Chandan Krishna

Minimally Invasive Tubular Resection of Lumbar Synovial Cysts: Report of 40 Consecutive Cases.

BACKGROUND Lumbar synovial cysts are a relatively common clinical finding. Surgical treatment of symptomatic synovial cysts includes computed tomography-guided aspiration, open resection and minimally invasive tubular resection. We report our series of 40 consecutive minimally invasive microscopic tubular lumbar synovial cyst resections. METHODS Following Institutional Review Board approval, a retrospective analysis of 40 cases of minimally invasive microscopic tubular retractor synovial cyst resections at a single institution by a single surgeon (B.D.B.) was conducted. Gross total resection was performed in all cases. RESULTS Patient characteristics, surgical operating time, complications, and outcomes were analyzed. Lumbar radiculopathy was the presenting symptoms in all but 1 patient, who presented with neurogenic claudication. The mean duration of symptoms was 6.5 months (range, 1-25 months), mean operating time was 58 minutes (range, 25-110 minutes), and mean blood loss was 20 mL (range, 5-50 mL). Seven patients required overnight observation. The median length of stay in the remaining 33 patients was 4 hours. There were 2 cerebrospinal fluid leaks repaired directly without sequelae. The mean follow-up duration was 80.7 months. Outcomes were good or excellent in 37 of the 40 patients, fair in 1 patient, and poor in 2 patients. CONCLUSIONS Minimally invasive microscopic tubular retractor resection of lumbar synovial cysts can be done safely and with comparable outcomes and complication rates as open procedures with potentially reduced operative time, length of stay, and healthcare costs. Patient selection for microscopic tubular synovial cyst resection is based in part on the anatomy of the spine and synovial cyst and is critical when recommending minimally invasive vs. open resection to patients.

Hemicraniectomy for Ischemic and Hemorrhagic Stroke: Facts and Controversies

Malignant large artery stroke is associated with high mortality of 70% to 80% with best medical management. Decompressive craniectomy (DC) is a highly effective tool in reducing mortality. Convincing evidence has accumulated from several randomized trials, in addition to multiple retrospective studies, that demonstrate not only survival benefit but also improved functional outcome with DC in appropriately selected patients. This article explores in detail the evidence for DC, nuances regarding patient selection, and applicability of DC for supratentorial intracerebral hemorrhage and posterior fossa ischemic and hemorrhagic stroke.

Spinal Schwannoma and Meningioma Mimicking a Single Mass at the Craniocervical Junction Subsequent to Remote Radiation Therapy for Acne Vulgaris

BACKGROUND Schwannomas and meningiomas are relatively common tumors of the nervous system. They have been reported in the literature as existing concurrently as a single mass, but very rarely have they been shown to present at the craniocervical junction. CASE DESCRIPTION We present a rare and interesting case of a patient previously treated with radiation therapy for acne vulgaris and who presented to us with a concurrent schwannoma and meningioma of the craniocervical junction mimicking a single mass. CONCLUSIONS These tumors can be solitary or mixed masses, and are known to be associated with certain disease processes such as long-term sequelae of radiation therapy and neurofibromatosis type 2. The precise mechanism behind the formation of these tumors is unknown; however, molecular cues in the tumor microenvironment may play a role.

Synthetic Replica for Training in Microsurgical Anastomosis: An Important Frontier in Neurosurgical Education

Medical education has evolved through the years, moving away from the Halstedian apprenticeship model. The medical governing bodies involved in medical graduate education have established a set of rulings and recommendations focused on improving patient safety and curbing resident fatigue including limiting work hours to 80 h a week. In addition to duty hour regulations, decreasing volumes and dilution of surgical cases among an increasing number of tertiary care centers have raised concern about the ability of residents to achieve appropriate levels of competency by the time of graduation. Therefore, simulation has seen an increased role in education in the last decade.

Complication Avoidance and Management Research

Complication avoidance is a major consideration with any surgical procedure, and evaluation of complications relies on clear definitions. However, defining what constitutes a complication can be difficult, as perspectives on errors of commission or omission often vary between providers and patients. Here, we present a concise analysis of complications related to neurovascular surgery (defined as any procedural care of patients with neurovascular diseases) and provide a framework for approaching research efforts. This is done by considering opportunities in disease screening and patient selection, perioperative morbidity reduction, and follow-up. In addition, the concept of complication avoidance through surgical simulation is briefly dealt with. This chapter is intended to serve as an initial reference point for the young neurovascular specialist for developing and elaborating on the concept of complication avoidance through various techniques of research.

Spontaneous resolution of ruptured intracranial pial arteriovenous fistula following spinal surgery

Pial arteriovenous fistulae (AVFs) are rare vascular abnormalities that are distinct from arteriovenous malformations and dural AVFs. These vascular lesions have been linked with trauma, ischemic syndromes, venous thrombotic diseases, and intracranial surgical procedures. In this report we describe a case of an intracranial ruptured pial AVF immediately following uneventful spinal surgery in an elderly patient with subsequent spontaneous resolution. He was a previous heavy smoker with a 60-pack-year history and alcohol abuse. His examination was positive for morbid obesity and mild weakness of the anterior tibialis and gastrocnemius muscles bilaterally. He underwent uneventful spinal surgery, suffering a generalized seizure shortly after extubation. Imaging studies demonstrated acute subarachnoid hemorrhage and cerebral angiography identified a pial AVF. He was stabilized medically and follow-up angiography demonstrated spontaneous resolution of the pial AVF. This case highlights a rare vascular malformation with rupture following uneventful spinal surgery.