The Rocker Technique for Atlantoaxial Dislocation With or Without Basilar Invagination: A Prospective Observational Study.

BACKGROUND AND OBJECTIVES: Atlantoaxial dislocation (AAD) poses a complex surgical challenge. Surgical approaches vary for reducible and irreducible cases. Challenges persist in reducing the atlantodental interval, especially in cases with oblique or vertical C1-C2 joints. The Rocker instrument (MJ Surgical), a less-explored technique, seeks to simplify instrumentation, reduce complexity, and enhance translation and retroflection reduction of AAD. METHODS: This prospective observational study was conducted from January 2022 to July 2023 at a tertiary neurosurgical center. Inclusion criteria covered all age groups with AAD, with or without basilar invagination. Exclusions included medically unstable patients and severe osteoporotic spine conditions. Preoperative assessments included dynamic X-rays, magnetic resonance imaging, and computed tomography scans. The Rocker technique was used, and patients were followed up for 6 to 12 months. RESULTS: Fifty-five patients (30 males, 25 females) underwent surgery. The mean age was 40.41 ± 15.01 years. Successful Rocker technique application was observed in 53 cases. Functional outcomes, assessed using Modified Ranawat grading, showed improvement postoperatively. Radiological outcomes revealed a significant reduction in the anterior atlantodental interval (7.21 ± 0.94 to 2.98 ± 0.78). Basilar invagination was reduced in all cases, whenever present. The technique exhibited versatility, applicability in various joint orientations, and cost-effectiveness. CONCLUSION: The Rocker technique is a safe and effective alternative for managing both reducible and irreducible AADs, with or without basilar invagination. It simplifies the reduction process, offering advantages over established techniques. Further trials, especially in rotational deformities, are warranted for validation.

Interpenetrating gallol functionalized tissue adhesive hyaluronic acid hydrogel polarizes macrophages to an immunosuppressive phenotype.

Innovative scaffold designs that modulate the local inflammatory microenvironment through favorable macrophage polarization and suppressing oxidative stress are needed for successful clinical translation of regenerative cell therapies and graft integration. We herein report derivation of a hydrazone-crosslinked gallol functionalized hyaluronic acid (HA-GA)-based hydrogel that displayed outstanding viscoelastic properties and immunomodulatory characteristics. Grafting of 6% gallol (GA) to a HA-backbone formed an interpenetrative network by promoting an additional crosslink between the gallol groups in addition to hydrazone crosslinking. This significantly enhanced the mechanical stability and displayed shear-thinning/self-healing characteristics, facilitated tissue adhesive properties to porcine tissue and also displayed radical scavenging properties, protecting encapsulated fibroblasts from peroxide challenge. The THP-1 human macrophage cell line or primary bone-marrow-derived murine macrophages cultured within HA-GA gels displayed selective polarization to a predominantly anti-inflammatory phenotype by upregulating IL4ra, IL-10, TGF-ß, and TGF-ßR1 expression when compared with HA-HA gels. Conversely, culturing of pro-inflammatory activated primary murine macrophages in HA-GA gels resulted in a significant reduction of pro-inflammatory TNF-α, IL-1ß, SOCS3 and IL-6 marker expression, and upregulated expression of anti-inflammatory cytokines including TGF-ß. Finally, when the gels were implanted subcutaneously into healthy mice, we observed infiltration of pro-inflammatory myeloid cells in HA-HA gels, while immunosuppressive phenotypes were observed within the HA-GA gels. Taken together these data suggest that HA-GA gels are an ideal injectable scaffold for viable immunotherapeutic interventions. STATEMENT OF SIGNIFICANCE: Host immune response against the implanted scaffolds that are designed to deliver stem cells or therapeutic proteins in vivo significantly limits the functional outcome. For this reason, we have designed immunomodulatory injectable scaffolds that can favorably polarize the recruited macrophages and impart antioxidant properties to suppress oxidative stress. Specifically, we have tailored a hyaluronic acid-based extracellular matrix mimetic injectable scaffold that is grafted with immunomodulatory gallol moiety. Gallol functionalization of hydrogel not only enhanced the mechanical properties of the scaffold by forming an interpenetrating network but also induced antioxidant properties, tissue adhesive properties, and polarized primary murine macrophages to immunosuppressive phenotype. We believe such immunoresponsive implants will pave the way for developing the next-generation of biomaterials for regenerative medicine applications.

Lumboperitoneal Shunts - Patient Selection, Technique, and Complication Avoidance: An Experience of 426 Cases.

BACKGROUND: Lumboperitoneal shunt is a known procedure for communicating hydrocephalus. Being an extracranial procedure, it can also be utilized in normal-sized ventricles. OBJECTIVE: To report our experience of lumboperitoneal shunt done with a minimal follow-up of 12 months with an emphasis on patient selection, technique, and complication avoidance. METHODS: This was a retrospective analysis of patients who underwent LP shunt during October 2014-October 2019 at the authors' institute. Inclusion criteria were patients with communicating hydrocephalus due to tubercular meningitis, normal pressure hydrocephalus, idiopathic intracranial hypertension, and postoperative refractory cerebrospinal fluid leaks. Data were collected for demographics, Glasgow coma scale and Glasgow outcome scale, vision, gait, memory, urinary incontinence, failed attempts, and complications. RESULTS: A total of 426 patients underwent the LP shunt procedure. The commonest indication was tubercular meningitis followed by idiopathic intracranial hypertension and normal pressure hydrocephalus. Age ranged from 16 to 72 years. There were 255 male and 171 female patients. The mean follow-up was 41 ± 8 months. Overall, 301 patients (70.6%) had neurological improvement. Shunt-related complications occurred in 112 (26.29%) patients, of which shunt block was the commonest. Other complications were infection in 17 (3.9%) patients and extrusion in four (0.9%) patients. Transient postural headache was seen in 46 (10.7%) patients, which gradually improved. CONCLUSION: Lumboperitoneal shunt was found to be a safe and effective treatment in appropriately selected communicating hydrocephalus patients. A meticulous technique reduces the complication rate.

Endoscopic single stage trans-oral decompression and anterior C1 lateral mass and C2 pedicle stabilization for atlanto-axial dislocation.

Although most of the cases of atlanto-axial dislocation (AAD) and basilar invasion can be managed by posterior approaches in the recent times, anterior decompression with stabilization is required in selected patients who persist with irreducible AAD even after manipulation of the C1-C2 facet joint under general anesthesia. A single stage endoscopic trans-oral decompression and stabilization can be used in such patients. It has not been described so far to the best of authors' knowledge. This is indicated in irreducible AAD with the mandibular angle lying below the C2-C3 disc space. It is not a proper choice when the mandibular angle is above the C2-C3 disc space, there is involvement of the facet joint by trauma or any other pathologies, and if a posterior compression at the cervicomedullary junction persists. All patients should undergo pre-operative radiographs, computed tomography (CT) scan and magnetic resonance imaging with angiogram of the cranio-vertebral region. Utilizing this technique, an intra-operative satisfactory reduction of the dislocation with C1-C2 stabilization could be achieved in 3 patients, and 7 required an additional odontoid excision. Post- operative plain radiographs should be performed to assess for C1- C2 alignment and fusion at 3 and 12 months after surgery. All 10 patients of our series had an irreducible AAD and two had an additional basilar invasion. All patients improved from the pre-operative Ranawat grade 3A (n = 8) and 3B (n = 2) to post-operative grade 1 (n = 9) and 2 (n = 1) at a 3-12- month follow-up assessment. The average duration of the procedure and blood loss was 145 minutes and 75 ml, respectively. Endoscopic trans-oral single stage decompression and stabilization seems to be an effective and safe alternative in selected patients with AAD and basilar invasion.

Role of endoscopic third ventriculostomy in tuberculous meningitis with hydrocephalus.

Hydrocephalus is one of the commonest complications of tuberculous meningitis (TBM). It can be purely obstructive, purely communicating, or due to combinations of obstruction in addition to defective absorption of cerebrospinal fluid (CSF). Endoscopic third ventriculostomy (ETV) as an alternative to shunt procedures is an established treatment for obstructive hydrocephalus in TBM. ETV in TBM hydrocephalus can be technically very difficult, especially in acute stage of disease due to inflamed, thick, and opaque third ventricle floor. Water jet dissection can be helpful in thick and opaque ventricular floor patients, while simple blunt perforation is possible in thin and transparent floor. Lumbar peritoneal shunt is a better option for communicating hydrocephalus as compared to VP shunt or ETV. Intraoperative Doppler or neuronavigation can help in proper planning of the perforation to prevent neurovascular complications. Choroid plexus coagulation with ETV can improve success rate in infants. Results of ETV are better in good grade patients. Poor results are observed in cisternal exudates, thick and opaque third ventricle floor, acute phase, malnourished patients as compared to patients without cisternal exudates, thin and transparent third ventricle floor, chronic phase, well-nourished patients. Some of the patients, especially in poor grade, can show delayed recovery. Failure to improve after ETV can be due to blocked stoma, complex hydrocephalus, or vascular compromise. Repeated lumbar puncture can help faster normalization of the raised intracranial pressure after ETV in patients with temporary defect in CSF absorption, whereas lumbar peritoneal shunt is required in permanent defect. Repeat ETV is recommended if the stoma is blocked. ETV should be considered as treatment of choice in chronic phase of the disease in obstructive hydrocephalus.