Aim: To assess the changes in frequency parameters of STN-DBS stimulation over 6 months required to optimize gait in PD patients. Methods: It's a single center, open label longitudinal study of PD patients after STN-DBS with gait disorders. Gait assessment using stand-walk-sit (SWS) test and freezing of gait (FOG) scores were done at baseline and after 6 months. Gait was assessed in five frequencies settings, that is, 60 Hz, 90 Hz, 130 Hz, 180 Hz and stimulation "OFF" during medication ON state. Voltage was maintained. Results: Fifteen post-deep brain stimulation (DBS) patients were included. Mean duration after surgery was 3.73 ± 2.82 years. In SWS and FOG at baseline, five patients have good response at 180 Hz frequency, five at 130 Hz, one at 90 Hz, two patients at 60 Hz, one both 60 and 90 Hz, and one at both 90 and 180 HZ. And after 6 months out of the 13 patients who were able to perform the test, four patients had good response at 180 Hz frequency, four at 130 Hz, two at 90 Hz, one each for 60 Hz and battery OFF state, and one for both 130 Hz and 180 Hz. At 6 months, four patients had good response at the same frequency as baseline, while 11 patients have change in frequency from baseline. Conclusion: Optimal frequency for gait varies in patients-both low and high frequency may be useful. Optimal frequency for improving gait changes over period of time. Regular assessment and changing frequency may improve gait after DBS.
Dystonia deafness syndrome (DDS) is a rare syndrome characterized by childhood onset sensorineural deafness followed by adult-onset dystonia. We here report the first case of DDS from India caused by ACTB gene mutation presented with deafness, generalized dystonia and scoliosis who showed improvement after Deep brain stimulation.
Background: Movement abnormalities pertaining to balance, posture, and gait are observed in Parkinson's disease patients. Gait characteristics vary widely and their analysis has been performed traditionally in gait labs. Freezing and festination usually occur at an advanced stage of the disease and are associated with reduced quality of life. Therapeutic strategies and surgical interventions are often modulated by the physician depending upon the clinical manifestations. Introduction of accelerometers and wireless data transmission systems made quantitative gait analysis possible and cost-effective. Objective: To assess spatiotemporal gait parameters (step height, length (spatial), and swing support time of each foot and double support time (temporal)) in subjects who underwent deep brain stimulation surgery using a purpose-built instrument-Mobishoe. Methods: A simple footwear-based gait sensing device-Mobishoe was built in-house. Thirty-six participants were included in the study after obtaining consent. Participants were made to wear Mobishoe and walk an empty corridor of 30m before Deep Brain Stimulation (DBS) in the drug on and off stated and post DBS in DBS stimulation on and medication off state (B1M0), DBS stimulation off-medication off state (B0M0), DBS stimulation off-medication on (B0M1), and DBS stimulation on and on medication (B1M1). Data was electronically captured and analyzed offline in MATrix LABoratory (MATLAB). Various gait parameters were extracted and analyzed. Results: Improvement in gait parameters was observed when the subject was on medication, on stimulation, or on both when compared to baseline. Improvement was similar with both medication and stimulation and was synergistic when both were used. Significant improvement was noted in spatial characteristics when the subjects were on both the treatments, which is the ideal treatment modality. Conclusion: Mobishoe is an affordable device which can measure spatiotemporal characteristics of gait. The best improvement was seen when the subjects were on both the treatment groups and the improvement can be justified as a synergistic effect of stimulation and medication.
BACKGROUND: Parkinson's disease (PD) is a neurodegenerative disease mainly involving the dopaminergic neurons of the substantia nigra. The subthalamic nucleus (STN) also plays an important role in the disease process and now is an important target for the surgical management of the disease. However, not much is known about its morphology as the disease progresses. The aim of this study was to evaluate the volume of STN and red nucleus (RN) on 3T MRI SWI and its possible correlation with the disease in patients with advanced Parkinson's disease. METHODS: A total of 30 patients were enrolled. They were evaluated by analysis of symptomatology, UPDRS III, MOCA. Radiological evaluation included volumetric SWI images in 3T MRI. The volumes of the STN and RN were measured on SWI coronal images. RESULTS: There were 24 (80%) males and 6 (20%) females. The mean volumes of STN and RN were 118.66 mm3 (80-170 mm3) and 379.66 mm3 (270-500 mm3). There was no significant difference between right and left STN volumes and RN volumes. There was a significant positive correlation between the disease duration and RN volumes (P=0.015) and STN volumes (in 6-13 years) (P=0.001). STN and RN volumes were negatively correlated with MOCA scores in males (P=0.008 and P=0.017), with no such correlation in females. In late-onset PD, there was a significant positive correlation between RN volume and UPDRS OFF and ON scores (P=0.028 and P=0.03). CONCLUSIONS: STN volumes show a positive trend as the disease duration increases and cognition declines. RN volumes also increase as the disease progresses.
Deep Brain Stimulation , Neurodegenerative Diseases , Parkinson Disease , Subthalamic Nucleus , Male , Female , Humans , Parkinson Disease/surgery , Red Nucleus/diagnostic imaging , Magnetic Resonance Imaging/methods , Subthalamic Nucleus/diagnostic imaging , Deep Brain Stimulation/methods
BACKGROUND: C2 vertebral body fractures are relatively rare fractures with no defined management protocol and outcomes. The aim of the study was to evaluate the clinical and radiological outcomes of C2 body fractures. METHODS: The study was conducted at the Department of Neurosurgery, Nizam's Iinstitute of Medical Sciences, Hyderabad, India, following clearance from the Institutional Ethical Committee. The data of all patients with traumatic C2 body fracture who were managed at our Department between January 2008 and January 2019 were retrieved from the database. Functional status of the patients was assessed by Neck Disability Index while pain was assessed by VAS at follow-up after at least 6 months. Fusion and regional kyphotic angles (O-C2 and C2-C7) were assessed for radiological outcome. RESULTS: There were a total of 16 patients with isolated C2 body fractures in the defined time period. The male (N.=11): female (N.=5) distribution was 2.2:1. Ten patients had road traffic accidents while the remaining 6 had history of fall from height. Only 3 patients presented with neurological deficits. Benzel type 3 fracture pattern distribution was the most common fracture pattern (type 1=1, type 2=5, type 3=9). Of these, 10 were operated and 6 were managed conservatively. The VAS and NDI values improved significantly in all at follow-up when compared to values at presentation (P=0.001). Time to return to work was significantly shorter in those treated with surgical intervention (mean: 2.9±0.87) (P=0.001). Fusion was achieved in all the patients in both groups. Mean O-C2 angle at follow-up was 21.13±10.1. Mean O-C2 angle was significantly decreased in non-surgical group at follow-up (P=0.039) but no significant reduction was observed in surgical group. CONCLUSIONS: The management of C2 body fractures needs to be individualized, reserving surgical management for fractures requiring fragment retrival or restitution of alignment if facets were fractured.
Spinal Fractures , Humans , Male , Female , Retrospective Studies , Spinal Fractures/surgery , Radiography , Fracture Fixation, Internal/methods , Treatment Outcome
BACKGROUND: Sagittal imbalance after spine surgery may be a major source of pain and disability and this holds good even for highly mobile cervical region. However, very few studies have addressed the issue of the impact on adjacent and distant spinal segments following occipito-cervical fixations. The aim was to analyze the changes in the sagittal alignment of subaxial spine following occipito-cervical fixations. METHODS: A total of 24 consecutive patients who underwent O-C2 fixation, with at least 2 years follow-up were retrospectively reviewed for changes in the parameters of sagittal alignment using mid-sagittal CT scan. Sagittal parameters, McGregor's line, O-C2 angle, C2-C7 angle, O-C7 angle and T1 slope were measured in pre- and at the final follow-up using Auto CAD software 2010 version (AutoDesk, Mill Valley, CA, USA); moreover, statistical analysis was done by using SPSS Statistics for Windows (IBM Corp., Armonk, NY, USA) version 21.0. RESULTS: The mean values were as follows: 1) MG slope preoperative: 5.96 (SD=3.81), postoperative: 9.42 (SD=9.6) (P=0.097); 2) O-C2 preoperative: 13.56 (SD=10.58), postoperative: 14.67 (SD=10.66) (P=0.32); 3) C2-C7 preoperative: 23.71 (SD=12.10), postoperative: 18.29 (SD=13.68) (0.128); 4) O-C7 preoperative: 20.04 (SD=8.85), postoperative: 25.33 (SD=11.08) (P=0.069); and 5) T1 slope preoperative: 14.42 (SD=10.68), postoperative: 16.58 (SD=8.78) (P=0.291). There was significant positive correlation (r=0.384, P=0.046) between cervical lordosis and T1 slope and a significant negative correlation between O-C2 and C2-C7 (r=-0.415, P=0.044). Subgrouping of fixation angles at O-C2 beyond 20 degrees had major changes in the subaxial spine which also percolated to the thoraco-lumbar spine. CONCLUSIONS: Fixation angles of occipito-cervical spine do impact the sagittal alignment of the subaxial spine.
Lordosis , Spinal Fusion , Humans , Retrospective Studies , Cervical Vertebrae/surgery , Neck
To report a patient with concomitant aceruloplasminemia (with a novel mutation) and IgG4-related pachymeningitis and to hypothesize on the possible relation between the two diseases. Clinical, radiological, and laboratory features of a 56-year-old lady with chronic headache, bifacial palsy, and cerebellar signs are described. Pathophysiology of aceruloplasminemia leading to hyperferritinemia and consequent immune activation is elucidated. A coherent explanation of IgG4-related pachymeningitis resulting from aceruloplasminemia and hyperferritinemia is given. The patient has aceruloplasminemia with a novel nonsense mutation. She also suffers from biopsy-proven IgG4 related pachymeningitis as per standard criteria. These two seemingly unrelated illnesses are linked by hyperferritinemia. This case is a fine example of Occam's razor. Immune dysfunction and autoimmune disorders in aceruloplasminemia need to be explored through further studies to look for causal associations.
Background: Diffuse gliomas are represented in the 2007 WHO classification of CNS tumors as astrocytomas, oligoastrocytoma, and oligodendroglioma of grades II/III and glioblastomas WHO grade IV, which was a pure morphologic classification. WHO 2016 classification combines morphology with molecular markers like IDH, ATRX, and 1p/19q codeletion to give an integrated diagnosis. Methods: The study was carried out on formalin fixed paraffin embedded tissues from 54 patients including three pediatric patients. Molecular studies were performed to know the 1p/19q codeletion status, IDH1R132H, and ATRX immunoexpression. Also, the IDH1R132H status was correlated with survival data. Results: The study included 54 tumors with oligodendroglial morphology. IDH1R132H positivity was seen in 85% of total cases and codeletion was seen in 72%. The integrated diagnosis revised the cases into oligodendroglioma (39), astrocytoma (5), and glioblastoma (6).IDH mutant tumors were found to have better survival than negative ones which was statistically significant. Conclusion: This study emphasizes the need for molecular work up of tumors with oligodendroglial morphology with readily available techniques like IHC and Fluorescence in situ hybridization.
Astrocytoma , Brain Neoplasms , Glioblastoma , Glioma , Oligodendroglioma , Astrocytoma/diagnosis , Astrocytoma/genetics , Brain Neoplasms/diagnosis , Child , Chromosomes, Human, Pair 1/genetics , Chromosomes, Human, Pair 19/genetics , Glioblastoma/pathology , Glioma/genetics , Glioma/pathology , Humans , In Situ Hybridization, Fluorescence , Isocitrate Dehydrogenase/genetics , Molecular Typing , Mutation , Oligodendroglioma/pathology
Background: Levine Edward's Type III Hangman's fractures are highly unstable and in absence of level 1 evidence, the treatment is individualized. A longer cantilever beam can achieve not just reduction of highly displaced fragments but can also provide a stable construct without the need of global instrumentation. Objective: We extrapolated the surgical techniques of the long cantilever beam to this rare group of cohorts for anterior alone, sequential reduction utilizing C3 rather than sacrificing in a single sitting and single approach. Materials and Methods: This is a prospective observational study from 2015 to 2019, of all consecutive 10 patients diagnosed and treated as Type III Hangman's fracture in the Department of Neurosurgery. Clinical evaluation and pain scores were recorded in the preoperative assessment. Radiological investigations included plain roentgenograms in anterior-posterior and lateral views, magnetic resonance imaging, and computed tomography scan of the cervical spine. Preoperative cervical traction was placed in all cases for the achievement of facetal reduction. The high cervical extra-pharyngeal approach was utilized for discectomy, bone grafting, reduction, and sequential plating. Results: Complete reduction was achieved in all the cases and none required additional posterior surgery. There was a significant decrease in axial neck pain with complete fusion of the graft, and healing of fracture site. Conclusion: The anterior alone approach with a longer cantilever for primary internal stabilization is a technically safe and suitable option for unstable Type III Hangman's fracture.
BACKGROUND: CSF rhinorrhea is a known complication that may occur after cranial base surgery, especially the trans-sphenoidal approaches to sellar tumors. It may occur following both microscopic and endoscopic procedures. Over a period, the balance has tilted toward endoscopy due to development of pedicled Hadad flap. Microscopic trans-sphenoidal surgery (TSS) continues to be performed in our institute as well as many other centers across the world due to familiarity of technique and unavailability of endoscopic equipment. Despite the fairly widespread use of this surgery, literature is devoid of any description of a local mucosal flap for repair of the surgical defect in microscopic TSS. METHODS: We herein described the procedure and our experience of harvesting such flap in 42 patients operated for pituitary adenomas in our department between September 2016 and February 2020, through microscopic sublabial TSS. RESULTS: All 42 of the patients included in this study underwent excision of pituitary tumors (macroadenomas). Thirty-nine (n = 39) patients were undergoing 1st time surgery, while three (n = 3) of these patients were undergoing second surgery following an earlier trans nasal trans-sphenoidal route. None of our cases have reported CSF leak postoperatively. CONCLUSION: This study attempts to highlight to ardent/obligate microscopic surgeons that a local vascularized flap can be harvested for repair of skull base defect and prevent postoperative CSF leak in microscopic sublabial TSS.
BACKGROUND: Deep brain stimulation (DBS) has been proven to be a safe, reversible, cost effective procedure for treatment of Parkinson's disease. Final electrode position remains a significant factor determining the outcomes of Subthalamic nucleus deep brain stimulation (STN-DBS). This study aims to analyze the final lead position in three-dimensional plane and its effect on gross and fine motor outcomes in cases of advanced Parkinson's disease operated for STN-DBS. METHODS: Patients who underwent bilateral STN DBS were prospectively followed for improvement in gross motor outcomes at 6 months. Improvement in dysgraphia was analyzed by Fahn-Tolosa-Marin Tremor Rating Scale Part B score. Postoperative outcomes were correlated with final electrode position. RESULTS: A total of 64 Patients (128 leads) were analyzed. Patients who were less than 65 years of age at time of surgery had more significant reduction in UPDRS III(p = 0.02). Cases with deviation of left x less than 3 mm had significant reduction in UPDRS III (p = 0.05) and speech sub-scores (p = 0.05). Deviation less than 2 mm in left x was associated with reduction in gait sub-scores (p = 0.04). Optimal placement of right y electrode was associated with reduction in UPDRS III (p = 0.02). Significant reduction in Fahn-Tolosa-Marin Tremor Rating Scale Part B score was noted after DBS(p =0.001). CONCLUSIONS: Subthalamic nucleus deep brain stimulation thus results in significantly improved functional outcome particularly in patients with age less than 65 years. Accurate final electrode position is associated with maximum clinical benefit and improvement in dysgraphia.
BACKGROUND: Pituitary dysfunction following severe traumatic brain injury (sTBI) is significant and may be correlated with the outcomes. AIMS AND OBJECTIVES: This study aimed to evaluate the early changes in pituitary hormone levels after sTBI and to correlate with outcomes in terms of severity and mortality. METHODS: This was a prospective, observational study, involving consecutive patients of 16-60 years, with sTBI (Glasgow Coma Scale GCS < 9) presenting to the hospital within 24 h of trauma. Demographic and clinical data were collected. Serum samples were collected in the morning (08-10 am) on day 1 and day 4 for cortisol, thyroid-stimulating hormone (TSH), triiodothyronine (T3), thyroxine (T4), and prolactin (Chemiluminescence immunoassay). Outcome was assessed in terms of mortality (which included both immediate and at 3 months) and Glasgow outcome scale at 3 months. RESULTS: 54 patients were studied. Mean cortisol on day 4 was 28.5 µg/dL in alive patients and 13.7 µg/dL in patients deceased at 3 months (P < 0.001). Patients who were deceased at 3 months had significantly lower T3 on day 4 (0.973 vs 1.4 ng/dL) and lower T4 (8.1 µg/L vs 6.1 µg/dL) as compared to patients who survived (P = 0.049 and 0.005, respectively). Acute phase TSH on day 4 levels were significantly lower in patients deceased at 3 months. There was no significant difference in the prolactin levels. CONCLUSION: Day 4 cortisol, T3, T4, and TSH correlated with the outcomes at 3 months and hence have predictive value post-sTBI.
BACKGROUND: Parkinson's disease is associated with significant changes in morphometry of subthalamic nucleus (STN); however, not much is known as the disease progresses. The aim of present study was to investigate the volume of STN and Red nucleus (RN) on 3T-magnetic resonance imaging (MRI) and its possible correlation with disease progression in advanced Parkinson's disease patients. METHODS: Patients of advanced Parkinson's disease were prospectively followed for clinical details, motor severity scores, and radiological evaluation. Volumes of the STN and RN were measured on susceptibility weighted imaging, coronal sections in 3T MRI and were correlated with demographic and clinical features. RESULTS: A total of 52 patients were included in our study. There were 42 (80.77%) males and 10 (19.23%) females. Mean age of onset of Parkinson's disease was 49.48 + 10.90 years. Average duration of disease in the present cohort was 7.65 + 4.31 years. Average STN and RN volume were 103.46 + 21.17 mm3 and 321.73 + 67.66 mm3. Age of onset, disease duration and Unified Parkinson's Disease Rating Scale Part III scores were not found to be associated with changes in STN Volumes. Weak positive trend was noted between RN volume and disease duration (Pearson cor. 0.204, P = 0.14). Patients in early-onset Parkinson's disease group had significantly more volume of RN than patients in late-onset Parkinson's disease group (P = 0.014). CONCLUSION: Disease duration and early age of onset in Parkinson's disease can be associated with increased RN volume. Volume of STN shows relatively no change even with disease progression.
BACKGROUND: Cervical degenerative disc disease is a common condition in neurosurgical practice. Elimination of a motion segment through fusion causes the load shift to the adjacent levels leading to disc degeneration. Our hypothesis is that by avoiding excessive dissection of the prevertebral soft tissue and placing anchoring screws away the adjacent endplate, we can reduce the load bearing and degeneration rate. METHODS: This is a prospective randomized control study .The study included 30 consecutive cases requiring single level ACDF, 15 each in conservative and minimal dissection group. MRI evidence of disc degeneration was assessed according to Matsumoto MRI grading system. RESULTS: No significant role of age on ASD was noted (P-0.26). ASD was worse in females than males especially at the inferior level(P- 0.035). ASD was noted to be higher when the patients were operated at C5-6 level (P-0.026). The reduction in VAS was 5.933 in the minimal dissection group which was significantly better than the conventional surgery group(5.14) (P-0.023). The increase in degeneration score was 0.97 & 0.6 at superior and inferior levels respectively in the conventional group and 0.13 & 0.34 in Minimal dissection group. CONCLUSIONS: The minimal soft tissue dissection for single level ACDF with PEEK cage placement appears to have reducing rate of ASD compared to conventional ACDF. Minimal soft tissue dissection has better Postoperative VAS scores.
