Pushing the limits of the Leksell stereotactic frame for spinal lesions up to C3: fixation at the maxilla.

BACKGROUND: Spinal radiosurgery is not considered in the domain of traditional Gamma Knife radiosurgery (GKRS) setup. The major obstacles in GKRS for upper cervical spine lesions remain in difficulty of frame fixation, avoiding collision and maintaining the integrity of the relative position of the lesion from image acquisition to treatment. METHODOLOGY: The supraorbital margin remains the standard lowest fixation point for Leksell stereotactic frame. We describe fixation at the maxilla to target and treat upper cervical spine lesions (up to C3 vertebra) with measures to ensure cervical immobilisation and precision of the GKRS treatment. RESULTS: We have treated two patients at the upper cervical spine up to C3 vertebra by fixing anterior pillars of the Leksell stereotactic frame at the maxilla. To ensure cervical immobilisation and precision of treatment, the neck was immobilised with a Philadelphia collar. The relative position between the head and sternum with the couch from image acquisition to the radiation delivery was kept constant. Docking angle was kept neutral (90 degrees) throughout the treatment (from image acquisition to actual treatment). CONCLUSIONS: The maxilla is a potential alternative for stereotactic frame fixation. Measures to ensure cervical immobilisation with lower-down frame position permits treatment of lesions as low as C3 vertebra.

Atlanto-axial instability in achondroplastic dwarfs: a report of two cases and literature review.

BACKGROUND: Achondroplasia is the commonest form of human dwarfism. The authors report atlanto-axial instability, in consequence to os odontoideum in this subgroup of patients. METHODS: Two achondroplastic dwarfs harboring atlanto-axial dislocation are described along with radiological findings. RESULTS: Both children underwent successful internal rigid immobilization, using sublaminar atlanto-axial wiring. CONCLUSIONS: Craniovertebral junction instability should be evaluated among these children, whenever foramen magnum insufficiency is being considered.

Please spare my teeth! Dental procedures and trigeminal neuralgia.

BACKGROUND: The correct diagnosis of trigeminal neuralgia (TN) is still a far cry and the patients suffer from unnecessary dental procedures before getting the definite treatment. In this study, we evaluated, if the patients have undergone dental procedures for their misdiagnosed TN before receiving definite treatment for the same. METHODS: A total of 187 patients received GKRS for their TN (excluding secondary TN) in two institutes from 2010 to 2019. We did a retrospective analysis of these patients' primary complaints on a standard questionnaire. RESULTS: One hundred and seventeen of the 187 patients responded. About 55.5% of patients had a toothache and 65.8% did visit a dentist for the pain. About 41.8% of patients underwent one dental procedure; 18.8% suffered from worsening of the pain while 8.5% received some partial improvement. About 19.6% also underwent root canal treatment while 6.8% had a nerve block. Mean of 1.6 teeth was extracted per person. About 71% of patients were satisfied with their Gamma Knife radiosurgery for TN at a median follow-up of 49 months. CONCLUSION: There is a need for a better understanding of the disease among the dentists and the patients for the timely and correct treatment, without losing their teeth. The onus lies on neurosurgeons/neurologists disseminate knowledge regarding proper diagnosis and treatment modalities.