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.

A Novel Brain Retractor for Endoscopic Evacuation of Chronic Subdural Hematoma.

Background: Endoscopic chronic subdural hematoma (CSDH) evacuation is a safe and effective alternative to the conventional burr hole technique. Although a rigid endoscope has the advantage of good visualization, there are risks of brain damage due to limited space to accommodate the scope and frequent lens soiling. Objective: This technical note describes a novel brain retractor to overcome the limitations of rigid endoscopy. Methods: The novel brain retractor (by senior author) was made by dividing a silicon tube longitudinally into two halves, and tapered for easy introduction in the operative cavity. Sutures were placed at the outer end of the retractor to prevent migration and to assist in angulation. Results: The novel retractor along with endoscopic assistance was used in 362 CSDH procedures. Endoscopy combined with this retractor provided additional help in complete removal of hematoma in organized/solid clots, septa, bridging vessels, and rapid expansion of brain in 83, 23, 21, and 24 patients, respectively (n = 151, 44%). Although there were three deaths (due to poor preoperative status), and two recurrences, there were no retractor-induced complications. Conclusions: The novel brain retractor assists endoscope in proper visualization of complete hematoma cavity by gentle and dynamic brain retraction, helps in thorough irrigation of hematoma cavity, protects the brain, and prevents lens soiling. It allows easy insertion of the endoscope and instruments using bimanual technique even in patients with a small width of hematoma cavity.

Rotational Occipital Scalp Flap for Occipital Pressure Ulcer.

Occipital pressure ulcers and wound gaping may occur in unconscious and malnourished patients. Most of the time, a large defect requires wound coverage by scalp flaps. This video describes a rotational occipital scalp flap for occipital pressure ulcer and wound gaping in a patient of operated midline posterior fossa mass & ventriculoperitoneal shunt. The defect measured 2.25 × 2.5 cm with exposed inion. The wound was included in an imaginary triangle, and the horizontal and vertical incision lengths were about four times the base of the triangle. The flap was based on the left occipital artery and raised in an avascular plane above the periosteum. The wound margins were freshened and undermined. The flap was rotated to bring it over the defect, and suturing was done in the standard manner. The flap had good healing, and the patient continued to be under care for his cerebellar medulloblastoma.

A new minimally invasive tubular brain retractor system for surgery of deep intracerebral hematoma.

Access to deep-seated brain lesions with traditional fixed and rigid brain retractors can be difficult without causing significant trauma to the surrounding brain. Tubular retractors offer an advantage of low retracting pressure. We developed a new inexpensive and simple tubular retractor which requires very small cortisectomy. The new tubular retractor was made up of silicone with inner diameter of 15, 18 and 23 mm and outer diameter of 17, 20 and 25 mm, respectively. This tube (1 mm thick) was cut in longitudinal direction. It was folded to make a small-diameter tube so that it could be introduced through a small cortisectomy. Margins of cortisectomy were gently and slowly retracted by Killian nasal speculum. Folded retractor, held by tissue forceps, was introduced inside the opened Killian nasal speculum. Tissue forceps and nasal speculum were removed leaving tubular retractor in place, which comes back to its normal tubular configuration after release. Surgery was performed using rigid Karl Storz 0° telescope (30 cm long and 4 mm in diameter) or microscope. Near-total removals of intracerebral hematomas, 37 hypertensive and 3 traumatic, was done using this retractor without any complication.

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.

Lumbar peritoneal shunt.

A lumbar peritoneal (LP) shunt is a technique of cerebrospinal fluid (CSF) diversion from the lumbar thecal sac to the peritoneal cavity. It is indicated under a large number of conditions such as communicating hydrocephalus, idiopathic intracranial hypertension, normal pressure hydrocephalus, spinal and cranial CSF leaks, pseudomeningoceles, slit ventricle syndrome, growing skull fractures which are difficult to treat by conventional methods (when dural defect extends deep in the cranial base or across venous sinuses and in recurrent cases after conventional surgery), raised intracranial pressure following chronic meningitis, persistent bulging of craniotomy site after operations for intracranial tumors or head trauma, syringomyelia and failed endoscopic third ventriculostomy with a patent stoma. In spite of the large number of indications of this shunt and being reasonably good, safe, and effective, very few reports about the LP shunt exist in the literature. This procedure did not get its due importance due to some initial negative reports. This review article is based on search on Google and PubMed. This article is aimed to review indications, complications, results, and comparison of the LP shunt with the commonly practiced ventriculoperitoneal (VP) shunt. Shunt blocks, infections, CSF leaks, overdrainage and acquired Chiari malformation (ACM) are some of the complications of the LP shunt. Early diagnosis of overdrainage complications and ACM as well as timely appropriate treatment especially by programmable shunts could decrease morbidity. Majority of recent reports suggest that a LP shunt is a better alternative to the VP shunt in communicating hydrocephalus. It has an advantage over the VP shunt of being completely extracranial and can be used under conditions other than hydrocephalus when the ventricles are normal sized or chinked. More publications are required to establish its usefulness in the treatment of wide variety of indications.

Endoscopic Anterior Cervical Discectomy (Disc Preserving).

BACKGROUND AND INTRODUCTION: Endoscopic anterior cervical approach has several advantages compared to conventional anterior cervical discectomy and fusion (ACDF). OBJECTIVE: This video demonstrates a step-by-step procedure for endoscopic anterior cervical discectomy. PROCEDURE: The patient is placed supine with the neck extended. A standard anterior cervical approach using about 3 cm skin incision is made and under "Easy Go" (Karl Storz, Tuttlingen, Germany) endoscopic vision, the uncinate process and uncus are drilled. Only a small portion of the normal disc, posterior longitudinal ligament (PLL), and compressing disc is removed. The closure is done in a standard manner. RESULTS: In 240 patients, the average postoperative reduction in disc height, operating time, and blood loss were 1.1 ± 0.2 mm, 110 ± 17 min, and 30 ± 11 mL, respectively. The average postoperative VAS score and Nurick grading improved significantly. There were no permanent complications or any mortality. CONCLUSION: Endoscopic technique is an effective and safe alternative to ACDF after attaining the learning curve.

Endoscopic single stage trans-oral decompression and anterior C1 lateral mass and C2 pedicle stabilization for atlanto-axial dislocation.

Although most of the cases of atlanto-axial dislocation (AAD) and basilar invasion can be managed by posterior approaches in the recent times, anterior decompression with stabilization is required in selected patients who persist with irreducible AAD even after manipulation of the C1-C2 facet joint under general anesthesia. A single stage endoscopic trans-oral decompression and stabilization can be used in such patients. It has not been described so far to the best of authors' knowledge. This is indicated in irreducible AAD with the mandibular angle lying below the C2-C3 disc space. It is not a proper choice when the mandibular angle is above the C2-C3 disc space, there is involvement of the facet joint by trauma or any other pathologies, and if a posterior compression at the cervicomedullary junction persists. All patients should undergo pre-operative radiographs, computed tomography (CT) scan and magnetic resonance imaging with angiogram of the cranio-vertebral region. Utilizing this technique, an intra-operative satisfactory reduction of the dislocation with C1-C2 stabilization could be achieved in 3 patients, and 7 required an additional odontoid excision. Post- operative plain radiographs should be performed to assess for C1- C2 alignment and fusion at 3 and 12 months after surgery. All 10 patients of our series had an irreducible AAD and two had an additional basilar invasion. All patients improved from the pre-operative Ranawat grade 3A (n = 8) and 3B (n = 2) to post-operative grade 1 (n = 9) and 2 (n = 1) at a 3-12- month follow-up assessment. The average duration of the procedure and blood loss was 145 minutes and 75 ml, respectively. Endoscopic trans-oral single stage decompression and stabilization seems to be an effective and safe alternative in selected patients with AAD and basilar invasion.

Expanding traumatic intracerebral contusion/hematoma.

BACKGROUND AND AIMS: Delayed traumatic hematomas and expansion of already detected hematomas are not uncommon. Only few studies are available on risk factors of expanding hematomas. A prospective study was aimed to find out risk factors associated with such traumatic lesions. MATERIALS AND METHODS: Present study is based on 262 cases of intracerebral hematomas / contusions out of which 43 (16.4%) hematomas expanded in size. computerized tomography (CT) scan was done in all the patients at the time of admission and within 24 hours of injury. Repeat CT scan was done within 24 hours, 4 days and 7 days. Midline shift if any, prothrombin time, activated partial thromboplastin time, bleeding time, clotting time and platelet counts, Glasgow coma scale at admission and discharge and Glasgow outcome score at 6 months follow up were recorded. RESULTS: Twenty six percent, 11.3 and 0% patients developed expanding hematoma in Glasgow Coma scale (GCS) of 8 and below, 9-12 and 13-15 respectively. The chances of expanding hematomas were higher in patients with other associated hematomas (17.4%) as compared to isolated hematoma (4.8%) (Fisher's exact results P =0.216). All the cases of expanding hematoma had some degree of midline shift and considerably higher proportion had presence of coagulopathy. The results of logistic regression analysis showed GCS, midline shift and coagulopathy as significant predictors for the expanding hematoma. Thirty nine patients (90.7%) of the total expanding hematomas developed within 24 hours of injury. CONCLUSIONS: Enlargement of intracerebral hematomas is quite common and majority of them expand early after the injury. These lesions were common in patients with poor GCS, associated hematomas, associated coagulopathy and midline shift.

Chronic subdural hematoma.

Chronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions. There is lack of uniformity in the treatment of CSDH amongst surgeons in terms of various treatment strategies. Clinical presentation may vary from no symptoms to unconsciousness. CSDH is usually diagnosed by contrast-enhanced computed tomography scan. Magnetic resonance imaging (MRI) scan is more sensitive in the diagnosis of bilateral isodense CSDH, multiple loculations, intrahematoma membranes, fresh bleeding, hemolysis, and the size of capsule. Contrast-enhanced CT or MRI could detect associated primary or metastatic dural diseases. Although definite history of trauma could be obtained in a majority of cases, some cases may be secondary to coagulation defect, intracranial hypotension, use of anticoagulants and antiplatelet drugs, etc., Recurrent bleeding, increased exudates from outer membrane, and cerebrospinal fluid entrapment have been implicated in the enlargement of CSDH. Burr-hole evacuation is the treatment of choice for an uncomplicated CSDH. Most of the recent trials favor the use of drain to reduce recurrence rate. Craniotomy and twist drill craniostomy also play a role in the management. Dural biopsy should be taken, especially in recurrence and thick outer membrane. Nonsurgical management is reserved for asymptomatic or high operative risk patients. The steroids and angiotensin converting enzyme inhibitors may also play a role in the management. Single management strategy is not appropriate for all the cases of CSDH. Better understanding of the nature of the pathology, rational selection of an ideal treatment strategy for an individual patient, and identification of the merits and limitations of different surgical techniques could help in improving the prognosis.

Role of endoscopic third ventriculostomy in tuberculous meningitis with hydrocephalus.

Hydrocephalus is one of the commonest complications of tuberculous meningitis (TBM). It can be purely obstructive, purely communicating, or due to combinations of obstruction in addition to defective absorption of cerebrospinal fluid (CSF). Endoscopic third ventriculostomy (ETV) as an alternative to shunt procedures is an established treatment for obstructive hydrocephalus in TBM. ETV in TBM hydrocephalus can be technically very difficult, especially in acute stage of disease due to inflamed, thick, and opaque third ventricle floor. Water jet dissection can be helpful in thick and opaque ventricular floor patients, while simple blunt perforation is possible in thin and transparent floor. Lumbar peritoneal shunt is a better option for communicating hydrocephalus as compared to VP shunt or ETV. Intraoperative Doppler or neuronavigation can help in proper planning of the perforation to prevent neurovascular complications. Choroid plexus coagulation with ETV can improve success rate in infants. Results of ETV are better in good grade patients. Poor results are observed in cisternal exudates, thick and opaque third ventricle floor, acute phase, malnourished patients as compared to patients without cisternal exudates, thin and transparent third ventricle floor, chronic phase, well-nourished patients. Some of the patients, especially in poor grade, can show delayed recovery. Failure to improve after ETV can be due to blocked stoma, complex hydrocephalus, or vascular compromise. Repeated lumbar puncture can help faster normalization of the raised intracranial pressure after ETV in patients with temporary defect in CSF absorption, whereas lumbar peritoneal shunt is required in permanent defect. Repeat ETV is recommended if the stoma is blocked. ETV should be considered as treatment of choice in chronic phase of the disease in obstructive hydrocephalus.

Morphometric analysis of posterior fossa and foramen magnum.

INTRODUCTION: Configuration and size of the foramen magnum and posterior fossa plays an important role in the pathophysiology of the posterior fossa and craniovertebral junction disorders. This study is aimed to find out various dimensions of the foramen magnum and posterior fossa. MATERIALS AND METHODS: This is a prospective study of 100 consecutive normal computerized tomography (CT) scans of posterior fossa and 100 dry adult skulls without any bony abnormality. The posterior fossa volume was calculated by abc/2 in method 1 and by advanced work station of CT scan in method 2. Various dimensions of posterior fossa and foramen magnum were also studied. RESULTS: Age ranged from 16 to 89 years with a mean of 51.3 years. Mean height of posterior fossa were 3.01 cm (±0.22) and 3.52 (±0.43) cm in dry skull and CT scan group, respectively (P < 0.0001). Mean volume of posterior fossa were 157.88 (±27.94) cm(3) and 159.58 (±25.73) cm(3) by method 1 and method 2, respectively (P > 0.05). All the dimensions of posterior fossa and foramen magnum were larger in male as compared to female. Mean anteroposterior (AP), transverse diameter and surface area of the foramen magnum were 3.31 (±0.35) cm, 2.76 (±0.31) cm, and 729.15 (±124.87) mm(2), respectively, in CT scan group as compared to 3.41 (±0.29) cm, 2.75 (±0.25) cm, and 747.67 (±108.60) mm(2), respectively, in dry skull group. CONCLUSION: Normal values of posterior fossa and foramen magnum could serve as a future reference. Dry skull dimensions could be different from CT scan measurement. More studies are needed as there could be variations in dimensions in different regions in India.

Transoral extrusion of the ventriculo-peritoneal shunt: A case report and review of literature.

There are several case reports of complications of ventriculo-peritoneal shunt. Extrusion of the peritoneal end of the shunt through mouth is extremely rare. There are few case reports. We are reporting one such case. A 1-year male child was admitted with the peritoneal end of ventriculo-peritoneal shunt coming out through mouth since 6 hours after an episode of vomiting. He was conscious and had no neurological deficits. The anterior fontanelle was depressed. There was no infection. The peritoneal end of the shunt was removed through the mouth. Shunt revision was performed. The patient was discharged 10 days after the revision without any complications. At 1-year follow-up the patient is doing well. Possible mechanisms of bowel perforation are discussed. Pulling the peritoneal end through mouth is probably the best way of management as small spontaneous gut perforation seals off spontaneously. It also decreases the possibility of infection, other morbidities, and hospital stay.

Expanding traumatic intracerebral contusion/hematoma.

BACKGROUND AND AIMS: Delayed traumatic hematomas and expansion of already detected hematomas are not uncommon. Only few studies are available on risk factors of expanding hematomas. A prospective study was aimed to find out risk factors associated with such traumatic lesions. MATERIALS AND METHODS: Present study is based on 262 cases of intracerebral hematomas / contusions out of which 43 (16.4%) hematomas expanded in size. computerized tomography (CT) scan was done in all the patients at the time of admission and within 24 hours of injury. Repeat CT scan was done within 24 hours, 4 days and 7 days. Midline shift if any, prothrombin time, activated partial thromboplastin time, bleeding time, clotting time and platelet counts, Glasgow coma scale at admission and discharge and Glasgow outcome score at 6 months follow up were recorded. RESULTS: Twenty six percent, 11.3 and 0% patients developed expanding hematoma in Glasgow Coma scale (GCS) of 8 and below, 9-12 and 13-15 respectively. The chances of expanding hematomas were higher in patients with other associated hematomas (17.4%) as compared to isolated hematoma (4.8%) (Fisher's exact results P =0.216). All the cases of expanding hematoma had some degree of midline shift and considerably higher proportion had presence of coagulopathy. The results of logistic regression analysis showed GCS, midline shift and coagulopathy as significant predictors for the expanding hematoma. Thirty nine patients (90.7%) of the total expanding hematomas developed within 24 hours of injury. CONCLUSIONS: Enlargement of intracerebral hematomas is quite common and majority of them expand early after the injury. These lesions were common in patients with poor GCS, associated hematomas, associated coagulopathy and midline shift.