Surgical Anatomy of Vertebral Artery in Relation to Atlantoaxial Instrumentation: A Cadaveric Study.

BACKGROUND: With the advent of pedicle screws and advanced instrumentation techniques, internal fixation and stabilization of upper cervical vertebrae are possible in fractures of an axis. However, the proximity of vertebral arteries (VAs) poses a unique challenge to surgeons during these procedures and can result in profound physical impairment to patients. Cadaveric studies contributing to fine anatomical details necessitate conducting such studies. METHODS: After receiving due ethical permission, this descriptive cross-sectional study was carried out on 10 cadavers in the department of Anatomy, All India Institute of Medical Science (AIIMS) Rishikesh. Twenty VAs were dissected along their course, and measurements of parameters related to the axis and atlas vertebra were noted. RESULTS: The length of the pre-osseous segment related to the axis (VAX-1) on the right and left sides were from 3.8 to 14.5 mm (7.48±3.88 mm) and 4.46 to 10.5mm (6.94±2.01mm) respectively. The length of the osseous segment related to the axis (VAX-2) on the right side and left sides were from 6.82 to 31 mm (17.9±7.84mm) and 7.35 to 20 mm (15.6±4.53). The osseous segment of the VA related to the axis (VAX-2) shows genu (bend), which extends to a variable distance towards the midline. The mean distance of VA genu from the midline of the axis vertebral body on the right and left sides was 15.6mm and 17.5 mm, respectively. The percentage of superior articular facet (SAF) surface area of the axis occupied by the VA was 25-50% in nine and 50-75% in 11 cadavers, reflecting incomplete occupancy. CONCLUSION: The study suggests that for instrumentation of the axis vertebra in the midline, the minimum distance between the genu of both sides of VA segments, related to an osseous segment of the axis (VAX-2) and medial extent of the VA groove of the atlas, should be considered as a safe zone to minimize inadvertent VA injury. During atlantoaxial fixation through a posterior approach in interarticular, pars, and pedicle screws, the surgical anatomy of the VA in relation to the osseous segment of the VA within the transverse process of the axis should be kept in mind to avoid inadvertent VA injury.

Graduating from Laboratory to Operating Rooms-the Way Forward for Future Surgeons!

Background: Changing healthcare and social scenarios are reducing the learning opportunities of surgical postgraduates in our country. Majority of surgical training centers in the developed world use laboratory training as an integral part of their curricula. However, in India, most of surgical residents are still trained by traditional apprenticeship model. Aims: To describe the role of laboratory training in improving the competency of surgical postgraduates. Settings and Design: Laboratory dissection was used as an educational intervention for postgraduates in tertiary care teaching hospital. Methods and Material: Thirty-five (35) trainees from various surgical subspecialties performed cadaveric dissection led by senior faculty members. The perceived knowledge and operative confidence of trainees were assessed before and three weeks after the course using a five-point Likert scale. A structured questionnaire was administered to explore the experience of training. Results were tabulated in percentage and proportion. Wilcoxon signed-rank test was applied to find any difference between pre and post perception of knowledge and operative competence of participants. Results: Thirty four (34/35; 96%) were males; 65.7% (23/35) trainees demonstrated improvement in knowledge level after dissection (p < 0.0001) and 74.3% (26/35) in operative confidence (p < 0.0001). Majority believe that cadaveric dissection helps to improve knowledge of procedural anatomy (33/35; 94.3%) and enhances technical skill (25/35; 71.4%). Thirty participants (86%) rated cadaveric dissection as the best tool for surgical training of postgraduates better than operative manuals, surgical videos, and virtual simulators. Conclusions: Laboratory training including cadaveric dissection is feasible, relevant, effective, and acceptable to postgraduate surgical trainees with few disadvantages, which can be taken care of. Trainees felt it should be made part of curriculum.

Difficult Mask Ventilation in Penetrating Facial Trauma Due to Animal Attack: A Unique Challenge in the Emergency Department.

Penetrating facial trauma can be a life-threatening condition, especially due to its impact on the airway. In a facial trauma, there is a distortion in the basic anatomy of the affected, making it a particularly difficult situation for managing the airway. Challenging intubation scenarios have been widely explored in the literature; however, difficult to ventilate situations have been undermined. We describe a case of a 35-year-old female who presented with a history of animal attack on the face. The extent of penetrating facial trauma warranted the need to secure the airway. Preserving spontaneous breathing and using an oral endotracheal tube for oxygenation saved the airway manager from cannot intubate and cannot oxygenate situation in a facial trauma patient. Difficult to mask ventilate while arranging for a definitive airway can be more pressing and challenging for the emergency physician. It also jeopardizes the patient's life, whose survival may only depend on acquiring the patency of the airway. Facial trauma patients may be conscious and spontaneously breathing, leading to the missed or delayed intervention in the airway; hence, prompt assessment and management of the airway in all facial trauma are of utmost importance.

Basal Cisternostomy in Head Injury: More Questions than Answers.

Background: Cisternostomy has recently been reintroduced in the setting of severe TBI as an adjuvant surgical technique for decreasing brain edema and refractory intracranial hypertension. However, there is not much clarity regarding its role in head injury. Objective: Study the effect of cisternostomy on intracranial pressure, morbidity, and mortality in head-injured patients. Material and Methods: We conducted a single-center quasi-experimental study between November 2018 and November 2020. All candidates for decompressive hemicraniectomy (DHC) were divided into two groups: DHC-BC (undergoing basal cisternostomy with DHC) and DHC (undergoing DHC alone). We compared the impact of surgery on decreasing ICP and clinical outcomes in both groups. Results: During the study duration, we admitted 659 head-injury patients. Forty patients were included in the study (9 in the DHC-BC group and 31 in the DHC group). Both the groups were comparable in terms of baseline clinical characteristics such as age, gender, preoperative GCS, head injury severity, radiological features, and opening ICP. Patients in both groups had a decline in ICP following surgery. The mean closing pressure in the DHC-BC group (11.3 ± 5.9) was significantly higher than that in the DHC group (5.3 ± 3.5) (P = 0.003). The mean drop in ICP in the DHC-BC group was 14.4 ± 11.5 while that in the DHC group was 18.9 ± 12.4 (P = 0.359). The average total number of hours of ICP >20 mm Hg and intracranial hypertension index were higher for the DHC-BC group. The average number of days of stay in the ICU and hospital were lower for the DHC-BC group (7.0 ± 6.1 and 15.0 ± 20.2, respectively) compared to the DHC group (10.6 ± 9.3 and 19.3 ± 13.9, respectively). The 30-day mortality rate was higher for the DHC-BC group (66.6%) than the DHC group (32.2%). The mean GCS at discharge was better in the DHC-BC group (11.7 ± 2.9) compared to 10.5 ± 3.7 in the DHC group, while 11.1% of patients in the DHC-BC group had a favorable outcome (1-month GOS-E) compared to 9.7% patients in the DHC group. Conclusions: Our preliminary single-center study failed to show a clear benefit of adding basal cisternostomy to decompressive hemicraniectomy in patients with head injuries.

Prognostication of COVID-19 patients using ROX index and CURB-65 score - A retrospective observational study.

Objectives: Coronavirus disease-2019 (COVID-19) disease has overwhelmed the healthcare infrastructure worldwide. The shortage of intensive care unit (ICU) beds leads to longer waiting times and higher mortality for patients. High crowding leads to an increase in mortality, length of hospital stays, and hospital costs for patients. Through an appropriate stratification of patients, rational allocation of the available hospital resources can be accomplished. Various scores for risk stratification of patients have been tried, but for a score to be useful at primary care level, it should be readily available at the bedside and be reproducible. ROX index and CURB-65 are simple bedside scores, requiring minimum equipment, and investigations to calculate. Methods: This retrospective, record-based study included adult patients who presented to the ED from May 1, 2020 to November 30, 2020 with confirmed COVID-19 infection. The patient's clinical and demographic details were obtained from the electronic medical records of the hospital. ROX index and CURB-65 score on ED arrival were calculated and correlated with the need for hospitalization and early (14-day) and late (28-day) mortality. Results: 842 patients were included in the study. The proportion of patients with mild, moderate and severe disease was 46.3%, 14.9%, and 38.8%, respectively. 55% patients required hospitalization. The 14-day mortality was 8.8% and the 28-day mortality was 20.7%. The AUROC of ROX index for predicting hospitalization was 0.924 (p < 0.001), for 14-day mortality was 0.909 (p < 0.001) and for 28-day mortality was 0.933 (p < 0.001). The AUROC of CURB-65 score for predicting hospitalization was 0.845 (p < 0.001), for 14-day mortality was 0.905 (p < 0.001) and for 28-day mortality was 0.902 (p < 0.001). The cut-off of ROX index for predicting hospitalization was ≤18.634 and for 14-day mortality was ≤14.122. Similar cut-off values for the CURB-65 score were ≥1 and ≥2, respectively. Conclusion: ROX index and CURB-65 scores are simple and inexpensive scores that can be efficiently utilised by primary care physicians for appropriate risk stratification of patients with COVID-19 infection.

Vertebral arteriovenous fistula in neurofibromatosis type 1.

INTRODUCTION: Vertebral arterio-venous fistulas (VAVFs) are uncommon lesions that can arise spontaneously or secondarily to iatrogenic or mechanical trauma. Among spontaneous cases, it is most commonly found to be associated with neurofibromatosis type 1 (NF1). EVIDENCE ACQUISITION: We performed a systematic review of the literature to obtain information regarding demographics, clinical presentation, treatment modalities and outcome of VAVFs associated with NF1. A literature search was performed by using databases PubMed Central, Embase, Cochrane Library, and Ovid MEDLINE. Also, the grey area search was done using the "Google Scholar" search engine. On screening of the original full-text English language articles, a total of 48 cases were considered suitable for inclusion in this review. EVIDENCE SYNTHESIS: VAVFs in NF1 commonly present between 3rd and 6th decade of life affecting females 2.4 times more than males. Left-sided fistulae were more common than the right side and most seen in the upper V2 segment of the vertebral artery. Most VAVFs in NF 1 patients were treated with constructive (occlusion of fistula only) endovascular therapy (N.=26) with a high success rate. Moreover, pooled proportion of the outcome data have shown significant difference between the endovascular constructive and destructive procedure. CONCLUSIONS: The spontaneous VAVF, commonly associated with NF-1, often requires treatment. Awareness of the coexistence between NF1 and VAVF is crucial to avoid diagnostic delays and unnecessary surgical intervention leading to disastrous outcomes. Endovascular treatment is the preferred treatment approach while open surgical treatment is required in some complex fistulae and failure of endovascular techniques.

Bilateral Extra-Cranial Internal Carotid Artery Aneurysms in a Young Adult: A Rare Entity.

Simultaneous bilateral aneurysms of the extra-cranial internal carotid artery (E-ICA) in a patient are one of the rarest lesions. Here, we report the case report of a 19­year­old male with bilateral E-ICA aneurysms. His left-sided, expanding aneurysm of E-ICA at skull base was successfully treated with surgical resection and interposition prosthetic graft placement. Successful surgical repair in this challenging field is safe and can be undertaken with an acceptable perioperative complication rate with excellent results.