Gd Satyarthee

Transorbital penetrating cerebral injury with a ceramic stone: Report of an interesting case

Penetrating cranial injury is a potentially life-threatening condition. The majority of war injuries are high-velocity penetrating cranial injuries; but in civilian cases, most penetrating cranial wounds are low-velocity type. We report an interesting case of transorbital penetrating cranial injury with a knife-sharpening stone made up of ceramic in a 28-year-old male. The pertinent literature is reviewed and management of such cases is discussed.

O-arm with navigation versus C-arm: a review of screw placement over 3 years at a major trauma center.

Abstract Introduction: There is a relatively high incidence of screw misplacement during spinal instrumentation due to distortion of normal anatomy following spinal trauma. The O-arm is the next-generation spinal navigation tool that provides intraoperative 3-D imaging and navigation for spine surgeries. Aims and objectives: To evaluate and compare the use of O-arm as compared to C-arm for spinal trauma in a Level I trauma center in India. Materials and methods: In this retrospective study over 3 years (July 2010–April 2013), All patients of spinal injury who underwent spinal instrumentation were divided into O-arm group and C-arm group. Accuracy of screw placement was assessed during each surgery in both groups. Results: A total of 587 patients were evaluated during the study period. There were 278 patients in O-arm group and 309 patients in C-arm group. Both groups were well matched in mean age (27.7 vs. 28.9 years), ASIA grades, and level of injury. The number of screws placed was significantly higher in the C-arm group as compared to the O-arm group (2173 vs. 1720). However, the O-arm group had significantly less screw malplacement rate of 0.93% (n = 16) as compared to malplacement rate in C-arm group of 8.79% (n = 191, p < 0.05). Conclusion: Use of O-arm imaging system ensures accurate screw placement and dramatically decreases screw malplacement rate, thus providing better patient safety. Its use is especially beneficial in academic and teaching centers where novice surgeons can attain results equivalent to that of experts in spinal instrumentation.

Can glasgow score at discharge represent final outcome in severe head injury

Background: Patients with head injury continue to improve over time and a minimum follow-up of six months is considered necessary to evaluate outcome. However, this may be difficult to assess due to lack of follow-up. It is also well known that operated patients who return for cranioplasty usually have the best outcome. Aims and Objectives: To assess the outcome following severe head injury using cranioplasty as a surrogate marker for good outcome. Materials and Methods: This was a retrospective study carried out from January 2009 to December 2010. All patients with severe head injury who underwent decompressive craniectomy (DC) in the study period were included. Patients who came back for cranioplasty in the same period were also included. Case records, imaging and follow up visit data from all patients were reviewed. Glasgow Coma Score (GCS) on admission and Glasgow Outcome Score (GOS) at discharge were assessed. Observations and Results: Of the 273 patients, 84.25% (n=230) were males and 15.75% (n= 43) were females. The mean age was 34.3 years (range 2-81 years, SD 16.817). The mean GCS on admission was 5.615 (range 3-8, SD 1.438). The in-hospital mortality was 54% (n=149). Good outcome (GOS of 4 or 5) at discharge was attained in 22% (n=60) patients. Sixty five patients returned for cranioplasty (with a GOS of 4 or 5) during the study period. There was no statistical difference in the number of patients discharged with good outcome and those coming back for cranioplasty in the study period (P>0.5). Patients who came back for cranioplasty were younger in age (mean age 28.815 years SD 13.396) with better admission GCS prior to DC (mean GCS 6.32 SD1.39). Conclusions: In operated severe head injury patients significant number of patients (24% in our study) have excellent outcome. However, insignificant number of patients had further improvement to GOS 4 or 5 (good outcome) from the time of initial discharge. This suggests that due to lack of intensive rehabilitative facilities, GOS at discharge may be representative of final outcome in the vast majority of cases of severe head injury in developing countries like India

Outcome in 2068 patients of head injury: Experience at a level 1 trauma centre in India.

Background: Traumatic brain injury (TBI) is one of the leading causes of death. Evidence-based guidelines for TBI care have been widely discussed, but in-hospital treatment and outcome of these patients has been highly variable especially in developing countries like India. Objectives: To evaluate the epidemiology and outcome of patients with head injuries at a Level 1 trauma center in India. Materials and Methods: In this retro-prospective study, all patients with head injury who were admitted in the department of neurosurgery over a 15 months period (November 2007-January 2009) were included in the study. Post-resuscitation GCS was used for categorizing the severity of head injuries and outcome was assessed at discharge using GOS. All patients were managed as per laid down departmental protocols. Results: A total of 2068 patients of head injury were admitted during the study period. The mean age was 24 years (range 1-85). 71.4% were male and 28.6% were female. The most commonly involved age group was 20-40 years (43%) and the most common mode of injury was road traffic accidents (64%). 53% of the patients had severe head injury (GCS ≤ 8), 18% had moderate head injury (GCS 9 ≤ 13) and 29% had minor head injuries (GCS ≥ 14). The mean hospital stay was 14 days (range 1-62 days). Overall in-hospital mortality was 22% (454 cases). 39% died within 48 hours of injury. 2% of minor, 12% of moderate and 36% of severe head injured patients expired; Mortality was 38% in children (≤12 years). Amongst those who survived, 45% had good outcome (GOS 4 or 5), 13% were severely disabled (GOS 3) and 19% were vegetative (GOS 2). Conclusions: This is the one of the largest single center study on severe head injuries and shows enormity of the problem facing developing countries like India.

Use of O-arm for spinal surgery in academic institution in India: Experience from JPN apex trauma centre

There is a relatively high incidence of screw misplacement during spinal instrumentation due to distortion of normal anatomy following spinal trauma. The O-arm® is the next-generation spinal navigation tool that provides intraoperative 3-D imaging for complex spine surgeries. In this prospective study over 1-month period, 25 patients (mean age 29.16 years (range 7-58 years), 22 (88%) males) with spinal injury who underwent spinal instrumentation under O-arm® guidance were included. Fall from height (64%) was the most common etiology seen in 16 patients. The majority (68%) had dorsolumbar fractures. Spinal canal compromise was seen in 21 patients (84%). Ten patients (40%) had American Spinal Injury Association (ASIA) grade A injuries, two patients (8%) had grade B, five patients (20%) had grade C, four patients (16%) each had grade D, and grade E injuries. A total of 140 screws were inserted under O-arm guidance. Of these, 113 (81%) were dorsolumbar pedicle screws, 2 were odontoid screws, 12 were anterior cervical screws, and 12 screws (48%) were lateral mass screws. Mean duration of surgery was 4.5 h with a mean blood loss of 674 mL. The mean postoperative stay was 6.3 days. None of the patients had screw malplacement ort canal breach. No patient deteriorated in ASIA grade postoperatively. The system was rated as excellent for ease of use by all faculty using the system. Accurate screw placement provides better patient safety and reduces the in hospital stay thereby leading early patient mobilization and may reduce the cost incurred in patient management.

Initial experience with mobile computed tomogram in neurosurgery intensive care unit in a level 1 trauma center in India

Neurosurgical patients, in particular patients with severe head injury require frequent computed tomogram (CT) of the head, usually at short notice. A mobile CT may prove to be invaluable for these patients. This report reviews the initial experience with a mobile CT at tertiary trauma center. A total of 1292 head CT scans were done during 9 months study period with an average of 4.78 CT scans for day. Of the 563 patients in whom the detailed prospective data was available, 456 (81%) patients were on ventilator, 450 (80%) patients were on sedation, and 37 (6.5%) patients were on ionotropic support at the time of doing CT scan. The mean Glasgow Coma Scale score at the time of CT was 8.1 (range 3-15). The average time to do a CT scan (from time of request to transmission into picture archiving and communication system) was 12.6 min (range 7.8-47 min). Image quality was judged to be excellent by all the neurosurgical faculty in the intensive care unit. During the study period, the main CT scanner broke down four times (for variable time periods) and the mobile CT scanner could manage the load of severe head injured patients in the casualty without any problems. The mobile CT machine itself broke down 36 times and the mean response time was 12.5 h (range 1-144 h) during each breakdown point. This experience suggests that mobile CT is extremely useful in the management of patients with severe traumatic brain injury and can be recommended for any high-volume neurosurgery department in the country.

Orbital roof intradiploic meningioma in a 16-year-old girl

Primary intraosseous or ectopic meningioma of the skull is a rare tumor accounting for about 1% of meningioma. Intradiploic meningioma is an extremely rare type of extraneuraxial meningiomas. Intradiploic meningioma of the orbit is extremely rare, and <8 such cases are reported till date in western literature occurring in the pediatric age group. Here the authors present a case of 16-year-old female, who presented with progressive proptosis, with normal vision and was managed successfully surgically. Clinical features, pathophysiology, and surgical management of this rare entity are discussed in the context of pertinent literature.

Hospital acquired infections: preventable cause of mortality in spinal cord injury patients.

Background: There is an alarming rate of morbidity and mortality observed in the trauma victims who suffer spinal cord injuries (SCI). Such patients are admitted immediately and stay for longer periods of time and thus are at risk of acquiring nosocomial infections. Aims: The aim of this study is to analyze the primary cause of mortality in SCI patients. Design: Retrospective study. Materials and Methods: We conducted a retrospective 4 year analysis of the postmortem data of 341 patients who died after sustaining SCI at a tertiary care apex trauma center of India. Epidemiological data of patients including the type of trauma, duration of hospital stay, cause of death and microbiological data were recorded. Results: On autopsy, out of 341 patients, the main cause of death in the SCI patients was ascertained to be infection/septicemia in 180 (52.7%) patients, the rest 161 (47.2%) died due to severe primary injury. Respiratory tract infections (36.4%) were predominant followed by urinary tract infections (32.2%), blood stream infections (22.2%), wound infections (7.1%) and meningitis reported in only 5 (2.1%) cases. Acinetobacter sp (40%) was the predominant organism isolated, followed by Pseudomonas sp (16.3%), Klebsiella sp (15.1%), Candida sp (7.8%), Escherichia coli (6.9%), Staphylococcus aureus (6.9%), Proteus sp (3.3%), Enterobacter sp and Burkholderia sp (two cases each) and Stenotrophomonas sp (one case). A high level of multidrug resistance was observed. Conclusions: Hospital acquired infections (HAI) are leading cause of loss of young lives in trauma patients; hence efforts should be made to prevent HAIs.

Split cord malformation with dorsally located bony spur: Report of four cases and review of literature

Split cord malformations (SCM) with a dorsally located bony spur are a very rare entity. The authors report a series of four such cases. The literature is reviewed regarding the pathogenesis and management of this uncommon variant of SCM. The presenting features include – scoliosis with motor and autonomic dysfunction (n = 1), scoliosis with cutaneous patch (n = 1), hypertrichotic area (n = 1), and motor deficits alone (n = 1). The location of spur was thoracic and lumbar in two patients (50%) each. Low-lying conus was present in three patients. Long segment syrinx was present in one patient. With respect to the bony anomalies, two patients had a hypertrophied posterior arch (HPA) and one patient had a dysraphic spine. All patients underwent surgical excision of the spur with detethering, if a low-lying conus was present. Two patients developed transient worsening of the neurological status after surgery which recovered at the time of the last follow-up; in both these patients, there was a HPA and a low-lying conus. Surgical excision of the spur with detethering of filum, in cases of low-lying conus, is the treatment of choice. Risk of post-operative worsening of the neurological status is increased in cases in which there is concomitant presence of HPA.

Cranioplasty as a surrogate marker for excellent outcome in severe head injury

Abstract Outcome in severe head injury is difficult to assess due to lack of follow up. Operated patients who return for cranioplasty usually have the best outcome. The aim of this study was to assess outcome following severe head injury using cranioplasty as a surrogate marker. This was a retrospective study carried out from November 2008 to March 2010. All patients with severe head injury who underwent decompressive craniectomy (DC) or cranioplasty in the study period were included. Case records, imaging and follow up visit data from all patients were reviewed. Glasgow Coma Score on admission and Glasgow Outcome Score at discharge were assessed. Of the 273 patients, 84.25% (n=230) were male and 15.75% (n=43) were female. The mean age was 34.3 years (range 2–81 years SD 16.817). The mean GCS on admission was 5.615 (range 3–8, SD 1.438). The in-hospital mortality was 54% (n=149). GOS of 4 or 5 at discharge was attained in 22% (n=60) patients. Sixty five patients returned for cranioplasty during follow up. The M:F ratio (6.2:1) matched with the study cohort. However, the difference in mean age (28.815 years SD 13.396) and mean GCS on first admission of 6.323 (SD 1.393) were statistical significant. Therefore, at the very minimum, 65 patients (24%) of the study cohort had excellent outcome. In operated severe head injury patients significant number of patients (24% in our study) have excellent outcome. Also, cranioplasty can serve as a useful marker to assess outcome of operated severe head injury patients in an institution.