ULTRASONOGRAPHY AS AN INTRAOPERATIVE TOOL FOR LOCALIZATION OF THE ANATOMICAL LEVEL IN LUMBOSACRAL SPINE SURGERIES

Aims and Objectives: The aims and objectives of the study are to find the effectiveness of ultrasound as a pre-operative adjunct to localize the anatomical intervertebral level of interest and study its accuracy by comparing it with the gold standard intra-operative fluoroscopy and to study factors affecting localization of anatomical vertebral level by ultrasound. Methods: This was a prospective study conducted in the Department of Neurology Department of Neurosurgery and Neuroimaging and Interventional Radiology, NIMHANS Hospital, Bengaluru, over a period of 1 year. 50 cases of lumbosacral degenerative diseases were included in this study on the basis of pre-defined inclusion and exclusion criteria. All patients underwent ultrasonography of the lumbosacral spine followed by pre-operative X-ray of the lumbosacral spine using the C-ARM. The accuracy of good localization of the desired level of the lumbosacral spine by ultrasound as compared to X-ray was determined. p<0.05 was taken as statistically significant. Results: There were 22 (44%) males and 28 (56%) females with a M: F ratio of 1:1.27. The mean age was 46.7±13.5 years. 46 (92%) cases were diagnosed with prolapsed intervertebral disc (PIVD) and 4 (8%) cases with Grade II spondylolisthesis radiologically. Good localization which constitutes exact localization, close upper, and close lower localization added up to 82% of the cases (41/50) and the rest 18% were tagged as poor localization (9/50). The accuracy of good localization in both the groups of PIVD and spondylolisthesis (listhesis) was 82.6% and 75%, respectively. Conclusion: Ultrasound can be used as an exceptionally good and accurate method of localizing the anatomical intervertebral level for patients undergoing various lumbosacral spinal surgeries

Response of Syrinx Associated with Chiari I Malformation to Posterior Fossa Decompression with or without Duraplasty and Correlation with Functional Outcome: A Prospective Study of 22 Patients

Background: The aim of the study is to correlate the surgical outcome with radiological changes in patients with Chiari I malformation (CMI) with syrinx. We also compared long-term functional and radiographic outcome in CM1 patients treated with posterior fossa decompression (PFD) with or without duroplasty. Patients and Methods: From December 2013 to October 2015, 22 patients who underwent surgery with the diagnosis of CMI and syrinx were included in the study. Measurements were performed on preoperative and postoperative magnetic resonance (MR) scans using the same software. All patients underwent PFD with or without duroplasty. Clinical results were evaluated on the basis of the Chicago Chiari Outcome Scale (CCOS). We assessed the degree of resolution of syrinx and outcome of Chiari decompression with PFD versus PFD with duroplasty. Mean duration of follow-up was 12.4 ± 5.37 months (range: 6–24 months). Results: Out of 19 patients in whom syrinx diameter decreased on postoperative MR imaging, 17 (89.5%) improved based on CCOS and 2 (10.5%) were unchanged while out of three patients in whom syrinx worsened, 2 (66.7%) improved and 1 (33.3%) was unchanged (P = 0.37). The cord diameter was found to have decreased in 12 patients and of these 11 (91.7%) improved. The cord diameter increased in 10 patients, but 8 (80%) improved (P = 0.57). The mean changes in syrinx, cord, and syrinx/cord ratio were studied in both groups with and without duroplasty, were not statistically significant. In this study, radiological parameters failed to predict functional outcome. Conclusions: The outcome does not correlate with change in any of the syrinx-related factors. Surgical decompression with or without duroplasty does not have a statistically significant relationship in the degree of syrinx resolution. Surgical decompression without duroplasty provides the benefits of surgical decompression while avoiding the complications of intradural techniques

Elderly pedestrian neurotrauma: A descriptive study from a premier neurotrauma center in India

Context: Experience with elderly pedestrian neurotrauma at a major neurotrauma tertiary center. Aims: To highlight the specific injuries and outcome of the elderly pedestrian neurotrauma patients within the city of Bangalore and its surrounding districts. Settings and Design: A retrospective study consisting of demographic data, clinical findings, radiological details, and outcomes. Materials and Methods: A study was conducted at the casualty services, in which 143 consecutive elderly pedestrian (age >60 years) head injury victims were studied from June to September 2009. The records from the hospital mortuary were analyzed from 2007 to 2009. An analysis of 77 elderly patients who died as a pedestrian in accidents during this period was performed. Statistical Analysis Used: SPSS 15. Results: The elderly pedestrians constituted 27% (143/529) of all pedestrian traumas. Two wheelers were the most common accident vehicle (56.6%, 81/143). Most of the injuries (38.5%, 55/143) occurred during peak traffic hours, that is, 4 pm to 9 pm. Majority sustained moderate to severe head injury (61%, 87/143). More than three‑fourths of patients required a computed tomography (CT) scan (77%, 110/143), in which there was a higher frequency of contusion (31.5%, 45/143), and subdural hemorrhage (23.1%, 33/143). Most of the injured (43.3%, 13/30) underwent surgery for intracranial hematoma. The mortality rate was 22.8% (8/35). Nearly one‑fourth of conducted postmortems among pedestrians belonged to the elderly age group (77/326, 23.6%). Conclusions: Elderly pedestrian neurotrauma patients sustain a more severe injury as evident by poorer Glasgow Coma Score (GCS) scores and CT scan findings, and hence have a higher mortality rate

Spinal dysraphism illustrated; Embroyology revisited

Spinal cord development occurs through three consecutive periods of gastrulation, primary nerulation and secondary neurulation. Aberration in these stages causes abnormalities of the spine and spinal cord, collectively referred as spinal dysraphism. They can be broadly classified as anomalies of gastrulation (disorders of notochord formation and of integration); anomalies of primary neurulation (premature dysjunction and nondysjunction); combined anomalies of gastrulation and primary neurulation and anomalies of secondary neurulation. Correlation with clinical and embryological data and common imaging findings provides an organized approach in their diagnosis

Anatomical Variations of the Temporomesial Structures in Normal Adult Brain - A Cadaveric Study

Background: Despite significant evolutional, functional, and clinical interest, the anatomical variations of the temporomesial structures in cadaveric samples have received little attention. This study was undertaken to document the anatomical variations observed in the temporal lobe of human brain with emphasis on the structures present in temporomesial region. Materials and Methods: Using 26 postmortem cadaveric cerebral hemispheres (13 right and 13 left hemispheres), several neurosurgically significant mesial structures were studied by blunt dissection under the operating microscope. The observed surface-based qualitative variations and right-left asymmetries were tabulated under well-defined, moderately defined, and ill-defined classification. Results: Among the areas, uncus (100%), limen insulae (88.4%), rhinal sulcus and hippocampus (81%), intralimbic gyrus (77%), Heschl's gyrus (73%), gyrus ambiens, semilunar gyrus, sulcus semiannularis, and calcar avis (69.2%) were well defined, and band of Giacomini (38.4%) was found to be distinctly ill-defined areas in the list. Further, our analysis confirmed the presence of consistent left-greater-than-right asymmetry in all the areas of interest in temporal region under well-defined category. Rightward asymmetry was noticed in moderately defined and ill-defined classification. However, no asymmetry was detected in the uncal region. P value for all the obtained results was >0.05. Conclusion: Our study offers a preliminary anatomic foundation toward the better understanding of temporal lobe structures. These variations may prove valuable to neurosurgeons when designing the appropriate and least traumatic surgical approaches in operating the temporomesial lesions

Apolipoprotein E polymorphism and outcome after mild to moderate traumatic brain injury: A study of patient population in India

Background: The nature and extent of recovery after traumatic brain injury (TBI) is heterogeneous. Apolipoprotein E (APOE) plays a major role in repair of cell membrane and growth of neurites following injury to cells. Studies done on the western population have shown that the APOE e4 genotype is associated with poor survival following neurotrauma. Aim: To explore the association of APOE polymorphism and outcome following TBI in a patient population from a tertiary care hospital exclusive for neurological diseases in south India. Patients and Methods: Ninety eight patients who sustained mild to moderate TBI (computed tomography (CT) scan brain showing traumatic parenchymal contusions) were the subjects of the study and the study period was from November 2003 to December 2008. APOE polymorphism status was determined by PCR technique using venous blood. Patients were assessed on follow-up with a battery of four neuropsychological tests as well as Glasgow outcome scale. Results: Of the 98 patients, 20 (20%) patients had at least one APOE e4 allele. A follow-up of minimum six months was available for 73 patients. None of the12 patients who had at least one APOE e4 allele had a poor outcome at six-month follow-up whereas 11(18%) patients without an APOE e4 allele had a poor outcome (Fisher′s Exact test, P=0.192). On the neuropsychological tests, performance of patients with APOE e4 allele did not differ significantly from those without these alleles. Conclusion: This study does not support the current contention that the presence of APOE e4 allele should have a significant negative effect on the outcome after TBI

Pathological Spectrum of Vascular Malformations of the Central Nervous System: A Single Institution Experience of a Decade

Background Vascular malformations (VMs) of the central nervous system comprise a variety of lesions that could affect the arteries, veins, or capillaries. Materials and Methods We analyzed the histopathological features of all the VMs diagnosed at our centre over a decade. Results Intracranial VM included arteriovenous malformation (AVM) (53%), cerebral cavernous malformations (CCMs) (45%), capillary telangiectasia (2%), venous angioma (0.5%), and arteriovenous fistula (AVF) (0.5%). In spinal VMs, capillary telangiectasia (40%) were the most common, followed by cavernomas (34%), AVF (16%), and AVMs and venous angiomas (5%). Clinical presentation varied from focal deficit to features of raised intracranial tension. Conclusion Imaging and histopathology plays an important role in the diagnosis and management of VMs. Histopathological examination is essential for characterization of the VMs, which influences the prognosis