Prognostication in cervical spondylotic myelopathy: Proposal for a new simple practical scoring system.

CONTEXT: The ability to preoperatively predict the outcome in cervical spondylotic myelopathy (CSM) helps in planning management and counseling the patient and family. AIMS: A simple prognostic scale, namely, the Madras Institute of Neurology Prognostic Scale (MINPS) for CSM has been proposed. SETTINGS AND DESIGN: Six well-known prognostic factors, namely, age, duration of symptoms, neurological disability (Nurick's grade), number of levels of compression, effective canal diameter, and intrinsic cord changes, have been taken into account. Each factor has been divided into three subgroups and allotted a score. The total score in this scale ranges from a maximum of 18 to a minimum of 6. MATERIALS AND METHODS: This scale has been evaluated in a group of 85 patients operated for CSM. STATISTICAL ANALYSIS USED: The usefulness of MINPS was statistically assessed using ANOVA test. RESULTS: It has been found that majority of patients with a score of 14 or more improved; those with a score of 9 or less deteriorated; those with a score between 10 and 13 remained static. CONCLUSIONS: The MINPS for CSM is a very practical scale which can be applied easily with the available clinical and radiological data, with good accuracy of outcome prediction. This is the first scale of its kind.

Cerebrospinal fluid dynamics study in communicating hydrocephalus.

CONTEXT: Communicating hydrocephalus often poses a challenge in diagnosis and management decisions. AIMS: The objective of this study is to measure the opening pressure (Po), pressure volume index (PVI), and cerebrospinal fluid outflow resistance (Rout), in patients with communicating hydrocephalus using bolus lumbar injection method and to evaluate its diagnostic and prognostic value. MATERIALS AND METHODS: The study was conducted in 50 patients with communicating hydrocephalus, including normal pressure hydrocephalus (NPH) (19), post-meningitic hydrocephalus (23) and post-traumatic hydrocephalus (8). An improvised bolus lumbar injection method [the Madras Institute of Neurology (MIN) method] was used. RESULTS: In the NPH Group, the CSF dynamics studies correlated well with the clinico-radiological classification. The prediction of shunt responsiveness by CSF dynamics studies correlated with good outcome in 87.5%. In the post-meningitic hydrocephalus group, the value of CSF dynamics studies in predicting patients needing shunt was 89.5%. The CSF dynamics studies detected patients who needed shunt earlier than clinical or radiological indications. In the post-traumatic hydrocephalus group, 62.5% of patients improved with the treatment based on CSF dynamics studies. CONCLUSIONS: The improvised bolus lumbar injection method (MIN method) is a very simple test with fairly reliable and reproducible results. Study of CSF dynamics is a valuable tool in communicating hydrocephalus for confirmation of diagnosis and predicting shunt responsiveness. This is the first time that the value of CSF dynamics has been studied in patients with post-meningitic hydrocephalus. It was also useful for early selection of cases for shunting and for identifying patients with atrophic ventriculomegaly, thereby avoiding unnecessary shunt.

Vertex epidural hematoma: An analysis of a large series.

CONTEXT: Vertex epidural hematoma (VEDH) is uncommon. A high index of suspicion is required to suspect and diagnose this condition, and the surgical management is a challenge to neurosurgeons. There are only isolated case reports or small series of VEDH in the literature. AIMS: We have tried to analyze a large series of VEDH seen in our institute. SETTINGS AND DESIGN: Retrospective observational study. SUBJECTS AND METHODS: This is an analysis of case records of patients with VEDH during 17 years period from 1995 to 2012. STATISTICAL ANALYSIS USED: Nil. RESULTS: Twenty nine cases of VEDH encountered over a period of 17 years have been analyzed, including 26 males and 3 females. Majority were due to road accidents. Headache, papilledema and lower limb weakness have been the major presenting features in these cases. The diagnosis was by direct coronal computerized tomography (CT) scan in most of them. Majority were managed conservatively with observation and serial imaging. Four patients who had large VEDH with altered sensorium were managed surgically. The source of bleeding was mainly from superior sagittal sinus. CONCLUSIONS: VEDH has to be suspected when a patient presents with impact over the vertex and features of raised intracranial pressure. Direct coronal CT or magnetic resonance imaging is useful in the diagnosis. Surgery is required when the patient develops progressive deterioration in sensorium and/or with the hematoma volume more than 30 ml. The present series of 29 cases is the largest reported so far.

The Madras Institute of Neurology, Madras Medical College, Chennai.

The Madras Medical College and its affiliated Government General Hospital, Chennai, are among the oldest medical institutions in India. The Madras Institute of Neurology (MIN) was the second neurosciences department to be started in India. The MIN has trained several batches of illustrious neurologists and neurosurgeons. This article briefly traces the history of the MIN, its important milestones, and its current developments.

Holocord abscess in association with congenital dermal sinus.

Intramedullary spinal cord abscess in children is rare and holocord abscess is rarer. An 18-month-old girl presented with rapidly progressive paraplegia with fever for 2 months. The patient had complete flaccid paraplegia with absent sensation below D4 level. There was very small dermal sinus discharging pus in the lower lumbar region. Magnetic resonance imaging showed evidence of extensive multiloculated intramedullary abscess extending from D4 to L5 with cord edema upto cervical level. Laminotomy, excision of the dermal sinus and myelotomy, and evacuation of intramedullary abscess was performed. Escherichia coli and Pseudomonas were grown on culture. The child was treated with long-term parenteral antibiotics and started showing neurological improvement. Holocord abscess secondary to congenital dermal sinus is extremely rare and this is only the fourth report of such an instance.

An anatomical study of the neurovascular relationships at the trigeminal root entry zone.

We aimed to study the neurovascular relationships at the trigeminal root entry zone in the normal population to help determine the pathogenesis of trigeminal neuralgia. We studied 50 fresh cadavers asymptomatic for trigeminal neuralgia or other facial pain during life and examined the 100 trigeminal root entry zones (REZ) using either a transtentorial (34 cadavers) or an infratentorial approach (16 cadavers). A vascular relationship was seen in 39 REZ (39%). There was an arterial relationship in 34 REZ (superior cerebellar artery in 23, anterior inferior cerebellar artery in 7, and pontine branches of the basilar artery in 4). A venous relationship was seen in 5 REZ. There was vascular contact only in 28 REZ, displacement of the nerve in 7 and grooving of the nerve in 4. We concluded that a neurovascular relationship at the trigeminal root entry zone is not uncommon in an asymptomatic population. The incidence of a vascular relationship in the Indian population seems similar to that in other major series. Electron microscopic studies of the nerve at the site of vascular contact in normal and symptomatic populations may help determine the exact pathogenesis of trigeminal neuralgia.