Cisternostomy - As An Adjuvant Or Standalone Approach For Management Of Traumatic Brain Injury: A Systematic Review And Network Meta-Analysis.

BACKGROUND: Traumatic brain injury (TBI) is a leading cause of morbidity in all age groups worldwide. Decompressive craniectomy (DC) is a salvage procedure in patients with TBI. Outcome and quality of life following DC is questionable. Basal cisternostomy (BC) has been proposed to reduce edema and leads to brain relaxation. It was initially used as an adjunct in TBI patients, thereby improving outcome. With gaining popularity among the neurosurgeons, BC was used as a standalone approach in TBI patients. The aim of this network meta-analysis is to analyse the role of BC either as an adjunct or as a standalone approach in managing TBI patients. METHODS: A comprehensive search of electronic databases (PubMed and SCOPUS) was performed using the search strategy using the field terms and medical subheading terms (MeSH Terms) to retrieve studies describing the role of BC in patients with TBI either as an adjunct with DC or standalone treatment and their outcome. RESULTS: Thirty-one articles were selected for full text review and eighteen articles were selected for the final analysis. BC alone group were found to have minimum in-hospital mortality (odds ratio [OR], 0.348; 95% credible interval [CrI], 0.254 to 0.477) followed by DC combined with BC group (OR, 0.645; 95% CrI, 0.476 to 0.875). DC combined with BC group were found to have minimum duration of mechanical ventilation (OR, 0.114; 95% CrI, 0.005 to 2.451) followed by BC alone group (OR, 0.604; 95% CrI, 0.024 to 15.346). DC combined with BC group were found to have maximum Glasgow outcome scale (GOS) (OR, 1.661; 95% CrI, 0.907 to 3.041) followed by BC alone group (OR, 1.553; 95% CrI, 0.907 to 3.041). CONCLUSION: Our analysis showed that BC alone was associated with lower in-hospital mortality rates in TBI patients. DC with BC had decreased requirement of mechanical ventilation. However, larger multicentric studies from other parts of the world are required to confirm these findings.

Supratentorial extra-ventricular ependymoma as a mass lesion in a child: report and literature review.

Supratentorial extra-ventricular ependymoma (SEE) are extremely rare in pediatric population and have varied presentation based on size, location, epicentre and compression on neurovascular structure. The authors report a 7-year-old girl presenting with seizure, who had a lobar SEE on MRI scan, successfully treated by microsurgical resection and adjuvant therapy.

Dorsal bony spur in pediatric split cord malformations: eight-year experience from a tertiary care hospital.

INTRODUCTION: Dorsal spurs in Type I split cord malformations (SCM-I) are infrequent findings. The pathogenesis of the same is debatable. The objective of this study is to analyze our experience with SCM-I patients having dorsal bony spurs. METHODOLOGY: Retrospective analysis of SCM patients operated from 2010 to 2017 was performed. Their demographic profile, clinic-radiological features, operative findings, and outcome following surgery were recorded. RESULTS: Twenty-four cases of Type I SCM harboring dorsal bony spurs were identified with mean age of 4.96 years. The commonest split site was lumbar, documented in 62.5%. Scoliosis was observed in 58.3%. Pre-operative neurological deficits were seen in 66.6% cases with asymmetric weakness of limbs seen in 16.6%. There was no new neurological deficit observed post-operatively. CONCLUSIONS: This is the largest series of dorsal spurs occurring in SCM, reported in literature so far. Meticulous pre-operative evaluation and imaging are important to identify dorsal spurs for appropriate management and good clinical outcome. Differentiating dorsal spur from ventral spur is important as it has a bearing on surgical approach.

O-Arm Assisted Anterior Odontoid Screw Fixation in Type II and Rostral Type III Odontoid Fractures: Single Center Surgical Series of 50 Patients.

Background: Accuracy of screw placement is one of the important factors necessary for adequate union in odontoid fractures with malposition rates as high as 27.2% with standard techniques. Objective: To evaluate efficacy of intraoperative O-arm assistance in improving accuracy of anterior odontoid screw placement and clinco-radiological outcome in type II and III odontoid fractures. Material and Methods: In this retrospective study, surgery consisted of anterior odontoid screw fixation under intraoperative O-arm assistance over 5 years. Demographical, clinical, radiological, operative details and postoperative events were retrieved from hospital database and evaluated for fusion and surgical outcome. Results: 50 patients (Mean age 34.6 years, SD 14.10, range: 7-70 years; 44 males and 6 females) with Type II and Type III odontoid fracture underwent O-arm assisted anterior screw placement. The mean interval between injury and surgery was 12 days (range 1-65 days). Mean operating time was 132.2 min ± SD 33.56 with average blood loss of 93 ml. ±SD 61.46. With our technique, accurate screw placement was achieved in 100% patients. At the mean follow-up of 26.4 month (SD13.75), overall acceptable fusion rate was 97.8% with non-union in 2.2% patients. Morbidity occurred in two patients; one patient developed fixation failure while other patient had nonunion which was managed with posterior C1-C2 arthrodesis. We had surgical mortality in one patient due to SAH. So overall our procedure was successful in 94% patients and among patients whose follow-up was available, acceptable fusion rates of 97.8% were achieved. Conclusion: We conclude that use of intraoperative three-dimensional imaging using O-arm for anterior odontoid screw fixation improves accuracy and leads to improved radiological and clinical outcomes. It further enables us to extend the indications of odontoid screw fixation to selected complex Type II and rostral Type III odontoid fractures.

Anterior Odontoid Screw Fixation for Pediatric and Adolescent Odontoid Fractures: Single-Center Experience Over a Decade.

OBJECTIVE: Management of pediatric odontoid fractures is tricky and controversial. This study will enrich world literature with intricacies of anterior odontoid screw (OS) fixation in the pediatric population learned over the last decade. METHODS: In this retrospective study, all patients with pediatric odontoid fracture who underwent anterior odontoid screw fixation from January 2010 to December 2019 were included and evaluated for surgical outcome. RESULTS: Thirteen patients were included in this study (mean age, 15 years; range, 6-18 years; male/female, 11:2; type II, 10; type IIA, 1; type III, 2). Common causes of injury were motor vehicle accidents (61.5%) followed by fall from height (38.5%) and all were acute fractures (2-30 days). Five patients had neurologic deficits. Accurate placement of screw was achieved in 92.3% of patients, including all 9 patients who used intraoperative O-arm. K wire migration during bicortical drilling resulted in neurovascular injury, with 1 mortality (7.7%). The remaining 12 patients were available for follow-up (mean, 36 months; range, 20-72 months) and all had preservation of neck movements. Successful OS fixation was achieved in 84.6% of patients, including 1 patient (7.7%) who had a fibrous union. One patient (8.3%) had nonunion because of migration of the screw head in the C2 body. CONCLUSIONS: Anterior odontoid screw fixation in the pediatric population provides good functional outcomes with instant fixation by direct osteosynthesis. However, the surgeon should be meticulous in the surgical approach and should achieve a lag effect. The surgeon should stop after engaging the outer cortex of the odontoid peg with K wire to avoid cranial migration. Intraoperative O-arm guidance is useful.

External Occipital Protuberance Projecting as Downward Curved Horn Presenting with Intractable Occipital Pain: Report of a First Case.

External occipital protuberance is normal anatomical entity, rarely it may show hyperostosis and may get prominent and causing pain and examination reveals presence of tender bony swelling. However, such occurrence is extremely uncommon.

Persistent Enlarged Occipital Sinus with Absent Unilateral Transverse Sinus.

The occipital sinus may occasionally remain patent, but the incidence is extremely low and observed in less than 10% of cases. A persistent patent occipital sinus (POS) may be associated with other venous sinus abnormality. The absence of transverse sinus in association with POS is an extremely rare condition and not reported yet. The neuroradiologist, neurosurgeons, otolaryngologist, and neurologist must be aware of the possible existence of POS and other associated venous sinus anomaly, as its warrants very crucial modification of surgical planning, selection of appropriate approaches, and, additionally, may also critically limit the extent of surgical exposure of target, and may hinder intended extent of surgical excision of tumor and associated possibility of injury to POS, which may produce catastrophic hemorrhage, brain swelling, and neurosurgical morbidity. The authors report a 35-year-old male who underwent suboccipital craniotomy for right-side giant acoustic schwannoma. Following the raising bone flap, a markedly prominent, turgid, occipital sinus was observed, not placed exactly in the midline but deviated to the right side, causing further restraining of dural opening. Surgical nuances and intraoperative difficulty encountered along with pertinent literature is reviewed briefly.

Management and Outcome Analysis of Conus and Filum ependymoma: A Tertiary Center Study.

BACKGROUND: Spinal ependymomas constitute approximately 2%-8% of primary adult central nervous system tumors. Authors analyzed demographic, clinical, radiological, surgical, and histopathological factors which correlated with the postoperative neurological outcome of patients who underwent surgery for conus and filum ependymoma (CFE). MATERIALS AND METHODS: A retrospective analysis of 31 patients regarding clinical feature, imaging study, surgical management, and McCormick grading system for assessing functional neurological status was carried out, who underwent surgical management for CFE between January 2009 and April 2014. Final neurological outcome at follow-up period was correlated with various factors in search to find out probable prognostic factors affecting final neurological outcome following surgical management. RESULTS: The myxopapillary ependymoma was observed in 55% of cases (n = 17), while 39% cases (n = 12) had Grade II ependymoma and rest 6% (n = 2) cases had anaplastic ependymomas. The mean age was 30 years (range 7-60 years) with male to female ratio of 1:0.82. Patients predominantly presented with pain (80.65%); mean duration of symptoms was 28.61 months. Only, the preoperative McCormick grade was found to be the statistically significant prognostic factor (P = 0.045), affecting neurological outcome however, the age, sex, duration of symptoms, location of the tumor, extent of the tumor, extradural spread, degree of surgical excision, vascularity of tumor, and histopathological World Health Organization grades were not found to be significant prognostic factors in the current study. CONCLUSION: The preoperative McCormick score was found to be the only statistically significant factor predicting the functional and neurological outcome after surgery, so surgical treatment should be offered early in the course of the disease to provide chance of preservation and good neurological recovery.

Adult Achondroplasia Patient with Extensive Long Segment Severe C1 to C6 Segment Spinal Canal Stenosis: Unique Presentation.

Achondroplasia represents the common variety of skeletal dysplasia causing short-limb dwarfism. It may be associated with congenial craniovertebral junction anomaly, including atlantoaxial dislocation, Os odointoideum or basilar invagination or acquired as a result of the previous foramen magnum region surgery. However, long segment cervical compression from the first cervical vertebra region to sixth cervical region, such extensive compression producing myelopathy is not reported, and current case represents first case in the western literature. He was managed surgically with a good outcome. Perioperative management along with brief review of pertinent literature along with the management of such case is discussed in brief. Anesthetic management of such patient with coexisting extensive cervical compression presents unique challenges in view of the multisystem involvement along with preexisting anatomical and physiological constraints.

Neurogenic Fever in Severe Traumatic Brain Injury Treated with Propranolol: A Case Report.

The causes of intractable fever in severe traumatic brain injury (TBI) patients can be diverse. Neurogenic fever (NF) which is a rare entity can develop due to autonomic dysregulation in the absence of infection or any other cause of fever. It manifests as fever, tachycardia, paroxysmal hypertension, dilated pupils, tachypnea, and extensor posturing in cases of severe TBI, brain neoplasms or brain haemorrhage. We found propranolol to be effective in controlling many of the manifestations of neurogenic fever in our patients with severe TBI. Fever in severe TBI patients is not an uncommon phenomenon, but when intractable with negative fever workup, a central cause should be considered. Propranolol is deemed as one of the most efficacious drugs for managing NF due to dysautonomia. We want to apprise the readers about this entity and its treatment with beta-blockers.