An Analysis of Temporal Trend of Incidence of Post-Resection Cerebrospinal Fluid Diversion in Pediatric Posterior Fossa Tumor Patients and the Predictive Factors.

Objective: We aim to find the temporal trend of incidence of post-resection cerebrospinal fluid (CSF) diversion (ventriculoperitoneal [VP] shunt/endoscopic third ventriculostomy [ETV]) in pediatric posterior fossa tumor (pPFT) patients with no pre-resection CSF diversion and the possible clinical predictors. Methods: We reviewed 108 operated children (age ≤16 years) with PFTs, from 2012 to 2020, at a tertiary care center. Patients with preoperative CSF diversion (n = 42), lesions within cerebellopontine cistern (n = 8), and those lost to follow-up (n = 4) were excluded. Life table, Kaplan-Meier curve, univariate and multivariate analyses were used to determine CSF-diversion-free survival and independent predictive factors, with significance defined as P < 0.05. Results: The median (IQR) age was 9 (7) years (M: F: 2.5:1). Mean (±SD) duration of follow-up was 32.43 ± 21.3 months. 38.9% of patients (n = 42) needed post-resection CSF diversion. Of these, 64.3% (n = 27) were done in early (≤ 30 days), 23.8% (n = 10) in intermediate (>30 days to ≤6 months), and 11.9% (n = 5) in late (≥6 months) postoperative period (P-value < 0.001). Preoperative papilledema (HR: -5.8, 95%CI: 1.7-5.8), periventricular lucency (PVL) (HR: 6.2, 95%CI: 2.3-16.6), and wound complication (HR: 3.8, 95%CI: 1.7-8.3) were found on univariate analysis as significant risk factors for early post-resection CSF diversion. On multivariate analysis, PVL on preoperative imaging (HR: -4.2, 95%CI: 1.2-14.7, P = 0.02) was identified as an independent predictor. Preoperative ventriculomegaly, raised intracranial pressure and intraoperative visualization of CSF egress from the aqueduct were not found to be significant factors. Conclusion: Significantly high incidence of post-resection CSF diversion in pPFTs occurs in early (≤30 days) postoperative period, with preoperative papilledema, PVL, and wound complication being its significant predictive factors. Postoperative inflammation, causing edema and adhesion formation can be one of the important factors for post-resection hydrocephalus in pPFTs.

Endoscopic intradural extramedullary lesion excision: Results of augmented duroplasty with artificial dura.

Objectives: Prevailing techniques of dural closure in endoscopic spine surgery (ESS) for intradural extramedullary (IDEM) tumor excision increase the steep learning curve and operative time. We aimed to assess the efficacy of augmented duroplasty with artificial dura and share our initial experience of ESS for IDEM excision. Materials and Methods: We retrospectively analyzed 18 (n = 18) consecutive patients of IDEM tumors operated by ESS using Destandau's endoscopic system. The pre-operative, post-operative, and at the latest follow-up clinical status were recorded in terms of Nurick's grades and the Oswestry Disability Index. Immediate post-operative complications and intraoperative findings were noted from hospital information system and patient records. Results: The mean (± SD) age of patients was 40.3 ± 14.9 (range 19-64) years, with M: F ratio of 2:1. All the lesions were intradural and present at lumber (n = 6), thoracic (n = 9), and cervical (n = 3) regions. The average duration of surgery, blood loss, hospital stay, and duration of follow-up were 157 ± 45.3 (90-240) min, 168.8 ± 78.8 (30-300) mL, 4.29 ± 1.4 (2-7) days, and 19.3 ± 7.2 (7-36) months, respectively. There were no CSF leaks, wound-related complications, or material-induced adverse events. Conclusion: In endoscopic IDEM excision, dural closure with artificial dura is efficient in preventing CSF leak. It shortens the steep learning curve and improves the surgical outcome due to technical ease.

The current status and surgical outcome of the minimally invasive techniques for lumbar interbody fusion in India: A systematic review and meta-analysis.

Objective: The global shift of trends to minimally invasive spine (MIS) surgery for lumbar degenerative diseases has become prominent in India for few decades. We aimed to assess the current status of MIS techniques for lumbar interbody fusion and their surgical outcomes in the Indian population. Materials and Methods: A systematic review (following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines) was performed using PubMed and Google Scholar till November 2020. The primary (visual analog scale [VAS] and oswestry disability index [ODI] scores; intraoperative blood loss; duration of surgery; duration of hospital stay, and fusion rate) and secondary (wound-associated complications and dural tear/cerebrospinal fluid (CSF) leak) outcomes were analyzed using Review Manager 5.4 software. Results: A total of 15 studies comprising a total of 1318 patients were included for analysis. The pooled mean of follow-up duration was 26.64 ± 8.43 months (range 5.7-36.5 months). Degenerative spondylolisthesis of Myerding grade I/II was the most common indication, followed by lytic listhesis, herniated prolapsed disc, and lumbar canal stenosis. The calculated pooled standard mean difference (SMD) suggested a significant decrease in postoperative ODI scores (SMD = 5.53, 95% confidence interval [CI] = 3.77-7.29; P < 0.01) and VAS scores (SMD = 6.50, 95% CI = 4.6-8.4; P < 0.01). The pooled mean blood loss, duration of postoperative hospital stay, duration of surgery, and fusion rate were 127.75 ± 52.79 mL, 4.78 ± 3.88 days, 178.59 ± 38.69 min, and 97.53% ± 2.69%, respectively. A total of 334 adverse events were recorded in 1318 patients, giving a complication rate of 25.34%. Conclusions: Minimally invasive transforaminal lumbar interbody fusion (TLIF) is the most common minimally invasive technique employed for lumbar interbody fusion in India, while oblique lumbar interbody fusion is in the initial stages. The surgical and outcome-related factors improved significantly after MIS LIF in the Indian population.

Quantitative assessment of brainstem distortion in vestibular schwannoma and its implication in occurrence of hydrocephalus.

PURPOSE: Anatomical distortion directly affects the clinical status of patients with vestibular schwannomas (VSs). It may vary for a given tumor size due to variability in posterior fossa anatomy. We aimed to quantitatively assess brainstem distortion (BSD) and review its role in occurrence of hydrocephalus associated with VSs. METHODS: Sixty-six patients with small (<3 cm, n= 8; 12.1%); large (3-4 cm; n= 26; 39.4%) and giant (>4 cm; n= 32; 48.5%) VSs were included. Cystic VSs were excluded. Tumor size, tumor-extent, linear displacement (LD; distance between line bisecting pons (line 1) and posterior fossa midline (line 2)) and angular distortion (AD; angle subtended between lines 1 and 2) in axial-T2-MRI section through pons, and their effect on hydrocephalus were assessed. RESULTS: Significant BSD occurred in a younger age (p value = .004/.003), larger-sized tumor (p value = .001/.002), hydrocephalus (p value = .001/.001), trigeminal (V) nerve palsy (p value = .004/.003) and long tract signs (p value = .001/.034). Tumors crossing midline had significant association with hydrocephalus (p value = .003). LD increased progressively even for 4-5 cm-sized tumors while AD stabilized. Receiver operating characteristic (ROC) curve revealed that diagnostic accuracy of LD (area under the ROC curve (AUROC): 78.9% (95% CI: 67.2%, 90.5%, p < .001)), AD (AUROC:77.6% (95% CI:65.8%, 89.5%, p < .001)) and LD × AD (AUROC:80.3% (95% CI: 69.2%, 91.2%, p < .001)) for predicting occurrence of hydrocephalus was better than tumor size (AUROC: 66.7% (95% CI: 53.5%, 79.9%, p < .05). Cut-off values of LD and AD for predicting occurrence of hydrocephalus were 6.25 mm and 14.6°, respectively. Hydrocephalus was significantly more when both LD was greater than  6.25 mm and AD was greater than 14.5° (p value = .034). The role of LD and AD in influencing hydrocephalus was greater than categorization based on tumor size (Spearman's correlation coefficient: 0.535 and 0.248, respectively). Hydrocephalus occurred at a lesser cut-off value of LD and AD when compared to long tract signs. CONCLUSIONS: LD and AD values in VSs have a significantly greater influence in the development of hydrocephalus compared to tumor size, and may aid, more reliably, in the prediction of hydrocephalus.

Seizure Outcome after Lesionectomy With or Without Concomitant Anteromedial Temporal Lobectomy for Low-Grade Gliomas of the Medial Temporal Lobe.

BACKGROUND: Mesial temporal lobe epilepsy attributed to low-grade glioma is known for intractable seizures and choice of surgery range from lesionectomy (Lo) to lesionectomy with anteromesial temporal resection (L0 + AMTR) is still debatable. We intend to analyze the seizure outcome after lesionectomy alone or with AMTR. SUBJECTS AND METHODS: Retrospective analyses of patients operated for medial low-grade temporal lobe tumors with seizures were included in the study. Preoperative records include video-electroencephalographic, magnetic resonance imaging (epilepsy protocol), and neuropsychological evaluation for language, memory, and dominance were assessed. Two groups (Lo [Group I] and Lo + AMTR [Group II]) were assessed after surgery by the international league against epilepsy (ILAE) seizure outcome scale. RESULTS: A total of 39 patients underwent Lo (n = 20) and Lo + AMTR (n = 19) with a mean age of 26.92 ± 12.96 months, and mean duration of seizures was 36.87 46.76 months. A total of 23 patients had long-term intractable seizures for >1 year despite >2 drugs(Group I [n = 10], Group II [n = 13]); remaining 16 had frequent seizures of <1-year duration. In the postoperative period, on a mean follow-up of 49.72 ± 34.10 months, the ILAE outcome scale shown a significant difference (P = 0.05) in seizure outcome between two groups. Four (40%) patients out of 10 having refractory seizures in Group I and 8 (80%) from the Group II out of 10 patients could achieved ILAE Class 1 outcome after surgery. Histopathology analysis includes low-grade astrocytoma (n = 29) and in two patients there were associated CA1 neuronal loss in hippocampus, one patient had mesial temporal sclerosis from Group II attributed to its intractability in seizures. CONCLUSION: For the mesial temporal low-grade glioma presenting with seizures, the seizure outcome by lesionectomy with AMTR is superior than lesionectomy only.

Lessons learned from surgical management of craniovertebral instability in Morquio syndrome: A series of four unusual cases.

Morquio syndrome (MS) is an autosomal recessive defect caused by the deficiency of N-acetylgalactosamine-6-sulfatase. Odontoid hypoplasia, periodontoid soft tissue deposition, and cervical stenosis lead to myelopathy and quadriparesis in these patients. Craniovertebral junction instability in MS possesses a surgical challenge as bones are yet to completely ossify. The atlantoaxial dislocation (AAD) is reducible, and the need of transoral decompression for the soft tissue deposition ventral to odontoid is debatable. We present a series of four cases (mean age 4.3 ± 0.4 years) operated through posterior-only approach (n = 2, C1-lateral mass to C2 pars-interarticularis [Goel's technique]; n = 1 sublaminar wiring followed by C1-lateral mass to C2 pars-interarticularis; and n = 1 suboccipital plate with pars-interarticularis of C2 screw and pedicle of C3 and rod fixation). All patients had acceptable outcome and doing well at the last follow-up (12-96-follow-up). None of our patient needed transoral decompression. Patients with MS frequently manifest with spastic quadriparesis at an early age due to reducible AAD. Early surgical fixation with posterior C1-C2 screw and rod technique is recommended for the favorable surgical outcome and long-term stability of the cervical spine.

Craniovertebral junction instability in Larsen syndrome: An institutional series and review of literature.

OBJECTIVE: Larsen syndrome (LS) is characterized by osteo-chondrodysplasia, multiple joint dislocations, and craniofacial abnormalities. Symptomatic myelopathy is attributed to C1-C2 instability and sub-axial cervical kyphosis. In this article, we have analyzed the surgical outcome after posterior fixation in LS with craniovertebral junction instability. METHODS: Ten symptomatic pediatric patients, operated between 2011 and 2019, were included, and the clinical outcome was assessed by Nurick grade, neurological improvement, and complications. The requirement of anti-spasticity drugs, the degree of bony fusion, and restriction of neck movement were also noted. At last follow-up, patient satisfaction score (PSS) and back to school status were studied. We also reviewed the literature and categorized two types of presentation of reported LS patients and discussed the pattern of disease progression among both. RESULTS: Ten patients, age range 1.5-16 years, underwent 12 surgeries (6 C1-C2 fixation, 4 long-segment posterior cervical fixation, and 2 trans-oral decompressions as the second stage); the mean follow-up was 23 (range, 6-86 months). All the ten patients in our study had the characteristic "dish-" like face and nine patients had acral anomalies. The median Nurick grade improved from preoperative (median = 4) to follow-up (median = 3). The requirement of anti-spasticity drugs decreased in seven patients and the neck-pain improved in nine patients. The median satisfaction at follow-up was good (median PSS = 2); five patients were going back to school. CONCLUSION: Craniovertebral junction instability in LS is rare and surgically challenging. Early posterior fixation showed a promising outcome with a halt in the disease progression.