Spine Surgery in a Geriatric Population. Is it Really Different?

OBJECTIVES: Spinal degenerative disorders are a major cause of morbidity in the elderly resulting in high dependency. Most of them have a trend to be managed conservatively considering age, comorbidities, and apprehensions of surgical complications. Surgical intervention at early stage with appropriate indications can have better outcomes rather than conservative management in fit patients. The objective of the study is to evaluate the functional outcome in geriatric patients > 60 years who have undergone various spinal procedures for degenerative spine. METHODS: The study is retrospective, which includes all cases of spinal degenerative disease operated between 2014 and 2016. They were divided into geriatric (>60 years) and non-geriatric cohorts. These include all patients undergoing spinal decompression and/or instrumentation for degenerative disorders of the spine. Patients were interviewed for their functional outcomes in the follow-up period. RESULTS: A total of 184 spine cases were operated upon by a single surgeon, out of which a total of 139 cases were operated for the spinal degenerative condition. Forty-eight patients underwent lumbar spinal fusion procedures, 67 underwent non-instrumented lumbar decompression, and 24 patients underwent cervical procedures. These were further divided into 65 geriatric cases and 74 non-geriatric cases. The outcome was assessed with improvement and functional outcomes for spinal disability. Statistical analysis was performed using SPSS 20. CONCLUSION: It is concluded that surgical intervention for spinal problems in geriatric patients is not different from the general population. The outcome is also satisfactory provided, the choice of surgical procedure as per its indication is appropriate. The usual preoperative evaluation for the geriatric age group is very important. The performance status before surgery and the comorbidities have a direct bearing on the outcome in these patients.

Pure Endoscopic Excision of Parenchymal Brain Tumors: Feasibilty, Risks, Advantages and Realities - A Beginners Perspective

Background Neuroendoscopy is gaining popularity and is reaching new realms. Young neurosurgeons are exploring the various possibilities associated with the use of neuroendoscopy. Neuroendoscopy in excision of parenchymal brain tumors is less explored, and young neurosurgeons should be aware of the realities. The present article is an approach to put forward the difficulties faced by a young neurosurgeon and the lessons learnt. Objective To report the experience of surgical excision of parenchymal brain tumors, in selected cases, using pure endoscopic approach and to discuss its feasibility, technical benefits, risks and comparison with conventional microscopic excision. Method Eight patients of variable age group with parenchymal brain tumors were operated upon by a single surgeon and followed up for a period varying from6months to 2 years. Data regarding operating time, illumination, clarity of the field, size of craniotomy, blood loss and course of recovery was evaluated. All of the tumors were resected using rigid high definition zero and 30° endoscope. Results Out of eight cases, seven had lesions in the supratentorial and one in the infratentorial location. The age group ranged from 27 to 74 years old. Near to gross total resection was achieved in all except two cases. All of the patients recovered well without any significant morbidity or mortality. Hospital stay was reduced by 1 day on average. Conclusion Excision of parenchymal brain tumors via pure endoscopic method is a safe and efficient procedure. Although there is an initial period of learning curve, it is not steep for those already practicing neuroendoscopy, but the approach has its advantages.

The predictors of recovery from diabetes mellitus following neurosurgical treatment of acromegaly: A prospective study over a decade.

OBJECTIVE: The natural history of glucose intolerance (GI) in patients with acromegaly undergoing surgical treatment has not been fully understood. This study was aimed to unravel the prevalence and predictors of recovery from GI in these patients in a prospective multivariate model. MATERIALS AND METHODS: Patients with acromegaly treated between 2007 and 2016 were prospectively studied with respect to demographics, clinicoradiological features, comorbidities, and hormonal investigations before surgery and at regular follow-up. The independent predictors of recovery from diabetes were analyzed. RESULTS: There were a total of 151 patients with active acromegaly included in the study. The median baseline growth hormone (GH) and insulin-like growth factor (IGF)-1 levels were 25 and 811 ng/mL, respectively. Diabetes mellitus (DM) and pre-diabetes were noted in 93 (61.6%) and 20 (13.2%) patients, respectively. Following surgical treatment, the median HbA1c decreased significantly from 6.4% to 5.5% (P < 0.001), with 46.8% having complete recovery from DM or pre-diabetes. This glycemic recovery had significant association with both biochemical (P = 0.001) and radiological remission (P = 0.01). The recovery from DM had a greater association with post-operative IGF-1 than GH, especially among those with discordant GH and IGF-1 levels (60% in normal IGF-1 and high GH vs. 20% in high IGF-1 and normal GH). Post-operative IGF-1 had a significant impact on recovery from DM (P = 0.01) independent of age, body mass index, duration of DM, and pre-operative HbA1c. CONCLUSION: Nearly half of the patients with acromegaly with DM or pre-diabetes had glycemic recovery, influenced by biochemical and radiologic remission. Post-operative IGF-1 appears to be the strongest independent determinant of recovery from DM.

Visual outcome in 2000 eyes following microscopic transsphenoidal surgery for pituitary adenomas: Protracted blindness should not be a deterrent.

OBJECTIVE: To study the visual outcome after surgery for pituitary adenomas with visual deficits. MATERIALS AND METHODS: All patients with pituitary adenoma, who presented from 2003-2014 in a tertiary care institute, were included in the study. Surgical outcome was measured in terms of difference in visual acuity, visual fields and optic fundus parameters documented before surgery, immediate post-operatively and at the third, and twelfth months following surgery. RESULTS: At the initial presentation, visual involvement was seen in 87.2% patients. One year after surgery, 93.2% patients having abnormal vision had improvement in visual acuity and visual fields; whereas visual parameters were static in 5.2%. Visual deterioration occurred only in 1.3% patients. Moreover, five-percent of those who did not even have perception of light at presentation experienced significant improvement in vision after surgery. The shorter the duration of visual symptoms, the more was the percentage of patients having faster recovery in the early postoperative period. CONCLUSION: Post-operative visual outcome was directly proportional to the pre-operative visual acuity. Though the visual outcome was good in the long run irrespective of the duration of symptoms, the speed of recovery was proportional to the duration of visual deficits. However, presence of long-standing visual symptoms should not deter us to subject the patient to surgery. Even patients who are completely visually impaired for years should be subjected to surgery as early as feasible.

Long-term outcome in surviving patients after clipping of intracranial aneurysms.

OBJECTIVE: The quality of life and functional outcome may be significantly impaired in patients of aneurysmal subarachnoid hemorrhage. The purpose of the present study was to assess the status of patients undergoing surgical clipping of intracranial aneurysms in a long-term follow-up and to identify factors affecting outcome. METHODS: 494 patients who underwent clipping of their intracranial aneurysms with a minimum follow-up of 1 year after their discharge were studied. Preoperative factors such as age, Hunt and Hess grade, Fisher grade, time interval between ictus and surgery, and site of aneurysm were recorded. The long-term status was assessed using Glasgow Outcome Scale (GOS), Modified Rankin Scale (MRS), Barthel index (BI), and Mini-Mental State Examination (MMSE). RESULTS: Site of aneurysm and ictus-surgery interval did not have any effect on any parameter at long-term follow-up. Majority of patients who were discharged continued to improve as measured by GOS, Modified Rankin Scale, and Barthel index. However a significant proportion of patients had impaired MMSE at long-term follow-up. Multivariate analysis showed a significant effect of age on MMSE and also a positive correlation between number of aneurysms and GOS. CONCLUSIONS: Most patients who survived and were discharged continued to improve in the postoperative period even though the immediate postoperative outcome was not favorable in many. However, a substantial subset had impaired cognitive function.

Pituitary dysfunction in survivors of spontaneous subarachnoid hemorrhage of anterior communicating artery and middle cerebral artery aneurysms: A comparative study.

BACKGROUND: The data on incidence of hypopituitarism after SAH are conflicting. Furthermore, it is still not known whether there is any difference in hormonal deficiencies between SAH due to anterior communicating artery (A-com) and middle cerebral artery (MCA) aneurysms. MATERIALS AND METHODS: This study includes both retrospective and prospective arms. The data collected included baseline demographic profile, clinical severity on admission to the hospital by the Hunt and Hess grading system and World Federation of Neurological Surgeons (WFNS) grading, radiological severity of bleed by the Fisher's classification, and treatment details. All the patients underwent detailed hormonal evaluation at baseline and 6 months in prospective group while at the end of 1 year in the retrospective group. Hormonal deficiencies between patients with A-com and MCA aneurysmal SAH were compared using appropriate statistical tests. RESULTS: Of 60 patients studied, 47 patients (A-com: 28 and MCA: 19) were in the retrospective group, while 13 patients (A-com-9, MCA-4) were in the prospective group. The baseline data were comparable between the two groups. At or after 6 months follow-up, 19 (31.6%) patients, 10 patients with A-com and 9 patients with MCA aneurysmal SAH, had some form of hormone deficiency. Furthermore, there was no difference in endocrine dysfunctions between the two groups. There was no correlation between the severity of hormonal deficiency and the clinical severity of SAH grade by Hunt and Hess and radiological grade of SAH by Fisher's grade. CONCLUSION: Hormonal deficiencies are not uncommon in patients with SAH. There is no difference in hormonal deficiencies and severity of hypopituitarism in patients with SAH due to A-com and MCA bleed.

Ruptured posterior cerebral artery aneurysm in association with neurofibromatosis type 2--a case report.

Intracranial aneurysms have been described in patients with Neurofibromatosis (NF)- 1, but not with NF-2 apart from one instance of a middle meningeal artery aneurysm (Louis DN, Ramesh V, Gusella JF. Neuropathology and molecular genetics of neurofibromatosis 2 and related tumors. We report a case of NF-2 and ruptured posterior cerebral artery aneurysm.

Dynamics of hearing status in closed head injury.

Hearing impairment can be one of the more subtle deficits seen after closed head injury (CHI), and it may not be diagnosed until late in the recovery phase if at all. Most studies have assessed patients immediately after CHI. Repeated assessments at regular intervals were not performed in the majority of studies done to assess whether any initial hearing loss regressed or progressed. Follow-up at later stages will shed more light on the audiological consequences of CHI. The aim of this study was to analyze the long-term audiological consequences of CHI. A total of 290 subjects with CHI were chosen and followed-up at 3, 6, and 12 months. The audiological test battery comprised pure tone audiometry (PTA), speech audiometry, tympanometry, auditory brainstem response (ABR), and middle latency response (MLR), and was administered to all subjects. The data from 96 subjects who completed all three follow-ups were analyzed for tympanometry, ABR, and MLR. However, for PTA and speech audiometry, data from only 76 subjects were analyzed, as unconscious and disoriented subjects could not undergo these tests at initial testing. The results revealed that hearing status after CHI varies, and that at follow-up significant changes in hearing were seen. Hearing of low frequencies improved, due primarily to improvements in middle ear function. Significant changes in ABR latencies and MLR amplitudes were also observed. This reflects the unequal rates of recovery observed in the different parts of the central auditory nervous system.

Relationship between severity of traumatic brain injury (TBI) and extent of auditory dysfunction.

OBJECTIVE: To find out the relationship between severity of traumatic brain injury (TBI) and extent of auditory dysfunction. BACKGROUND: Most of the studies have taken the subjects with TBI as one group without taking into account the extent of head injury viz. mild, moderate and severe. Combining all the three groups has resulted in presenting an incomplete picture of auditory deficits following TBI. METHODS AND PROCEDURES: The sample population consisted of 290 subjects with TBI (study group) and 50 otologically normal subjects as controls. The subjects in the study group were further sub-divided into mild (n = 150), moderate (n = 100) and severe (n = 40) TBI. The audiological assessment consisted of pure tone audiometry, speech audiometry, tympanometry, acoustic reflex testing, auditory brainstem response and middle latency response audiometry. RESULTS AND CONCLUSIONS: An association was observed between the extent of auditory dysfunction and severity of TBI. This association was more pronounced for hearing status at high frequencies and ABR/MLR components. ABR Wave V absolute latency and I-V interpeak latency increased with severity of TBI. Amplitude of MLR wave Na and Pa decreased with increasing severity. It is suggested that subjects should be evaluated for hearing difficulties based on their severity of TBI.

Audiological deficits after closed head injury.

BACKGROUND: Damage to the peripheral auditory structures has long been recognized as a common component of head injury. It is estimated that a majority of patients with skull trauma have resultant hearing impairment. Damage to the peripheral and/or central auditory pathways can occur as a primary or secondary injury. Considering the high incidence of hearing loss, it was considered worthwhile to conduct an in-depth investigation by administering a comprehensive audiological test battery on head-injured patients. METHOD: The sample population consisted of 290 subjects with closed head injury (study group) and 50 subjects with otologically normal subjects (control group). The subjects in the study group were further divided into mild (n = 150), moderate (n = 100), and severe (n = 40) category on the basis of Glasgow Coma Scale score. The audiological assessment consisted of pure tone audiometry, speech audiometry, tympanometry, acoustic reflex testing, auditory brain stem response audiometry, and middle latency response audiometry. RESULTS AND CONCLUSIONS: It is concluded that there is higher prevalence of hearing impairment in the study group compared with control group. Majority of the patients who incur hearing loss after closed head injury have mild degree of hearing impairment. A significant difference between the study and control group observed on majority of the auditory brain stem response and middle latency response parameters studied.

Infected intraparenchymal dermoids: an underestimated entity.

Infection secondary to a dermal sinus most commonly occurs in the form of cutaneous, epidural, or subdural abscesses. Rarely, it can result in an intramedullary abscess as a result of a dermal sinus. This study presents a clinicoradiological profile of 19 cases harboring abscesses within the dermoids and highlights the importance of dermal sinus acting as a pathway for infections to enter the nervous system. Emergent exploration, pus drainage, and minimal abscess wall excision along with prolonged antibiotic administration remained the management of choice in all cases. Methicillin-sensitive Staphylococcus aureus was the commonest offending organism. In all, 7 patients recovered to normal neurological status, 5 showed no improvement, and 7 improved partially. Improvement in motor power was noted, albeit partially, but bladder functions failed to recover even at long-term follow-up. Even when such infective complications of dermal sinuses are rare, these are potentially serious and disabling.

Psychosocial, demographic, and treatment-seeking strategic behavior, including faith healing practices, among patients with epilepsy in northwest India.

The data on sociocultural, demographic, and psychosocial aspects and types of treatment strategies adopted by families of patients with epilepsy in northwestern India were collected by the interview schedule method from 400 patients (200 idiopathic and 200 symptomatic) at the outpatient department of the Neurology and Epilepsy Clinic of the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. Epilepsy was classified as idiopathic or symptomatic on the basis of clinical tests (EEG, CT scan, and MRI). It was observed that socioeconomic factors had no bearing on epilepsy in the present sample. Early onset, that is, before 20 years of age, reduced the chances of patients' finding a spouse among those who disclosed the disease information, thereby impacting the nuptial and fertility rates of patients with epilepsy. The present sample of patients was well informed about and sensitized to the efficacy of the modern system of medicine, as 80% of patients sought medical treatment on the very same day as or within a week of onset of seizures. The data were compatible with the framed hypothesis that well-being and safety of the patient would override the stigma burden factor, as 94% of the affected families made no attempt to hide the disease from their neighbors, friends, and colleagues, and teachers of the affected patients. Surprisingly, only 7.5% of the families admitted that they consulted a faith healer. Families did adopt some culturally prevalent methods to control involuntary movements during seizures. It can be concluded that trust in faith healers exists strongly as an undercurrent, but is not overtly admitted by the majority of patients. Some families concurrently visited modern hospitals and occult healers seeking a cure for the disease. The fear of having a child with epilepsy or other abnormalities discouraged married patients from becoming pregnant after developing epilepsy.

Neuroprotective effect of progesterone on acute phase changes induced by partial global cerebral ischaemia in mice.

The possible neuroprotective effect of progesterone, a steroid hormone, on acute phase changes in a mouse model of cerebral ischaemia induced by bilateral common carotid artery occlusion (BCAO) was studied. A total of 72 male mice were included in the study. The BCAO model was used to induce partial global cerebral ischaemia. Morphological assessment included measurement of infarct size and brain oedema. Post-ischaemic seizure susceptibility was assessed using a subconvulsive dose of pentylenetetrazole (30 mgkg(-1) i.p.). Biochemical estimations included tumour necrosis factor alpha (TNF-alpha) levels and enzyme parameters such as lipid peroxidation, superoxide dismutase, catalase and glutathione peroxidase, and protein estimation. BCAO induced a significant infarct size and oedema in the saline-treated control group, along with an increase in oxidative stress, indicated by increased lipid peroxidation and decreased levels of antioxidants such as superoxide dismutase, catalase and glutathione peroxidase. Progesterone (15 mgkg(-1) i.p.) administration showed a neuro-protective effect by significantly reducing the cerebral infarct size as compared with the control group. Post-ischaemic seizure susceptibility was also reduced as the number of positive responders decreased. Brain oedema subsided, but not significantly. Progesterone significantly reduced TNF-alpha levels compared with the ischaemia group. Progesterone improved levels of all the antioxidants, indicating activity against oxidative stress induced by BCAO. The results demonstrate the neuroprotective effect of progesterone against ischaemic insult, suggesting a role for the steroid as a neuroprotective agent.

Endonasal transsphenoidal pituitary surgery: is tumor volume a key factor in determining outcome?

PURPOSE: This study was conducted to evaluate the role of tumor volume in excision of pituitary adenomas. MATERIALS AND METHODS: A total of 20 patients with pituitary adenoma underwent surgical excision of the tumor by endonasal transsphenoidal approach. RESULTS: A preoperative tumor volume of more than 5 mL is associated with a 90.90% probability of residual tumor (P < .05, statistically significant). CONCLUSION: Tumor volume as a predicting factor for the surgical outcome is an evolving concept. Other factors determining the efficacy of tumor removal are parasellar and suprasellar extension.

Internal carotid artery bifurcation aneurysms: surgical experience.

Internal carotid artery (ICA) bifurcation aneurysms are relatively uncommon and frequently rupture at a younger age compared to other intracranial aneurysms. We have treated a total of 999 patients for intracranial aneurysms, of whom 89 (8.9%) had ICA bifurcation aneurysms, and 42 of the 89 patients were 30 years of age or younger. The present study analyzed the clinical records of 70 patients with ICA bifurcation aneurysms treated from mid 1997 to mid 2003. Multiple aneurysms were present in 15 patients. Digital subtraction angiography films were studied in 55 patients to identify vasospasm and aneurysm projection. The aneurysm projected superiorly in most of these patients (37/55, 67.3%). We preferred to minimize frontal lobe retraction, so widely opened the sylvian fissure to approach the ICA bifurcation and aneurysm neck. Elective temporary clipping was employed before the final dissection and permanent clip application. Vasospasm was present in 24 (43.6%) of 55 patients. Forty-eight (68.6%) of the 70 patients had good outcome, 14 (20%) had poor outcome, and eight (11.4%) died. Patients with ICA bifurcation aneurysms tend to bleed at a much younger age compared to those with other intracranial aneurysms. Wide opening of the sylvian fissure and elective temporary clipping of the ICA reduces the risk of intraoperative rupture and perforator injury. Mortality was mainly due to poor clinical grade and intraoperative premature aneurysm rupture.

Tuberculosis of the craniovertebral junction: is surgery necessary?

OBJECTIVE: Tuberculosis of the craniovertebral junction is an uncommon entity and its optimal management remains controversial. In this study, we present the evolution of management protocol of this disease in our institute in the past 3 decades. METHODS: A total of 51 patients with craniovertebral junction tuberculosis presenting as atlantoaxial dislocation from 1978 through 2004 were reviewed. The disease was rated from Stage I to Stage III, depending on the radiological findings. All patients received antitubercular treatment for 18 months. In the initial period of this study (1978-1986), all patients (n = 10) underwent surgery, usually a posterior fusion. In the second period (1987-1998), patients with less severe disease (Stages I and II, n = 14) were managed with external rigid immobilization, whereas patients with severe disease (Stage III, n = 11) underwent either a transoral decompression with or without posterior fusion or posterior fusion alone. More recently (1999-2004), all patients (n = 16) in all stages (Stages I-III) have been managed without surgery by a rigid external immobilization. RESULTS: Except for two patients who died (one because of miliary tuberculosis, the other because of acute hydrocephalus), clinical recovery occurred in all. Follow-up imaging demonstrated radiological healing as well, with regrowth of the destroyed bone. CONCLUSION: The mainstay of management of tuberculosis of the craniovertebral junction is prolonged antitubercular treatment with a rigid external immobilization. Surgery is not necessary, even in patients with advanced stages of disease. Complete clinical and radiological healing occurs in all patients with conservative treatment.

Diagnosis and prognostication of adult spinal cord injury without radiographic abnormality using magnetic resonance imaging: analysis of 40 patients.

BACKGROUND: Spinal cord injury without radiographic abnormality (SCIWORA) is not uncommon among middle-aged and elderly people. It is less reported in adults as compared with children. This study was undertaken to find the incidence, magnetic resonance imaging (MRI) changes, and outcome of SCIWORA in adults and to demonstrate the prognostic value of MRI in SCIWORA. MATERIALS AND METHODS: Forty adult patients who sustained SCIWORA for a period of 2 years (January 1999 to December 2000) were admitted to our hospital. Methylprednisolone was given in therapeutic doses, for a period of 24 hours, to those arriving within 6 hours of injury. Magnetic resonance imaging was performed within 72 hours of admission to the hospital. In all patients, sagittal, axial, and coronal T1, spin, and T2 images of MRI were obtained. Clinical status of the patient at the time of admission and discharge was correlated with MRI. RESULTS: Four patients (10%), who were in Frankel grade D, with no demonstrable injury on MRI, improved to Frankel grade E at the time of discharge. Two patients (5%) with cord edema and extraneural injury improved to a useful neurological grade (Frankel grades D or E), whereas 13 patients (32.5%) with MRI features of cord contusion and hemorrhage did not achieve useful neurological function. CONCLUSION: Spinal cord injury without radiographic abnormality contributes 12% of cases of spinal cord injury. Magnetic resonance imaging is the investigation of choice, having diagnostic and prognostic value because it demonstrates neural and extraneural injuries and helps to pick up surgically correctable abnormality. Patients with minimal cord changes on MRI have the best outcome followed by those with cord edema. Patients with parenchymatous hemorrhage and contusion on MRI fare badly.