctional instability. Our literature survey did not locate any report of such association. Significance of bone alterations is analyzed. Two young patients presented with neck pain, torticollis, webbed neck, and spastic quadriparesis. In both patients, the investigations revealed basilar invagination, Klippel-Feil abnormality and Sprengel's deformity of the shoulder. Apart from these relatively common associations, both the patients had omovertebral bone that extended from the transverse process of C5 vertebra to scapula. Following atlantoaxial stabilization surgery, the patients rapidly recovered from all symptoms. Musculoskeletal abnormalities at the craniovertebral junction that include Klippel-Feil abnormality, Sprengel's shoulder, and omovertebra are secondary alterations to primary atlantoaxial instability.

Is "En Masse" Tumor Resection a Safe Surgical Strategy for Low-Grade Gliomas? Feasibility Report on 74 Patients Treated Over Four Years.

BACKGROUND: Gliomas are "confined" tumors arising from a named white fiber tract and displacing adjoining "normal" white fibers. The surgical strategy of "en masse" resection of gliomas based on this concept is evaluated. OBJECTIVE: We evaluate the feasibility of the surgical strategy of "en masse" tumor resection for low-grade gliomas arising from the short arcuate fibers. METHODS: We retrospectively evaluated our series of 74 patients with low-grade gliomas involving the short arcuate fibers who were operated on between the years January 2016 and June 2019. The tumor resection was done on the premise that gliomas arise from and grew along a specific white fiber tract and the expanding tumor displaced but did not transgress the border formed by adjoining tracts. Although modified as per the situation, an en masse tumor resection strategy was the basis of surgical resection. Intraoperative motor cortical and subcortical mapping was performed in 14 cases. Awake surgery was performed on 11 patients. RESULTS: There were 46 males and 28 females. Total/supratotal tumor resection was achieved in 62 (83.8%) patients. Forty-seven patients had an essentially en masse tumor resection. Seventy-one patients improved in their preoperative complaints. The follow-up ranged from 11 to 56 months. Sixty-two patients who underwent a total or supratotal resection were not given any adjuvant treatment. Twelve patients with subtotal resection were subjected to adjuvant radiotherapy with or without additional chemotherapy. CONCLUSIONS: En masse tumor resection of low-grade gliomas is possible and "safe" based on understanding that gliomas are "confined" tumors and have a well-defined plane of surgical dissection.

Anatomic Correlates and Surgical Experience with Goel Orbital Cortical Approach to Caudate Head Tumors.

OBJECTIVE: We analyzed cortical landmarks, trajectory of approach, and various fiber tracts in the vicinity of our earlier described approach through the orbital/basal surface of the frontal lobe to access tumors located in the region of the caudate nucleus. We also present a new lateral orbital trajectory to approach these tumors. METHODS: The orbital surfaces of 3 formalin fixed and frozen cadaveric brain specimens were dissected to decipher the white fibers in the region of the caudate nucleus. Safe trajectories to lesions of the head of the caudate nucleus were identified, and the anatomic landmarks of the approach were evaluated. Three patients with caudate head tumors were operated using this approach. RESULTS: The caudate head lies at an average distance of 34 mm from the tip of the frontal pole, 24 mm from the basal medial orbital surface of the frontal lobe, 35 mm from the basal lateral orbital surface, and 37 mm from the superior surface of the frontal lobe. Two avenues were identified to approach the caudate head: one by making a cortical incision in the lateral orbital gyrus (lateral orbital approach), and the second by making a corticectomy in the medial orbital gyrus (medial orbital approach) in line with the temporal pole. All 3 patients were operated successfully using this approach. CONCLUSIONS: Surgical approach to the caudate head through the orbital surface of the frontal lobe as described by us provides the shortest trajectory and safe surgical route to access tumors of the caudate nucleus.

Cervico Medullary Junction "Intramedullary Schwannoma" Masquerading As Glioma: A Surprise During Surgery.

BACKGROUND: Intramedullary schwannomas (IS) at cervicomedullary junction (CMJ) are exceedingly uncommon. There is hardly any clinicoradiological marker for preoperative diagnosis and prognostication. CASE: We report a case of a 17-year-old boy with progressive spastic quadriparesis of six months duration. On radiology, there was a contrast-enhancing lesion expanding the cord extending from the medulla to C5 level. During surgery, the cord was expanded and the tumor was eccentric. Histopathology and immunohistochemistry were suggestive of schwannoma. In view of the ill-defined plane of separation from the normal neural tissue, only subtotal resection could be achieved. CONCLUSION: Schwannoma should be considered as a remote differential of intramedullary lesions. The extent of resection should be tailored according to the plane of dissection and intraoperative neuromonitoring guidance. Though a masquerader, schwannoma carries better prognosis than rest of the pathologies.

Atlantoaxial and Subaxial Cervical Spinal Instability in Two Cases with Neurofibromatosis-Type 1.

This is a report of two patients who were diagnosed to have NF-1. The patients had severe dystrophic soft tissue and bone changes leading to craniovertebral junction and subaxial cervical spinal instability and deformity. Both the patients underwent atlantoaxial and subaxial cervical spinal stabilization. No bone, soft tissue or tumor resection was done for decompression. Both patients had gratifying clinical recovery. Follow-up in both the patients is more than 12 months.

"Apoplectic" Recurrence of Massive Trigeminal Neurinomas: Report of 7 Cases.

OBJECTIVE: The pattern of recurrence of large trigeminal neurinomas is analyzed on the basis of experience with 7 cases. METHODS: This is a report of 7 cases of large trigeminal neurinomas that were operated on an average of 11 years earlier. After being relatively asymptomatic over the years, these patients worsened relatively suddenly in their neurologic symptoms and were reoperated. RESULTS: Imaging showed massive recurrence with tumor having cystic and solid components with sizes ranging from 4.5-11 cm. In 4 cases, the cysts at the time of initial presentation and at the time of recurrence showed a well-defined fluid level within the fluid content of the cyst. During operation it was seen that the tumor contained "hemorrhagic" fluid that was under significant pressure. The solid component in the circumferential periphery of the cyst fluid was soft, necrotic, and vascular. The entire recurrence in the middle and posterior cranial fossa and in the extracranial compartment was "interdural" or within the dural confines. Radical tumor resection within the dural confines by deploying relatively small surgical exposure resulted in "unusually" rapid recovery in the symptoms. Histological examination of the tumor did not reveal any malignant transformation. CONCLUSIONS: The cases add further insight to the growth pattern and characteristics of large trigeminal neurinomas.

Outcome of Osteophytes After Only-Fixation as Treatment for Multilevel Cervical Spondylosis-A Minimum of 12 Months Follow-Up.

OBJECTIVE: This report analyzes the significance of osteophytes in the overall pathologic scheme in patients with single-level or multilevel cervical spinal degeneration. METHODS: From January 2010 to December 2018, 249 patients with cervical spondylosis were surgically treated. The alterations in ventral compression caused by disc bulges, osteophytes, and ligament buckling (disc-osteophye-ligament [DOL] complex) at single or multiple levels were evaluated after surgical treatment that involved only spinal fixation and did not involve any kind of bone or soft tissue decompression. Delayed (≥1 year after surgery) postoperative imaging was available in 165 patients and these patients formed the study group. Forty-five patients underwent facet distraction arthrodesis (group A), 106 patients underwent only-fixation involving transarticular screw insertion (group B), and 14 patients underwent hybrid fixation that involved both intra-articular spacers and transarticular fixation techniques (group C) as the surgical treatment. RESULTS: The size of the DOL complex at the segments that underwent fixation was reduced in 136 patients. The size of the DOL complex or its related dural or neural compression did not increase in any of the cases evaluated. Reduction in the size of DOL was more pronounced in patients in group A in both immediate postoperative and delayed images and in patients in group C at spinal levels at which facet distraction was performed using facet distraction spacers. CONCLUSIONS: Spinal stabilization reduces the size of osteophytes. Facet distraction spacers are more effective in reduction of the size of DOL in both immediate and delayed postoperative periods.

Familial Giant Enchondroma of Thoracic Spine: A Rare Manifestation of a Rare Disease.

We present a rare case of spinal enchondromatosis in a 15-year-old boy. The patient presented with spastic paraparesis. He also had multiple bony swellings over the long bones. On inquiry it was found that his father had enchondromatosis. Such a familial form of enchondromatosis has not been previously described in the literature.

Atlantoaxial Instability Treated with Posterior Atlantoaxial Fixation in Two Siblings with Dyggve-Melchior-Clausen Syndrome.

AIM: To discuss the rare association of atlantoaxial instability in patients with the Dyggve-Melchior-Clausen syndrome, a rare autosomal recessive disease characterized by progressive spondyloepimetaphyseal dysplasia and mild to severe mental retardation. MATERIAL AND METHODS: We report an uncommon association of two siblings with Dyggve-Melchior-Clausen syndrome, odontoid hypoplasia and atlantoaxial instability. Both the patients were treated with Goel?s atlantoaxial fixation procedure. RESULTS: The patients had a remarkable neurological recovery following the stabilization procedure. CONCLUSION: Atlantoaxial instability is a potentially life-threatening condition in patients with this syndrome and should be treated early with atlantoaxial stabilization. Recognition and treatment of atlantoaxial instability in patients with Dyggve-Melchior- Clausen syndrome can give gratifying results.

Recurrence of Intraventricular Meningioma along the Surgical Track.

This is a report of three cases of intraventricular meningiomas treated in our department wherein the tumors recurred along the surgical tract. The meningioma in each case was histologically "benign" at the time of first surgery and even at the time of recurrence. Although reported earlier, such cases of recurrence of meningiomas along the surgical tract are relatively rare.

Silent stellate ganglion paraganglioma masquerading as schwannoma: A surgical nightmare.

A 28-year-old normotensive female presented with Horner's syndrome and paresthesia over the left side of the chest. Imaging study showed a large heterogeneous enhancing lesion in short-T1 inversion recovery sequence with flow voids in T2W sequence of magnetic resonance imaging. The lesion was located in the left-sided D1 and D2 regions extending into the neural foramina and apical part of the lung. During surgery, even minimal dissection of the tumor resulted in marked fluctuation in hemodynamic parameters, requiring temporary suspension of the surgery multiple times until hemodynamic parameters were brought under control by the anesthesiologist with drugs. The massive fluctuation in hemodynamic parameters in an unprepared and unanticipated scenario was a challenge for the anesthetist and surgeon. The tumor was radically excised with improvement of paresthesia in the immediate postoperative period, but Horner's syndrome persisted. After 18-months of follow-up, she was relieved of all symptoms including Horner's syndrome. Histopathological examination confirmed our suspicion as paraganglioma.

Adult idiopathic de novo lumbar scoliosis: Analysis of surgical treatment in 14 patients by "only fixation".

OBJECTIVE: The authors report their experience with 14 cases having adult idiopathic de novo lumbar scoliosis (AIDLS) and presenting with the predominant symptoms of claudication pain in the low back and legs. The patients were treated by only multisegmental stabilization, and the surgical procedure aimed for arthrodesis without any form of bone or soft-tissue decompression. The clinical outcome of this novel form of surgical treatment is presented. MATERIALS AND METHODS: During the period of June 2014 to June 2019, 14 patients having AIDLS (degenerative scoliosis) were surgically treated. Apart from clinical and radiological guides, instability was diagnosed on the basis of direct physical observation of the status of articulation and by manual manipulation of bones of the region. The Camille transarticular facet screw fixation technique provided a quick, safe, and strong segmental spinal fixation. An additional inter-screw metal link plate provided intersegmental stability at selected levels. The Oswestry Disability index and visual analog scale were used to assess the patients before and after surgery and at follow-up. In addition, a personalized Patient Satisfaction Score was used to assess the outcome of surgery. RESULTS: Clinical symptomatic recovery was observed in all patients in the immediate postoperative period. During the average follow-up period, 100% patients had varying degrees of symptomatic relief. CONCLUSIONS: Spinal instability is the nodal point of pathogenesis of spinal degeneration-related AIDLS. Only fixation of the involved spinal segments is necessary, and decompression by bone or soft-tissue resection is not necessary.

"Only Spinal Fixation" as Surgical Treatment of Cervical Myelopathy Related to Ossified Posterior Longitudinal Ligament: Review of 52 Cases.

BACKGROUND: Ossification of the posterior longitudinal ligament (OPLL) is a hyperostotic condition resulting in a progressive narrowing of the spinal canal and subsequent neurologic deficits. Although systemic and local factors in combination with genetic abnormality have been considered in its etiopathogenesis, OPLL remains a poorly understood pathology. Surgical management of OPLL and the choice of the most appropriate treatment are still controversial issues. Here the authors report a series of OPLL-affected patients treated by "only-fixation" technique. METHODS: Between June 2012 and June 2019, 52 patients having OPLL were treated by a surgical strategy involving only spinal fixation without any form of bone or soft tissue decompression. Facetal fixation for both the atlantoaxial and subaxial spine formed the basis of the surgical treatment. Clinical parameters, analysis of video recordings before and after surgery, and patient self-assessment were included in the analysis of outcome. RESULTS: During the mean follow-up period there was an immediate postoperative and progressive recovery in symptoms in 51 patients. Of 14 patients who were wheelchair bound before surgery, 12 walked independently on follow-up assessment of 6 months. All patients had successful arthrodesis in the surgically treated segments. There were no infective- or implant-related complications. CONCLUSIONS: Decision making in the surgical management of cervical OPLL is still controversial. The concept of spinal instability has been shown to be a nodal point in the pathogenesis of OPLL, and "only-spinal fixation" can be considered a rationale for an appropriate surgical treatment.

"Interdural" Surgical Strategy for Lower Cranial Nerve Neurinomas-A Report of 14 Cases.

OBJECTIVE: We describe the dural relationships and its surgical implications for large lower cranial nerve (CN) neurinomas. The study is based on surgical experience with 14 cases. METHODS: During the period January 2014 to December 2019, 14 consecutive cases with large lower CN neurinomas were surgically treated with the aim of radical tumor resection. RESULTS: There were 9 males and 5 females, ranging in age from 17 to 65 years. All patients were operated in a single stage. The principal surgical observation was that the entire extent of tumor, which included intracranial, jugular fossa, and extracranial components, was within the "dural" confines and the tumor adjoining critical neural and vascular structures was displaced around the dome of the tumor. Radical surgical resection was achieved in all cases. During the follow-up period that ranged from 3 to 71 months (average 32 months), no symptomatic recurrence was observed and no patient needed reoperation. At the time of last clinical follow-up, the lower CN function in all patients was better than at the time of presentation. CONCLUSIONS: The "dural" cover of the lower CN neurinomas forms a strong and reliable plane of compartmentalization and allows safe tumor resection.

Chiari 1 Formation Redefined-Clinical and Radiographic Observations in 388 Surgically Treated Patients.

OBJECTIVE: The subject of Chiari formation is revisited and redefined. Results of surgical treatment of patients with Chiari formation by atlantoaxial fixation are presented. METHODS: Results were analyzed of 388 patients with Chiari formation surgically treated during 2010 to June 2019. RESULTS: Two hundred and sixty-six patients had syringomyelia. Two hundred and three patients had no craniovertebral bone abnormality and 74 patients had group A and 111 patients had group B basilar invagination. Twenty-nine patients had been earlier treated by foramen magnum decompression surgery with or without duroplasty. Clinical parameters, analysis of video recordings both before and after surgery, and patient self-assessment were included in the analysis of outcome. Immediate postoperative and sustained clinical improvement was observed in 385 patients (99.4%). CONCLUSIONS: Satisfactory clinical outcome in most patients after atlantoaxial fixation and without any manipulation of neural structures, dura, or bone in the region of foramen magnum consolidates the viewpoint that atlantoaxial instability is the nodal point of pathogenesis of Chiari 1 formation. The study suggests that Chiari 1 formation may be a secondary natural neural alteration in the face of atlantoaxial instability. The role of foramen magnum decompression surgery needs to be reassessed.

Is C2-3 fusion an evidence of atlantoaxial instability? An analysis based on surgical treatment of seven patients.

OBJECTIVE: The authors analyze the rationale of atlantoaxial fixation in patients presenting with symptoms related to cervical myelopathy and wherein the radiological images depicted C2-3 fusion and presence of single or multiple level neural compression of the subaxial cervical spinal cord attributed to "degenerative" spine. MATERIALS AND METHODS: Seven adult males were analyzed who presented with long-standing symptoms of progressive cervical myelopathy and where imaging showed presence of C2-3 fusion, no cord compression related to odontoid process, and evidence of single or multiple level lower cervical cord compression conventionally attributed to spinal degeneration. There was no other bone or soft tissue abnormality at the craniovertebral junction. There was no evidence of atlantoaxial instability when assessed by conventional radiological diagnostic parameters. Atlantoaxial instability was diagnosed on the basis of clinical understanding, atlantoaxial facetal malalignment, and manual assessment of instability by bone handling during surgery. All the seven patients underwent atlantoaxial fixation and no surgical manipulation at lower cervical spinal levels. RESULTS: At an average follow-up of 34 months, all patients have recovered satisfactorily in their neurological function. CONCLUSION: The presence of C2-3 fusion is an indication of atlantoaxial instability and suggests the need for atlantoaxial stabilization. Effects on the subaxial spine and spinal cord are secondary events and may not be surgically addressed.