Instrumentation in cervical spine injury: neurological outcome measurement using ASIA impairment scale.

Cervical spinal cord injuries make up more than half of all spinal cord injuries. It affects 2-3% of all trauma patients and accounts for 8.2% of all trauma related deaths. Cervical spine surgery has been evolving in terms of surgical technique, equipment, and instrumentation. We have analyzed a series of patients with cervical spine injuries stabilized with various instrumentation techniques. The objective of the study was to evaluate the outcome of instrumentation in cervical spine injury measured on ASIA Impairment Scale. We present prospective observational descriptive analysis, for 36 patients, looking at the clinical and neurological outcomes following instrumentation for cervical spine injuries from Jun 2011 to July 2013. All 36 patients underwent various instrumentation techniques for stabilization and decompression of the cervical spinal cord. The outcome was compared by the ASIA impairment scale. There were 27 (75%) males and 9 (25%) females. The mean age at presentation was 46 years (17-74 years). The most common mode of injury was fall (62%), with ASIA grade C and D, 31% each. C5/6 level was the most common level (26.2%) of injury. The timing of surgery ranged between 8 - 270 days from injury. Out of thirty-six, thirty-two patients were available for follow-up. Eighteen of these patients had spinal cord injury and improved by at least one ASIA grade. It is concluded that instrumentation in cervical spine injury is an effective surgical procedure with minimal post-operative morbidity for the management of cervical injury, allowing an improved physiologic environment for maximal neurologic improvement. The post-operative outcome measured on ASIA impairment scale was comparable to international study.

Bilateral, mirror-imaged, postero-inferior cerebellar artery aneurysms: report of a rare case.

A 60-year-old right-handed lady presented with the features of subarachnoid haemorrhage. The CT angiogram showed a pair of very rare bilateral, mirror-imaged distal postero-inferior cerebellar artery aneurysms. Both aneurysms were clipped via the midline posterior fossa craniectomy under general anaesthesia. The literatures is reviewed on the incidence, presentation, management and outcome of bilateral distal posterior-inferior cerebellar artery aneurysms.

Unusual cause of severe knee pain.

MRI is the preferred modality to investigate seizure as diagnostic yield is higher and more specific due to its varied applications. Total of 160 brain MR images of patients suffering from seizure during one year period was evaluated. All seizure cases underwent specific protocol for imaging that targeted hippocampal/mesial temporal lobe imaging.

Analysis of the cholinergic pathology in the P301L tau transgenic pR5 model of tauopathy.

Cholinergic deafferentation of telencephalon is a major factor contributing to cognitive impairment in Alzheimer's disease. There is evidence that the degeneration of cholinergic fibers which innervate the cortex and hippocampus is due to the development of neurofibrillary tangles in the perikarya of origin. Neurofibrillary tangle formation has been modeled in the transgenic pR5 mouse strain that overexpresses the longest human tau isoform together with the P301L mutation that has been previously identified in familial cases of frontotemporal dementia and parkinsonism linked to chromosome 17 (FTDP-17). To test the suitability of the pR5 model as a model of Alzheimer's disease concerning the cholinergic innervation of the telencephalon, we determined the expression of the human tau transgene and the presence of neurofibrillary changes in the basal nucleus of Meynert, the septal nuclei and the diagonal band of Broca, sources of cholinergic innervation of the cerebral cortex and hippocampus. We found that the cholinergic neurons of these nuclei, despite widespread expression of the human tau transgene, neither expressed human tau nor displayed immunoreactivity with antibodies AT8 and AT180 which recognize hyperphosphorylated tau. Immunoreactivity for choline-acetyl transferase did not reveal significant differences between pR5 mice and non-transgenic littermates in the basal forebrain, cortex and hippocampus. However, in the amygdala dystrophic cholinergic neurites were observed which were not present in non-transgenic mice. Our data show that although pR5 mice develop neurofibrillary lesions, they do not model the degeneration of basal forebrain cholinergic neurons observed in Alzheimer's disease.

Frontal recurrence of medulloblastoma five years after excision and craniospinal irradiation.

Medulloblastomas were originally classified under gliomas of the cerebellum until Bailey and Cushing in 1925 named these tumors as medulloblastoma. At present these tumors are classified under primitive neuroectodermal tumor. Surgical excision followed by craniospinal irradiation is the treatment of choice. A 13-year-old-girl operated for posterior fossa medulloblastoma 5 years ago presented with history of headache and vomiting on and off for 4 days in late August 2008. The MRI showed left frontal tumor which on excision was reported as medulloblastoma. Even after optimal treatment reports of recurrence abound in literature. The most common location is in the posterior fossa, followed by spinal, supratentorial, and uncommonly, systemic metastases. We conclude that medulloblastomas are highly aggressive tumor with high local recurrences if the initial excision is incomplete and that recurrence in the supratentorial area although uncommon is still a possibility. This mandates regular follow up of these children till adulthood to catch early recurrences and metastatic disease.

Traumatic posterior fossa extradural haematoma.

Posterior fossa extradural haematoma is known for the vague signs and symptoms and a notorious course that varies from recovery to sudden death. The incidence of posterior fossa epidural hematomas among intracranial epidural hematomas has been reported from 4% to 7%. Subsequently, PFEDH with low GCS or the haematoma of more than 10 ml were subjected to evacuation. Since the volume of the posterior fossa is limited, patients deteriorate early with the development of obstructive hydrocephalus, which is visible in the CT scan in only thirty percent of cases. A retrospective study of 43 cases was done in this Institute from May 1999 to December 2005. The males (98%) have a clear predominance over female patients (2%). Road traffic accidents accounted for the majority of the cases (80%), fall for the rest (17%) and one case due to a bullhorn injury. Vomiting was the most common symptom accounting for 67% of cases followed by transient loss of consciousness in 48% and headache in 34%. On arrival to the hospital 67% presented with a GCS more than 13, 28% with score of 9-12 and the rest 5% with GCS of less than 8. Out of the total 43 cases of PFEDH surgical evacuation was done in 33(76%) and conservative management in 10 cases (23%). A dichotomised Glasgow outcome score was used to measure the outcome. This was favorable in 27 of the 33 cases operated (81%), and 7 out of the 10 conservatively managed group (70%). Overall favorable outcome was found in 34 cases (79%) with overall mortality of the study being 7%.

Cervical spondylosis in Nepalese porters.

Neck pain with or without radiculopathy and myelopathy is a very common problem in clinical practice. The incidence is believed to be higher in subgroups carrying load on their head. It has been reported in literature that radiographic spondylosis is appreciable in 25% to 50% of population by the age of 50 years and 75% to 85% by the age of 65 years. One hundred and nineteen lateral X-rays of cervical spine were analyzed as case-control study in patients between 40 and 50 years age with the objective of finding out proportion of cervical spondylosis in this age group and difference in the prevalence between porters and non-porters. Out of the 119 cases 54 (45.4.2%) were porters and 65 (54.6%) were non-porters. There were 98 (82.4%) males and 21 (17.6%) females. The overall prevalence of radiological cervical spondylosis was 69 (58%). The prevalence of cervical spondylosis was significantly lower (x2=14.795, p=0.0001) in porters in comparison to non-porters. The odds ratio was found to be 0.23 (0.10, 0.53) at 95% confidence interval indicating that portering significantly prohibited development of spondylosis. This study concludes that the overall prevalence of cervical spondylosis in the Nepalese population is slightly higher than in the Caucasian and contrary to other studies there is significantly lower prevalence of such degeneration among the Nepalese porters.

Role of repeat CT scan head in initially inoperable cases of traumatic head injury.

The CT scan has become popular in cases of head injury. In this study 71 cases (M:48; 68.0% and F:23; 32.0%) with traumatic head injury admitted and initially managed conservatively at National Neurosurgical Referral Centre, Bir hospital starting from May 2005 to April 2006. The most common cause of injury was road accidents (43 cases) with motorcycle and bus injuries as the leading causes. Nausea and vomiting were the most common symptom in 41 (57.0%) cases, followed by headache in 31 (43.0%). Contusions were the most common radiological findings in 84.0% followed by extradural haematoma in 8.0% and pneumocephalus in 7.0%. Out of these the most common location for contusion was frontal (16 cases), followed by parietal (12 cases) and then bilateral contusions. The mean volume was 12 ml, 9 ml and 9 ml for frontal, parietal and temporal contusions, respectively. Repeat scan showed increase in volume of contusion in 31 cases (44.0%), no change in 28 cases (40.0%) and decrease in 12 cases (16.0%). The increase was mainly due to edema in 20 cases (64.0%) and due to actual increase in contusion in only 11 cases (35.0%). Only 5 (7.0%) cases needed operative intervention. It is concluded that routine use of repeat scan in mild to moderate head injury has no role unless there is clinical deterioration.

Single burr hole drainage for chronic subdural haematoma.

Chronic subdural haematoma is a common neurosurgical condition and surprisingly surgical treatment ranges from twist drill craniostomy to more radical membranectomy. However, the outcome is generally favourable with appropriate therapy. This retrospective study is aimed at analyzing the result of single burr hole drainage of such haematoma under local anaesthesia over a period of fifteen years. There were a total of 365 patients ranging from 6 months to 89 years with the mean age of 60 years. Recurrence of haematoma was noted in 17 (4.6%) patients and majority of them (65.0%) were managed by aspiration through the previous burr hole. Favorable outcome was noted in 98.6% patients. Those with adverse outcome were in coma preoperatively. This study suggests that single burr hole drainage under local anaesthesia is sufficient in the majority of patients and outcome was favorable even in the elderly provided they presented before lapsing into coma.