Indian Neurosurgeons at the Forefront: A Comprehensive Exploration of their Pioneering Contributions to Neuroendoscopy.

This article delves into the profound impact of Indian neurosurgeons on the expansive canvas of neuroendoscopy. By scrutinizing their trailblazing research, innovations, new surgical techniques, and relentless dedication to education and training, we aim to unravel the intricacies of their influence on a global scale. The review, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, conducts a comprehensive analysis of the literature related to neuroendoscopy contributed by Indian neurosurgeons. The exploration covers a spectrum of achievements, ranging from pioneering research and innovations to complication avoidance, neuroendoscopic training, and global recognition. Despite challenges, Indian neurosurgeons continue to lead the way in shaping the future of neuroendoscopy, ensuring better patient outcomes and improved quality of life. Many Indian neurosurgeons have contributed significantly to the development of neuroendoscopy in India. Prof. YR Yadav's contributions stand significant in the form of research articles and publications on almost all subjects on neuroendoscopy, the textbook on neuroendoscopy, popularizing neuroendoscopy by starting the first university-certified neuroendoscopy fellowship training program in India, describing many innovative techniques/first report of endoscopic techniques and conducting regular endoscopic workshops in his institutions and other major cities of India.

Comparative Analysis of Hemispherotomy in Adults versus Children- A Prospective Observational Series.

BACKGROUND: Hemispherotomy (HS) is an effective treatment for unilateral hemispheric onset epilepsy. There are few publications for HS in adults, and there is no series comparing adults and pediatric patients of HS. OBJECTIVE: To compare the hemispherotomies done in adult patients with pediatric ones in terms of efficacy and safety. METHODS: Data was prospectively collected for HS patients (up to 18 years and more) from Aug 2014 to Aug 2018. Comparison between the groups was made for seizure onset, duration of epilepsy, frequency of seizures, number of drugs, intraoperative blood loss, postoperative seizure control, postoperative stay, postoperative motor functions, and preoperative and postoperative intelligence quotient. Follow-up was one year. RESULTS: A total of 61 pediatric and 11 adults underwent HS. The seizure onset was earlier in children, and the duration of epilepsy was longer in adults. The frequency of seizures per day was more in children being 14.62 ± 26.34 in children, and 7.71 ± 5.21 per day in adults (P - 0.49). The mean number of drugs was similar in the preoperative and postoperative periods in both. Class I seizure outcome was similar in both the groups being 85.24% in children and 90.9% in adults (P - 0.56). Blood loss, postoperative stay, was similar in both the groups. No patient had a new permanent motor deficit. Power worsened transiently in 1 pediatric patient and in 4 adult patients. The visual word reading and object naming improved in both the groups (no intergroup difference), and IQ remained the same in both groups. One adult patient had meningitis, and another had hydrocephalus requiring shunt placement. CONCLUSION: Hemispherotomy is a safe and effective procedure in adults as in children in appropriately selected patients.

Diagnostic utility of intraoperative squash smear cytology of Intra-cranial lesions in a resource limited setup of central India.

Introduction: Intraoperative squash smear cytology is a useful diagnostic tool in case of CNS lesions. In resource poor countries where frozen section is unavailable, cytology is the mainstay method in giving a rapid intraoperative diagnosis which helps Surgeons regarding the extent of excision. The current study aims to assess the feasibility and accuracy of intraoperative squash cytology in evaluation of CNS tumors. Definitive diagnosis is confirmed by histopathological examination. Materials and methods: This retrospective observational study was carried out at Department of Neuropathology. All patients diagnosed with space occupying lesion (SOL) in CNS were enrolled in the study. Intra-operative cytological diagnosis was compared to histopathological diagnosis. WHO classification of CNS tumors 2021 was used to classify tumors. Results: Total seventy patients with intracranial SOLs were enrolled in this study who were operated for the same and their specimens were examined. Two samples were found to be inadequate and not included in final analysis. Mean age was 38.8 ± 17.85 (SD). Male-female ratio was 1.5:1 with 41 (60.3%) males and 27 (39.7%) females. 58 had neoplastic and rest 10 had non-neoplastic lesions. Complete concordance was achieved in 61 cases (Diagnostic Accuracy-88.2%). 3 (4.4%) cases showed partial concordance and 4 (5.9%) were discordant. For detection of malignant lesions through squash smear cytology overall Sensitivity was 73.9%, Specificity-97.8%, Positive Predictive Value-94.4% and Negative Predictive Value-88%. Conclusions: Squash smear cytology is a simple, rapid and cost-effective method relying solely on the expertise of pathologist. High diagnostic accuracy can be achieved with squash cytology by taking clinical and radiological findings into consideration.

A Novel Brain Retractor for Endoscopic Evacuation of Chronic Subdural Hematoma.

Background: Endoscopic chronic subdural hematoma (CSDH) evacuation is a safe and effective alternative to the conventional burr hole technique. Although a rigid endoscope has the advantage of good visualization, there are risks of brain damage due to limited space to accommodate the scope and frequent lens soiling. Objective: This technical note describes a novel brain retractor to overcome the limitations of rigid endoscopy. Methods: The novel brain retractor (by senior author) was made by dividing a silicon tube longitudinally into two halves, and tapered for easy introduction in the operative cavity. Sutures were placed at the outer end of the retractor to prevent migration and to assist in angulation. Results: The novel retractor along with endoscopic assistance was used in 362 CSDH procedures. Endoscopy combined with this retractor provided additional help in complete removal of hematoma in organized/solid clots, septa, bridging vessels, and rapid expansion of brain in 83, 23, 21, and 24 patients, respectively (n = 151, 44%). Although there were three deaths (due to poor preoperative status), and two recurrences, there were no retractor-induced complications. Conclusions: The novel brain retractor assists endoscope in proper visualization of complete hematoma cavity by gentle and dynamic brain retraction, helps in thorough irrigation of hematoma cavity, protects the brain, and prevents lens soiling. It allows easy insertion of the endoscope and instruments using bimanual technique even in patients with a small width of hematoma cavity.

Seventh Cervical Nerve (C7) Transection for Spastic Arm Paralysis After Cerebral Injury.

BACKGROUND: Spastic limb paralysis because of cerebral injury can cause long-term disability. Its treatment varies from conservative to operative; however, the optimum treatment is yet to be found. OBJECTIVE: To test the hypothesis that patients with spastic arm paralysis who receive C7 nerve transection to their paralyzed side might have reduction in spasticity, pain, and improvement in arm function. METHODS: Four patients with spastic hemiparesis that had ceased to improve after 1 year of rehabilitation, having pain and poor function, were included. All 4 patients underwent C7 nerve transection plus rehabilitation. The outcome was assessed at 1, 3, and 6 months by the Fugl-Meyer upper extremity scale for motor recovery, by the Modified Ashworth Scale score for spasticity, and by the visual analogue score for pain. Functional use of the limb was also assessed by performance of activities such as dressing, tying shoe laces, wringing a towel, and operating a mobile phone. RESULTS: At the end of 6 months, there was a significant improvement in mean Fugl Meyer score, reduction in Modified Ashworth score, and Visual Analogue scale for pain. At the beginning of the study, none of the patients could perform any day-to-day activities; however, at the end of 6 months, 3/4 of the patients could perform at least 1 activity. CONCLUSION: C7 neurectomy leads to improved motor function, reduction of spasticity and pain, and improvement in function in patients with spastic arm paralysis because of cerebral injury.

Epilepsy-Related Injuries in Children: An Institution-Based Study.

Background: Epilepsy carries a lifetime risk of seizure-related accidents. The risk varies according to the socioeconomic profile of a place. Sufficient data is lacking for epilepsy-related accidents in the pediatric population. Objective: We aimed to identify the proportion of pediatric epileptic patients who met with accidents and their associated factors. Methods: A prospective study was done. Patients of less than 18 years with epilepsy of more than 1-year duration were included and were given a questionnaire modified for the pediatric population. The demography of accidents during seizures and drugs taken were recorded. Results: 135 epileptic children were included. 70.4% of patients suffered seizure-related accidents ranging from 1-10 accidents in their epilepsy duration. Falls (83.15%) were the most common, 25.26% of them required hospitalization. Accidents due to missing of drug dosage were observed in 23% patients. Conclusion: Seizure-related accidents are common in the pediatric population, and may lead to major accidents. Better epilepsy management with extra care for high-risk epilepsy patients may decrease their incidents.

Rotational Occipital Scalp Flap for Occipital Pressure Ulcer.

Occipital pressure ulcers and wound gaping may occur in unconscious and malnourished patients. Most of the time, a large defect requires wound coverage by scalp flaps. This video describes a rotational occipital scalp flap for occipital pressure ulcer and wound gaping in a patient of operated midline posterior fossa mass & ventriculoperitoneal shunt. The defect measured 2.25 × 2.5 cm with exposed inion. The wound was included in an imaginary triangle, and the horizontal and vertical incision lengths were about four times the base of the triangle. The flap was based on the left occipital artery and raised in an avascular plane above the periosteum. The wound margins were freshened and undermined. The flap was rotated to bring it over the defect, and suturing was done in the standard manner. The flap had good healing, and the patient continued to be under care for his cerebellar medulloblastoma.

Mini Temporal Craniotomy Using Anatomical Surface Landmarks for Temporal Lobe Epilepsy: Technical Note and Clinical Outcomes.

Background: Patients with temporal lobe epilepsy are subjected to standard temporal lobectomy wherever indicated. This is performed using a reverse question mark flap and a standard frontotemporal craniotomy. We describe the technique of minitemporal craniotomy (3 × 3cms) for temporal lobe epilepsy (TLE) and analyze the clinical outcomes of patients operated using this approach. Objectives: To describe the technique of minitemporal craniotomy for TLE without navigation guidance and to analyze the clinical outcomes of patients operated using this approach. Materials and Method: This was a retrospective analysis of all consecutive TLE cases operated at our institute from 2014 to 2019, via minitemporal craniotomy, using surface landmarks only without navigation guidance. The surgical technique, indications for surgery, and their clinical outcomes were analyzed. Results: A total number of 48 patients underwent surgery for TLE. There were no complications except three patients who had transient hemiparesis. The average duration of hospital stay was 4 days following surgery. Out of 28 patients with mesial temporal sclerosis, 22 (82%) had international league against epilepsy, Class I seizure outcome, 4 (12.5%) had Class II outcome and 2 (5.5%) had Class III outcome. 9 patients with dysembryoplastic neurectodermal tumor (DNET), 4 gangliogliomas, 2 neurocystecercosis (NCC), all had Class I outcome. Out of the five patients with MTS and associated anterior temporal focal cortical dysplasia (FCD), four (80%) had a Class I outcome, whereas one (20%) had Class II outcome. Conclusion: Utilizing surface anatomical landmarks, minitemporal craniotomy can be performed in even peripheral centers without neuronavigation, with good cosmesis, seizure outcomes.

Cadaveric study to assess the feasibility of S1 neurectomy and contralateral S1 transfer for spastic hemiparesis.

Purpose: Acquired brain injury causing spasticity, pain and loss of function is a major cause of disability and lower quality of life. Sacral 1 (S1) neurectomy claims promising outcomes in spastic hemiparesis. This cadaveric study was conducted to study the surgical anatomy, surgical approach and feasibility of S1 neurectomy and contralateral S1 (cS1) transfer. Methods: This study was conducted over a period of 10 months and 10 cadavers (age 18-60 years, 7 male and 3 female) were included in the study. 2 cadavers underwent endoscopic S1 neurectomy and 8 cadavers underwent open S1 neurectomy. Mean S1 root length and diameter were recorded using Schirmer tear strips and Vernier calliper. Feasibility of transfer was also assessed by measuring the length of donor nerve and distance between distal ends to proximal end of recipient nerve. Results: Mean thickness of right S1 root was 4.02 ± 1.5 mm and left S1 was 3.89 ± 1.18 mm. Mean length of right S1 root was 24.9 ± 4.56 mm and left S1 was 23.6 ± 2.86 mm. Endoscopically dissected length of S1 was much less as compared to open technique. Conclusion: S1 neurectomy is simple procedure to reduce spasticity in lower limb without any permanent deficit. It can be done by open as well as with endoscopic approach while for contralateral S1 transfer open approach need to be used.

Endoscope-controlled Access to Thalamic Tumors using Tubular Brain Retractor: An Alternative Approach to Microscopic Excision.

BACKGROUND: Surgery for thalamic lesions has been considered challenging due to their deep-seated location. Endoscopic excision of deep-seated brain tumors using tubular retractor has been shown to be safe and effective in prior studies; however, there are limited reports regarding its use for thalamic tumors. We present our experience of endoscope-controlled resection of thalamic tumors using a tubular retractor. MATERIAL AND METHODS: This was a prospective observational case series done at a tertiary center specialized for endoscopic neurosurgery during the period from 2010 to 2019. Surgeries were performed under the endoscopic control using a silicon tubular retractor. Lesions were approached transcortically or trans-sulcally. Data were collected for the extent of resection, amount of blood loss, operative time, need for conversion to microscopy, and complications. RESULTS: Twenty-one patients of thalamic masses of 14- to 60-year age underwent the surgeries. Pathologies ranged from grade I to IV gliomas. Gross total and near-total resection could be done in 42.85% of cases for each group. The average blood loss and operative time were164.04 ± 83.63 mL and 157.14 ± 28.70 minutes, respectively. Complications included a small brain contusion, two transient hemipareses, and one transient speech deficit. CONCLUSION: Endoscopic excision of thalamic tumors using a tubular retractor was found to be a safe and effective alternative to microscopic resection.

Endoscopic-Assisted C2 Transverse Process Mass Excision.

BACKGROUND AND INTRODUCTION: C2 transverse process exostoses are rare lesions. Due to critical structures surrounding them, their excision is challenging. There are sparse reports of anterior retropharyngeal approach (ARPA) for high-cervical transverse process mass and none for endoscopic ARPA approach. OBJECTIVE: A step-by-step technical report with its video is presented. SURGICAL TECHNIQUE: A 14-year-old girl presented with chronic right-sided neck pain. The computed tomography scan revealed a 6.5 cm3 mass in the right transverse process extending into the lateral mass of the C2 vertebra. The mass was anterior and in direct contact with the vertebral artery. She underwent a minimally invasive endoscopic ARPA. RESULTS: The mass could be excised along with its cartilaginous cap without any complications. The patient's symptoms resolved completely. The biopsy came out as osteochondroma. CONCLUSION: Endoscopic ARPA is a minimally invasive option for high-cervical tumors and was found safe and effective for C2 transverse process osteochondroma.

Comparison of Peripheral Neurectomy vs. Medical Treatment for Migraine: A Randomized Controlled Trial.

BACKGROUND: Migraine is a common form of primary neurologic headache. Many patients are chronic migraineurs and suffer from a significant disability and adverse effects of drugs. There are various surgical options available to treat migraines, including peripheral neurectomies. OBJECTIVE: To study the surgical and functional outcomes of migraine surgeries using peripheral neurectomies and compare them with conservatively treated patients. MATERIALS AND METHODS: Migraine patients who had a unilateral onset pain were given local bupivacaine block at the suspected trigger site, and those who were relieved were given the option for surgery. In the operative group, the peripheral nerve of the trigger site was lysed under local anesthesia. The conservative group was continued with the standard treatment. Evaluations with a baseline and 6 months visual analog score (VAS), migraine headache index (MHI), migraine disability assessment test (MIDAS), and pain self-efficacy questionnaire (PSEQ) scores were done. RESULTS: A total of 26 patients got benefitted with the local bupivacaine block, out of which 13 underwent surgery. At baseline, the VAS, MHI, MIDAS, and PSEQ scores were similar in both the groups. The operative group had significant (P < 0.001) improvement in all these parameters 6 months after the surgery. All patients of the operative group got free from prophylactic migraine treatment; however, 11 out of 13 patients still needed occasional  use of analgesics. There was one complication of transient temporal numbness. CONCLUSION: Migraine surgery using peripheral neurectomies was more effective than chronic drug treatment in appropriately selected patients.

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 Third Ventriculostomy - A Review.

BACKGROUND: Endoscopic third ventriculostomy (ETV) has become a proven modality for treating obstructive and selected cases of communicating hydrocephalus. OBJECTIVE: This review aims to summarize the indications, preoperative workup, surgical technique, results, postoperative care, complications, advantages, and limitations of an ETV. MATERIALS AND METHODS: A thorough review of PubMed and Google Scholar was performed. This review is based on the relevant articles and authors' experience. RESULTS: ETV is indicated in obstructive hydrocephalus and selected cases of communicating hydrocephalus. Studying preoperative imaging is critical, and a detailed assessment of interthalamic adhesions, the thickness of floor, arteries or membranes below the third ventricle floor, and prepontine cistern width is essential. Blunt perforation in a thin floor, while bipolar cautery at low settings and water jet dissection are preferred in a thick floor. The appearance of stoma pulsations and intraoperative ventriculostomography reassure stoma and basal cistern patency. The intraoperative decision for shunt, external ventricular drainage, or Ommaya reservoir can be taken. Magnetic resonance ventriculography and cine phase-contrast magnetic resonance imaging can determine stoma patency. Good postoperative care with repeated cerebrospinal fluid drainage enhances outcomes in selected cases. Though the complications mostly occur in an early postoperative phase, delayed lethal ones may happen. Watching live surgeries, assisting expert surgeons, and practicing on cadavers and models can shorten the learning curve. CONCLUSION: ETV is an excellent technique for managing obstructive and selected cases of communicating hydrocephalus. Good case selection, methodical technique, and proper training under experts are vital.