Endoscopic Management of Chronic Subdural Hematoma Using a Novel Brain Retractor.

BACKGROUND: Endoscopic procedures are useful in chronic subdural hematoma especially when there are septations, solid/organized hematoma, and the presence of bridging or neovessels in the cavity. Visualizing the distal hematoma cavity by a rigid scope is challenging in large and curved ones due to the hindrance by the brain surface. Combining rigid endoscopy and brain retractor can overcome this limitation. METHODS: A retrospective study of 248 patients managed by endoscopic technique was performed and the relevant literature was reviewed. RESULTS: The brain retractor was used in all patients. Average operative time, subgaleal drainage duration, and hospital stay were 56 minutes, 3.1 days, and 4.6 days, respectively. The average preoperative Glasgow coma scale (GCS) score was 12, which improved to 14 and 15 in 223 and 23 patients, respectively at discharge. There were solid clots, septations, bridging vessels, curved hematoma cavities, rapid expansion of the brain after partial hematoma removal, and recurrences in 59, 52, 15, 49, 19, and 2 patients, respectively. There were 2 deaths, without any procedure-related mortality. CONCLUSIONS: Endoscope was very effective and safe in the management of chronic subdural hematoma, especially in about 51% patients with solid clots, septations, and bridging vessels which could have been difficult to treat by conventional burr hole. It can avoid craniotomy in such patients. Good visualization and complete hematoma removal were possible with the help of an endoscope and brain retractor in about 27% of patients which could have been difficult with a rigid endoscope alone.

A Model with Feedback Mechanism for Learning Hand-Eye Coordination: A Pilot Study.

BACKGROUND: Practicing neuroendoscopic skills like hand-eye coordination is mandatory before embarking on actual surgeries. Synthetic models are able alternatives for cadavers and animals. Presently available models in the literature are either very costly or lack a feedback mechanism, which makes training difficult. OBJECTIVE: We aimed to make a basic low-cost neuroendoscopic hand-eye coordination model with a feedback mechanism. METHODS AND MATERIALS: An electronic circuit in series was designed inside a clay utensil to test inadvertent contact of the working instrument with implanted steel pins, which on completion lighted a light-emitting diode (LED) and raised an alarm. Two exercises-moving-a-rubber exercise and passing copper rings of multiple sizes were made and tested by 15 neurosurgeons. RESULTS: The moving-a-rubber exercise was completed by 6/15 (40%) neurosurgeons in the first attempt, 6/15 (40%) in the second, and 3/15 (20%) in the third attempt. For the 1.5 cm copper ring passing exercise, 12/15 (80%) successfully performed in the first attempt; for 1 cm copper ring, 6/15 (40%) performed in the first; and for the 0.5 cm copper ring, 1/15 (6.6%) performed in the first attempt. The time to finish all the exercises significantly decreased in the third successful attempt compared to the first. CONCLUSION: The model gave excellent feedback to the trainee and examiner for basic neuroendoscopic hand-eye coordination skills.

Endoscopic posterior approach for cervical myelopathy and radiculopathy using tubular retractor. Our experience, surgical technique, and literature review.

BACKGROUND: Endoscopic posterior approach can effectively decompress cervical root and cord secondary to posterior compression. This publications is aimed to present our experience in 229 patients using tubular retractor and the relevant literature is reviewed. METHODS: Retrospective analysis of multilevel myelopathy and or radiculopathy was performed. Indications for posterior approach was primary posterior compressions at cord and or root. Combined compression from posterior side and mild to moderate anterior pressure with acceptable lordosis were also decompressed. Bilateral cord decompression and foraminotomy for radiculopathy was performed using tubular retractor. RESULT: There were myelopathy and radiculopathy in 220 and 9 patients respectively. A total of 53 foraminotomy procedures were performed in 36 patients. All patients showed improvement, with the mean preoperative Nurick grade decreasing from 2.72 ± 0.799 to 0.78 ± 0.911 after surgery. There was significant improvement in postoperative Nurick grades compared to preoperative grades (Z-value =13.306, P less than 0.0001). Operative results were better in patients with good preoperative Nurick grades (grades 1 and 2) compared to those with poorer grades (grades 3 and 4). Minor bleeding, small dural tear, and root injury was observed in 42, 4 and 8 patients respectively. CONCLUSION: Endoscopic approach was effective and safe for root and cord decompression. This study was limited by its single-center, retrospective design, exclusion of some eligible patients, a short postoperative Nurick grade assessment period of six months, and absence of a comprehensive long-term postoperative biomechanical assessment. To validate these results, a prospective multicenter study addressing these limitations is needed.

Lumboperitoneal Shunts - Patient Selection, Technique, and Complication Avoidance: An Experience of 426 Cases.

BACKGROUND: Lumboperitoneal shunt is a known procedure for communicating hydrocephalus. Being an extracranial procedure, it can also be utilized in normal-sized ventricles. OBJECTIVE: To report our experience of lumboperitoneal shunt done with a minimal follow-up of 12 months with an emphasis on patient selection, technique, and complication avoidance. METHODS: This was a retrospective analysis of patients who underwent LP shunt during October 2014-October 2019 at the authors' institute. Inclusion criteria were patients with communicating hydrocephalus due to tubercular meningitis, normal pressure hydrocephalus, idiopathic intracranial hypertension, and postoperative refractory cerebrospinal fluid leaks. Data were collected for demographics, Glasgow coma scale and Glasgow outcome scale, vision, gait, memory, urinary incontinence, failed attempts, and complications. RESULTS: A total of 426 patients underwent the LP shunt procedure. The commonest indication was tubercular meningitis followed by idiopathic intracranial hypertension and normal pressure hydrocephalus. Age ranged from 16 to 72 years. There were 255 male and 171 female patients. The mean follow-up was 41 ± 8 months. Overall, 301 patients (70.6%) had neurological improvement. Shunt-related complications occurred in 112 (26.29%) patients, of which shunt block was the commonest. Other complications were infection in 17 (3.9%) patients and extrusion in four (0.9%) patients. Transient postural headache was seen in 46 (10.7%) patients, which gradually improved. CONCLUSION: Lumboperitoneal shunt was found to be a safe and effective treatment in appropriately selected communicating hydrocephalus patients. A meticulous technique reduces the complication rate.