Olfactory groove meningiomas: An analysis based on surgical experience with 129 cases.

OBJECTIVE: The surgical strategy and outcome for 129 patients operated for an olfactory groove meningioma is retrospectively analyzed. MATERIAL AND METHODS: One hundred and twenty nine patients with an olfactory groove meningioma operated between the years 1987 and 2016 were analyzed on the basis of clinical and radiological factors that appeared to affect the conduct of surgery and its outcome. Each factor was given points, and the points were added to obtain a score. On the basis of the score, the tumors were divided into three grades. The grades determined the difficulties that could be anticipated during surgery. In the initial part of the series, a bifrontal craniotomy was done to resect the tumor in all patients. In the later half of the series, majority of the patients were operated by the use of a unifrontal craniotomy. The aim of surgery was to resect the tumor completely. RESULTS: Total tumor resection was achieved in 86 patients, and subtotal tumor resection with less than 10% tumor left behind was achieved in 43 patients. Seven patients died in the immediate postoperative period. All patients where a subtotal tumor resection was done and where the patient died after surgery had a higher grade tumor. The average follow-up period was 82 months. There was non-symptomatic recurrence in 11 patients. CONCLUSIONS: The location and size of the tumor, extent and duration of visual symptoms, extent of tumor adjoining cerebral edema, encasement of anterior cerebral artery complex and extension in the extracranial compartment were more important factors that affected the outcome of surgery.

Laminectomy with Rib Shears: A Technical Note.

Introduction: Laminectomy/laminoplasty either free or vascularized pedicle flap is currently performed with a variety of expensive instruments. Use of Tudor Edwards rib shears to perform above procedure is described. Materials and Methods: Tudor Edwards rib shear was used to cut lamina in 18 cases for a variety of spinal lesions. Depending upon the size of lesion, laminectomy/laminoplasty was required for 2 to 8 levels. Vascularized pedicle laminoplasty or free flap laminoplasty was done with Tudor Edwards rib shears. Ligamentum flavum and interspinous and supraspinous ligaments were preserved in cases of vascularized pedicled laminoplasty, which was carried out in 12 cases. Free flap laminoplasty was carried out in 6 cases. Results: In all our cases, laminectomy was successfully achieved with rib shears without any injury to the dura or its underlying structures. It was possible to perform vascularized pedicle laminoplasty or free flap laminoplasty in all cases. Laminectomy was easier to perform in the cervical region and dorsal region, while it was difficult in the lumbar region due to the wider, thick lamina and its angulation, especially in adults. Conclusion: Laminectomy/laminoplasty with Tudor Edwards rib shears is quick, safe, and easy. Beveled cut edges with minimal bony loss prevents sinking of laminoplasty, thereby facilitates lamina fixation. This is an alternative method of performing laminectomy/laminoplasty, especially for those not having accessibility to expensive equipment.

Report of an eight-year experience with Camille's transarticular technique of cervical spinal stabilization.

We present our experience with Camille's cervical transarticular screw fixation technique. During the period June 2012 to April 2020, 2422 screws were implanted in 321 patients by Camille's transarticular cervical spinal screw fixation technique. The indications of screw implantation were radiculopathy/myelopathy related to cervical spondylosis in 258 cases, cervical OPLL in 54 cases and Hirayama disease in 9 cases. The follow-up ranged from 6 to 92 months. In the entire series, there were no nerve or vessel injury or any other intraoperative 'complications' related to screw implantation. There was no instance of screw pull out or screw failure. There was no metal implant related infection. Satisfactory arthrodesis of all the treated spinal segments was observed on investigations done at a minimum follow-up of 6 months. Camille's transarticular screw fixation technique is a relatively simple surgical procedure and provides a safe, strong and reliable arthrodesis at the fulcrum of spinal movements.

Antegrade Subperiosteal Temporalis Muscle Elevation and Posterior Retraction Technique Avoiding Muscle Incision for Pterional Craniotomy: A Technical Note.

Background: The current technique of pterional craniotomy involves temporalis muscle incision followed by retrograde elevation. Feasibility of antegrade temporalis muscle elevation without any direct incision over its bulk is evaluated. Objective: Incisionless "antegrade, subgaleal, subfascial, and subperiosteal elevation" of temporalis muscle preserves vascularity and muscle bulk. Posterior maneuvering of "bare" temporalis muscle bulk either above (out rolling) or under (in rolling) the scalp for pterional craniotomy is discussed. Material and Methods: Technique of antegrade, subfascial, subperiosteal elevation, and posterior rotation of temporalis muscle without incising in its bulk by "out rolling" or "in rolling" along the posterior aspect of the scalp incision was carried out in 15 cadavers and later in 50 surgical cases undergoing pterional craniotomy. Postoperatively, patients were evaluated for subgaleal collection and periorbital edema. Operated side cosmesis and temporalis muscle bulk was compared with nonoperated temporalis muscle at 6 months interval. Results: Antegrade subperiosteal dissection of temporalis muscle was possible in all cases. "In-rolling" or "out rolling" technique provided adequate surgical exposure during pterional craniotomy. Postoperative subgaleal collection and periorbital edema was prevented. Facial nerve paresis or temporalis muscle-related complications were avoided. Conclusion: Antegrade, subgaleal, subfascial, and subperiosteal dissection techniques of temporalis muscle elevation without any direct incision in its bulk enables neurovascular and muscle volume preservation. Posterior maneuvering of elevated temporalis muscle with "out rolling" or "in-rolling" technique is easy, quick, and provides adequate exposure during pterional craniotomy. Opening and closing of scalp layers without violating subgaleal space prevent postoperative subgaleal hematoma and periorbital edema.

Anchoring the Temporalis Muscle with an Intact Fascial Layer Along the Superior Temporal Line in Pterional Craniotomy: A Technical Note.

BACKGROUND: Manipulation of the temporalis muscle during pterional and frontotemporal approaches poses major cosmetic and functional issues postoperatively. The temporalis muscle has usually been secured in its normal position using implants or by leaving a thin rim of muscle and fascia attached along the superior temporal line. In the present report, we have described a pure tissue-based method of anchoring the intact temporalis muscle precisely along the superior temporal line. METHODS: A total of 30 consecutive cases of pterional or frontotemporal craniotomy were performed by single surgeon (SKR). A subfascial dissection technique was used to expose the transition zone of the frontal pericranium with the temporalis fascia. These were then separated by sharp dissection along the superior temporal line at which the muscle is attached. The temporalis muscle and fascia were repositioned during closure, precisely at their original anatomical location by passing multiple anchoring sutures along the free edge of the muscle and fascia lying along the superior temporal line. RESULTS: Temporalis muscle reattachment was achieved in all 30 cases with good cosmesis and functional outcome without temporalis muscle-related complications at 6 months of follow-up. CONCLUSIONS: The approximation of sutures running through the free edge of the temporalis muscle with intact fascia along the superior temporal line from anteriorly to posteriorly restored the muscle and fascial layer to its original position. Avoidance of the formation of any potential dead space during surgical exposure will prevent periorbital edema and/or subgaleal collection postoperatively. The described inexpensive technique avoids implant-related complications, with good functional and aesthetic outcomes. A comparative study is needed to establish the superiority of this procedure over other techniques.

Rotatory atlantoaxial dislocation presenting as spinal kyphoscoliosis.

A 16-year-old male presented with primary complaint of worsening dorsal spinal kyphoscoliosis (SKS) for 3 years. More recently, he developed spasticity in legs, breathlessness on mild exertion, and sleep apneas. Apart from SKS, investigations revealed rotatory atlantoaxial dislocation. Atlantoaxial fixation resulted in rapid recovery from all symptoms including from spinal deformity. Observations in this patient suggest that rotatory dislocation can be a cause of spinal deformity.

Lumbar canal stenosis in "young" - How does it differ from that in "old" - An analysis of 116 surgically treated cases.

OBJECTIVE: Patients treated for lumbar canal stenosis (LCS) were retrospectively analyzed to evaluate the differences in clinical management in those below (Group A) and those above (Group B) the age of 50 years. All patients were treated with the premise that instability is the nodal point of the pathogenesis of LCS and "only-stabilization" is the surgical treatment. MATERIALS AND METHODS: During the period June 2014 to June 2020, 116 cases were diagnosed to have LCS and surgically treated by the Goel modification of Camille's transarticular screw fixation technique. RESULTS: Twenty-four patients in Group A and six patients in Group B had a history of "significant" injury to the back at the onset of clinical symptoms. The indices suggested that the intensity of symptoms was relatively more severe in Group A than in Group B. Unilateral leg symptoms were more common in Group A (68%) than in Group B (31.8%). Neurological motor deficits were more common in Group A (28%) than in Group B (12%) patients. Spinal segments surgically treated in Group A ranged from 1 to 4 (average 2 levels) and in Group B it ranged from 2 to 5 (average 3 levels). During the follow-up period that ranged from 6 to 72 months (average 37 months), 100% of patients had varying degrees of relief from symptoms. CONCLUSIONS: LCS is confined to a lesser number of spinal segments in the Group A patients. The symptoms were radicular in nature and relatively severe in Group A than in Group B patients.

"Apoplectic" Recurrence of Massive Trigeminal Neurinomas: Report of 7 Cases.

OBJECTIVE: The pattern of recurrence of large trigeminal neurinomas is analyzed on the basis of experience with 7 cases. METHODS: This is a report of 7 cases of large trigeminal neurinomas that were operated on an average of 11 years earlier. After being relatively asymptomatic over the years, these patients worsened relatively suddenly in their neurologic symptoms and were reoperated. RESULTS: Imaging showed massive recurrence with tumor having cystic and solid components with sizes ranging from 4.5-11 cm. In 4 cases, the cysts at the time of initial presentation and at the time of recurrence showed a well-defined fluid level within the fluid content of the cyst. During operation it was seen that the tumor contained "hemorrhagic" fluid that was under significant pressure. The solid component in the circumferential periphery of the cyst fluid was soft, necrotic, and vascular. The entire recurrence in the middle and posterior cranial fossa and in the extracranial compartment was "interdural" or within the dural confines. Radical tumor resection within the dural confines by deploying relatively small surgical exposure resulted in "unusually" rapid recovery in the symptoms. Histological examination of the tumor did not reveal any malignant transformation. CONCLUSIONS: The cases add further insight to the growth pattern and characteristics of large trigeminal neurinomas.

Large lateral intraventricular tumors - Outcome of radical surgery.

This is a retrospective analysis of 145 cases of lateral intraventricular tumors that were larger than 4 cm in their maximum dimension. The aim of surgery was radical tumor resection. During the period January 2000 to December 2019, 145 cases of lateral intraventricular tumors were treated by surgery by an interhemispheric approach. There were 101 males and 44 females. The ages of the patients ranged from 2 months to 77 years (average 29 years). Histological examination of tumors identified 73 central neurocytomas, 20 choroid plexus papillomas, 23 subependymal giant cell astrocytomas (SEGA), 5 ependymomas, 21 gliomas, 2 primitive neuroectodermal tumors (PNET/embryonal tumors) and 1 atypical teratoid rhabdoid tumor (ATRT). Nineteen patients had mild to severe hemiparesis in the immediate post-operative period. Eight patients died in the postoperative period. At a follow up of 1 year 137 patients were leading active and symptom free lives. Twenty seven patients received adjuvant radiation treatment. At a follow-up of more than 3 years, 8 additional patients died of their disease. Tumor recurrence or re-growth was observed in 13 patients and 2 patients needed reoperation. Surgery on large lateral intraventricular tumors can be associated with significant postoperative morbidity and mortality. Majority of tumors in this location are relatively 'low-grade' malignant tumors and when successfully treated, the long term outcome can be gratifying.

Outcome of Osteophytes After Only-Fixation as Treatment for Multilevel Cervical Spondylosis-A Minimum of 12 Months Follow-Up.

OBJECTIVE: This report analyzes the significance of osteophytes in the overall pathologic scheme in patients with single-level or multilevel cervical spinal degeneration. METHODS: From January 2010 to December 2018, 249 patients with cervical spondylosis were surgically treated. The alterations in ventral compression caused by disc bulges, osteophytes, and ligament buckling (disc-osteophye-ligament [DOL] complex) at single or multiple levels were evaluated after surgical treatment that involved only spinal fixation and did not involve any kind of bone or soft tissue decompression. Delayed (≥1 year after surgery) postoperative imaging was available in 165 patients and these patients formed the study group. Forty-five patients underwent facet distraction arthrodesis (group A), 106 patients underwent only-fixation involving transarticular screw insertion (group B), and 14 patients underwent hybrid fixation that involved both intra-articular spacers and transarticular fixation techniques (group C) as the surgical treatment. RESULTS: The size of the DOL complex at the segments that underwent fixation was reduced in 136 patients. The size of the DOL complex or its related dural or neural compression did not increase in any of the cases evaluated. Reduction in the size of DOL was more pronounced in patients in group A in both immediate postoperative and delayed images and in patients in group C at spinal levels at which facet distraction was performed using facet distraction spacers. CONCLUSIONS: Spinal stabilization reduces the size of osteophytes. Facet distraction spacers are more effective in reduction of the size of DOL in both immediate and delayed postoperative periods.

Modified Ipsilateral Endonasal Endoscopic Trans-Sphenoidal Approach to Sphenoid Sinus Lateral Recess Cerebrospinal Fluid Leak Management in Two Cases: A Technical Note.

Background Cerebrospinal fluid (CSF) leak from the sphenoid sinus lateral recess (SSLR) is very rare. Majority prefer transpterygoid approach which is extensive and time consuming. Two such cases were managed with least possible dissection/destruction of paranasal sinus. Methods Two cases of SSLR were accessed through the ipsilateral nostril from the side of CSF leak. Wide ipsilateral anterior sphenoidotomy was done preserving intersinus septum of sphenoid sinus. Middle turbinate was lateralized and remaining paranasal structures were preserved. Two handed single nostril approach was done in both the cases by 45- and 70-degree endoscope along with angled instruments. SSLR defects were visualized and packed with autologous fat graft and glue. Results SSLR defects could be visualized and packed with fat graft in both the cases from ipsilateral side. Both cases had uneventful outcome with no leak with mean -follow-up of 11.5 months. Conclusion Modified ipsilateral endonasal endoscopy trans-sphenoidal approach is least invasive technique for SSLR leak. Use of angled scope and instruments help in defect visualization, avoiding extensive paranasal sinus dissection and bony removal. Tedious time-consuming reconstructive procedures can be avoided with simple fat graft with good outcome.

Chiari Malformation and Syringomyelia Associated with Hirayama Disease.

BACKGROUND: To the best of our knowledge, the presence of Chiari formation and Hirayama disease in the same patient has not been previously reported. On the basis of the presented case, we have attempted to identify the common pathogenesis of both of these clinical entities. CASE DESCRIPTION: We have reported a case of a 23-year-old male patient who had presented with complaints of pain in the nape of neck and shoulders of 9 months' duration, weakness and stiffness in all 4 limbs, and wasting and weakness of muscles of both hands of 6 months' duration. The investigations showed Chiari formation and syringomyelia. Additional investigations depicted the characteristic radiological features associated with Hirayama disease. The patient was treated by atlantoaxial and multisegmental subaxial cervical spinal fixation. CONCLUSIONS: Spinal instability seems to be the nodal point of the pathogenesis of both Chiari formation and Hirayama disease.

Mobilization of the Vertebral Artery-Surgical Option for C2 Screw Fixation in Cases With "High Riding" Vertebral Artery.

BACKGROUND: Mobilization of intraosseous course of vertebral artery for safe screw insertion into pedicle of axis in cases with high riding vertebral artery is discussed. OBJECTIVE: To show drilling, exposure, and mobilization of the "high-riding" vertebral artery loop during its course in relationship with superior facet/pedicle of C2 vertebra can provide safety to techniques of atlantoaxial fixation that involve insertion of screws in the pars/pedicle/facet of C2. METHODS: During the period June 2016 to April 2018, 15 patients operated for atlantoaxial stabilization underwent vertebral artery exposure and mobilization using the technique discussed. The ages of the patients ranged from 6 to 48 yrs. Four patients had mobile and reducible atlantoaxial dislocation. Seven patients had basilar invagination. Four patients had os-odontoideum. Gentle and precise drilling of bone that covers the "high-riding" vertebral artery can lead to its safe and wide surgical exposure. The arterial loop can then be either completely or partially mobilized out of the vertebral artery groove such that C2 screw insertion can be conducted under direct surgical visualization of the vertebral artery. RESULTS: During the average follow-up period of 14 mo, there have been no complications related to the surgical procedure, metal implant, or vertebral artery. CONCLUSION: Vertebral artery exposure and mobilization is rather simple and safe procedure and is remarkably effective in providing a space for C2 screw implantation.

Muscle Weakness-Related Spinal Instability Is the Cause of Cervical Spinal Degeneration and Spinal Stabilization Is the Treatment: An Experience with 215 Cases Surgically Treated over 7 Years.

BACKGROUND: The rationale of only fixation without any kind of bone, ligament, disc, or osteophyte decompression as a treatment for single- or multiple-level cervical spinal degeneration was analyzed. The concept was based on the understanding that muscle weakness-related spinal instability is the cause of spinal degeneration, and spinal stabilization is the treatment. MATERIALS AND METHODS: During the period June 2012 to June 2019, 215 patients with single- or multiple-level cervical spinal degeneration who presented with symptoms of radiculopathy and/or myelopathy were treated. Age range of patients was 35-76 years. The series included 194 men and 21 women. Patients with acute symptoms and disc herniation, prolapse, or extrusion were excluded from the analysis. Only spinal stabilization by deploying facet screw fixation techniques was done in all cases. No decompression by resection of any bone, soft tissue, disc, or osteophyte was done. The minimum follow-up was 6 months. RESULTS: Postoperative clinical outcome was measured using Japanese Orthopaedic Association score, Goel clinical grade, and visual analog scale score. In addition, 2 specialist neurosurgeons were recruited to assess clinical outcome. Clinical assessments and videos were used to document the outcome. There were no significant complications. Varying degree of clinical recovery was seen in all patients. None of the patients in the series underwent reoperation for persistence or recurrence of symptoms. CONCLUSIONS: Instability of spinal segments forms the basis of spinal degeneration. Stabilization forms the basis of surgical treatment. The role of decompression needs to be re-evaluated.

Silent stellate ganglion paraganglioma masquerading as schwannoma: A surgical nightmare.

A 28-year-old normotensive female presented with Horner's syndrome and paresthesia over the left side of the chest. Imaging study showed a large heterogeneous enhancing lesion in short-T1 inversion recovery sequence with flow voids in T2W sequence of magnetic resonance imaging. The lesion was located in the left-sided D1 and D2 regions extending into the neural foramina and apical part of the lung. During surgery, even minimal dissection of the tumor resulted in marked fluctuation in hemodynamic parameters, requiring temporary suspension of the surgery multiple times until hemodynamic parameters were brought under control by the anesthesiologist with drugs. The massive fluctuation in hemodynamic parameters in an unprepared and unanticipated scenario was a challenge for the anesthetist and surgeon. The tumor was radically excised with improvement of paresthesia in the immediate postoperative period, but Horner's syndrome persisted. After 18-months of follow-up, she was relieved of all symptoms including Horner's syndrome. Histopathological examination confirmed our suspicion as paraganglioma.

Os Odontoideum: Analysis of 190 Surgically Treated Cases.

OBJECTIVE: The aim of this study was to report an experience with 190 cases of os odontoideum over 20 years. The management outcome following atlantoaxial fixation was analyzed. METHODS: From January 2000 to September 2018, 190 patients with os odontoideum were surgically treated. There were 113 male patients and 77 female patients; average age was 24 years (range, 2-68 years).The patients were divided into 3 groups depending on the nature of atlantoaxial dislocation (group 1, mobile and partially or completely reducible atlantoaxial dislocation; group 2, fixed or irreducible atlantoaxial dislocation; group 3, presence of basilar invagination). There were 65 pediatric patients (<18 years old). All patients underwent atlantoaxial joint manipulation and lateral mass plate and screw fixation. The goal of surgery was segmental atlantoaxial arthrodesis. No transoral or posterior foramen magnum bone decompression was done. Occipital bone was not included in the fixation construct. RESULTS: On direct bone handling and observation, atlantoaxial joint pathologic hyperactivity related instability was identified in all patients. Atlantoaxial segmental stabilization resulted in clinical symptomatic and neurologic improvement in 100% of patients. CONCLUSIONS: Os odontoideum signifies chronic or long-standing atlantoaxial instability. Segmental atlantoaxial fixation is a reliable form of surgical treatment. Bone decompression is not necessary. Inclusion of occipital bone and subaxial vertebrae in the fixation construct is not necessary.

Ossified Anterior Foramen Magnum Meningioma: Report of Long-Term Surgical Outcome.

BACKGROUND: Technical surgery-related issues for large ossified/calcified meningioma that encased one or both vertebral arteries located anterior to brainstem in the region of foramen magnum are discussed. Relatively long-term outcome of successful surgery is reported. CASE DESCRIPTION: Three women were operated on for symptoms of progressive quadriparesis. Investigations revealed ossified meningioma located anterior to the brainstem. One or both vertebral arteries were encased within the confines of the tumor. Large size, bone-hard consistency, location anterior to the brainstem, and intimate vascular relationship made the surgery a formidable surgical problem. A midline posterior suboccipital approach was used to resect these tumors. Radical tumor resection was achieved in all cases successfully. Tumor drilling or heavy tumor breaking instruments were not necessary to debulk the tumor. Histologic examination in all 3 cases revealed psammomatous meningioma. During the follow-up period that ranged from 2 to 12 years, all 3 patients were leading a normal life, and there has been no documented recurrence in any case. CONCLUSIONS: Successful resection of "ossified" meningioma is associated with satisfactory long-term clinical outcome.

Is C2-3 fusion an evidence of atlantoaxial instability? An analysis based on surgical treatment of seven patients.

OBJECTIVE: The authors analyze the rationale of atlantoaxial fixation in patients presenting with symptoms related to cervical myelopathy and wherein the radiological images depicted C2-3 fusion and presence of single or multiple level neural compression of the subaxial cervical spinal cord attributed to "degenerative" spine. MATERIALS AND METHODS: Seven adult males were analyzed who presented with long-standing symptoms of progressive cervical myelopathy and where imaging showed presence of C2-3 fusion, no cord compression related to odontoid process, and evidence of single or multiple level lower cervical cord compression conventionally attributed to spinal degeneration. There was no other bone or soft tissue abnormality at the craniovertebral junction. There was no evidence of atlantoaxial instability when assessed by conventional radiological diagnostic parameters. Atlantoaxial instability was diagnosed on the basis of clinical understanding, atlantoaxial facetal malalignment, and manual assessment of instability by bone handling during surgery. All the seven patients underwent atlantoaxial fixation and no surgical manipulation at lower cervical spinal levels. RESULTS: At an average follow-up of 34 months, all patients have recovered satisfactorily in their neurological function. CONCLUSION: The presence of C2-3 fusion is an indication of atlantoaxial instability and suggests the need for atlantoaxial stabilization. Effects on the subaxial spine and spinal cord are secondary events and may not be surgically addressed.

Adjacent-segment "central" atlantoaxial instability and C2-C3 instability following lower cervical C3-C6 interbody fusion: Report of three cases.

AIM: We report adjacent-segment "central" or "axial" atlantoaxial instability and C2-C3 instability as the cause of delayed neurological worsening following multisegmental cervical spinal stabilization. MATERIALS AND METHODS: Three male patients aged 34, 56, and 70 years had been operated earlier for cervical spondylosis by multilevel C3-C6 cervical interbody fusion 6-11 years earlier. After an initial improvement for few years, the patients observed relatively rapid clinical deterioration. When admitted, all the three patients were severely quadriparetic and were brought to the hospital on a wheelchair. Central atlantoaxial instability was diagnosed on the basis of our previously published clinical and radiological parameters. C2-C3 instability was essentially diagnosed on the intraoperative observations. The patients underwent atlantoaxial and C2-C3 fixation. RESULTS: All the three patients had rapid clinical recovery that started in the immediate postoperative period. At an average follow-up of 21 months, the patients walked independently. CONCLUSIONS: Identification and treatment of adjacent-segment central atlantoaxial and C2-C3 instability can lead to gratifying clinical outcome.