A Comparative Analysis of Transcranial and Endoscopic Repair for Traumatic CSF Rhinorrhea.

BACKGROUND: Surgical treatment of anterior cranial base traumatic cerebrospinal fluid (CSF) rhinorrhea is challenging and is fraught with complications. Whether a person should be offered open craniotomy or endoscopic endonasal repair is a dilemma faced by most surgeons. This study is one of the few to directly compare the two forms of management. METHODS: Data were collected from two groups of 15 patients each who underwent transcranial CSF leak repair and endoscopic endonasal CSF leak repair in a tertiary care hospital over a 3-year period. Information including demographics, recurrence rates, complications, and hospital and intensive care unit (ICU) stay was recorded and analyzed. Outcome was assessed up to 6 months. RESULTS: Recurrence was seen in 9/30 patients, 6 in the transcranial group and 3 in the endoscopic group. Hospital stay was longer than 1 week in all the transcranially operated patients and only in 73% of the endoscopically operated patients (p = 0.439) although ICU stay was reduced in the endoscopic group (p = 0.066). Complications were more common with transcranial repair (seven of eight patients who underwent transcranial repair, p = 0.035) with anosmia being the most common (33.3%, p = 0.042). CONCLUSION: The transcranial open repair is a reasonable choice especially for leaks that occur through the frontal sinus and extend backward into the frontoethmoidal region. However, this approach has the drawbacks of greater number of complications, higher recurrence rate, and longer ICU and overall hospital stay. The endoscopic endonasal repair enjoys a lower morbidity profile although it may not be an adequate treatment for leaks that are placed far laterally in the frontal sinus.

Pituitary Apoplexy, Meningitis and Cerebral Infarction - A Perplexing Trifecta

Pituitary apoplexy (PA) is a clinical diagnosis comprising a sudden onset of headache, neurological deficits, endocrine disturbances, altered consciousness, visual loss, or ophthalmoplegia. However, clinically, the presentation of PA is extremely variable and occasionally fatal. While meningitis and cerebral infarcts are themselves serious diseases, they are rarely seen as manifestations of PA and are exceedingly rare when present together. We present the case of a 20-year-old male with a rapid progression of symptoms of meningitis, PA and stroke. The present article seeks to emphasize a rare manifestation of PA with an attempt to understand the intricacies of its evaluation and management.

Axial Plane Deformity of the Shoulder in Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Prospective observational study. OBJECTIVE: To study axial plane deformation of the shoulder in adolescent idiopathic scoliosis (AIS) and try to correlate it with curve type and surgical correction. SUMMARY OF BACKGROUND DATA: It is established that AIS is a 3-dimensional deformity. The rib hump is the most common manifestation of axial plane deformations; the least common manifestation seems to be upper trunk and shoulder rotation, which has been hitherto undescribed. METHODS: Fourteen consecutive, operated cases of AIS were analyzed prospectively. Preoperative and postoperative x-rays of the spine and clinical photographs were studied. Clinical photographs (top view) were taken with patients in the sitting position, to show shoulder level in relation to the axis of the head and pelvis. Chest computed tomography scans were also studied to determine the direction of apical vertebra and trunk torsion. RESULTS: All 14 patients in this series had their right shoulders anteriorly rotated preoperatively (anticlockwise). The direction of rotation seemed unrelated to the curve type and shoulder elevation, although most had rib humps on the right. This shoulder rotation was corrected postoperatively by routine maneuvers done for scoliosis correction. Minor residual rotation was seen in 6 patients who also had minimal persisting rib hump. In 1 case the axial plane rotation worsened, although the shoulder level and trunk symmetry improved significantly. The apical vertebral rotation on computed tomography had little bearing on the direction of shoulder rotation. CONCLUSIONS: Axial plane rotation of the shoulder is a hitherto un-described dimension of AIS deformity complex. Much of it corrects spontaneously with correction of the thoracic spinal deformity.

Post-operative shoulder imbalance in adolescent idiopathic scoliosis: a study of clinical photographs.

STUDY DESIGN: Retrospective observational study. OBJECTIVE: To assess what features determine post-operative shoulder asymmetry in Adolescent Idiopathic Scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Shoulder balance is one of the major determinants of the cosmetic outcomes of AIS surgery. Yet, other than level of the shoulders we are not clear what parameters are to be measured to assess torso symmetry. This study looks at the various features that might affect the appearance of the shoulder region. METHODS: The records of 157 operated cases of AIS were retrospectively reviewed. Eight patients with documented post-operative shoulder asymmetry and were dissatisfied with their cosmetic outcomes were selected for the study. Their clinical photographs alone were studied. Three regions- the base of the neck, the shoulder and upper arm region- were analysed separately. Four measures each for the neck and shoulder and two for the arms were documented. No statistical tools were employed since the numbers were quite small but consensus was obtained between two Consultant Orthopaedic surgeons regarding the cosmetic impact of each parameter. RESULTS: The neck and the shoulder appeared independent determinants of cosmesis of the proximal trunk. The base of neck symmetry seemed to be dependent on four features viz. centralization of the neck, neck tilt, trapezius angle and base of neck angle. The appearance of the shoulder itself depended on its level, axillary fold level, scapular level and the scapular prominence. The upper arm parameters appeared less critical in determining the cosmetic impact. CONCLUSIONS: Proximal trunk symmetry in AIS depends on the symmetry of the base of the neck and shoulder regions. The level of the shoulders, axillary folds along with the base of neck angle, Trapezius angle appear to be key determinants of symmetry.

Patterns of shoulder imbalance in adolescent idiopathic scoliosis: a retrospective observational study.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To study the relationship between the proximal spine and shoulder levels in adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: It has been frequently observed that the shoulder levels do not correspond to the spinal curve direction in AIS. MATERIALS AND METHODS: Eighty-five operated cases of AIS were analyzed retrospectively of which 69 were Lenke type I and II curves. Preoperative anteroposterior standing x-rays of the spine and clinical photographs were studied. T1 tilt and intercoracoid line (ICL) tilt and their mutual relationship were documented. The curve type (Lenke), magnitude, and direction of the proximal and main thoracic (PT and MT) curves were also noted. RESULTS: The shoulder level as depicted by the ICL showed 3 patterns-horizontal, left side elevated, or right side elevated. The T1-ICL relationship was either concordant or discordant. In the concordant case the T1 was tilted to the same side as the ICL; and vice versa in the discordant. The shoulder level was dependent on the MT curve if the ICL tilted to the same side as the MT curve and it was dependent on the PT curve if it tilted to the same side as the PT curve. This relationship appeared unrelated to curve type. CONCLUSIONS: Preoperative shoulder levels in AIS may be concordant with the T1 or discordant-each can have left or right shoulder elevation or balanced shoulders. Further, the shoulder might be MT dependent or PT dependent. Theoretically therefore, surgical balancing of the shoulder and upper instrumented vertebra placement should not depend only on the magnitude and stiffness of the PT curve.