Jayesh Sardhara

Craniovertebral junction anomalies: When is resurgery required?

BACKGROUND Craniovertebral junction (CVJ) abnormalities, such as atlantoaxial dislocation (AAD) with or without basilar invagination (BI), with or without associated Chiari malformation (CM), may cause a high cervical myelopathy. Occasionally, mechanical factors such as inadequate canal decompression, torticollis, and/or scoliosis may lead to lack of improvement following the primary surgery. Furthermore, implant-related factors, requiring implant revision/removal, or the presence of surgical site infections may cause the patient to undergo resurgery. AIMS This study was aimed at highlighting the underlying etiopathogenesis of resurgery following the primary surgery undertaken in CVJ abnormalities. SETTING AND DESIGN This was a retrospective study from a tertiary care referral institute focusing on 414 operated cases of CVJ anomalies. MATERIALS AND METHODS The data of 55 patients who underwent resurgery included their clinicoradiological assessment and operative records. The inclusion criteria included failed primary procedure, repeat procedure for construct failure, infection at the surgical site, or wound dehiscence. Pure CM patients without bony anomalies were excluded from the study. RESULTS A total of 137 procedures were performed in 55/414 (13%) patients. Causes of resurgery could be divided into ventral [redo or denovo transoral decompression (TOD) or wound-related complications, n = 33, 40.2%] and dorsal causes (implant-related factors/wound infections, n = 49, 59.8%). De novo TOD was done in persisting myelopathy following posterior fusion (PF) with C1-2 distraction (n = 15,18.3%,). Redo TOD was done for residual anterior bony compression [n = 8, 9.6%, OR 0.61; [CI = 0.20-1.86]. Causes for oral wound reexplorations (n = 10, 12.2%) included velopharyngeal insufficiency, wound resuturing, oral bleeding, and cerebrospinal fluid (CSF) leak. Dorsal causes included: (A) Implant factors (n = 27, 32.7%) and (B) neck wound reexplorations (n = 22, 26.8%). Presence of subaxial spine scoliosis, torticollis, and asymmetric joints increased the incidence of reexploration. Occipitocervical fusion rather than C1-2 fusion was more prone towards construct loosening. CONCLUSIONS Patients undergoing distraction with PF may require transoral surgery due to persisting myelopathy, especially in the presence of torticollis, scoliosis, and symmetrical joints. Single stage TOD+PF increases the chances of implant infection due to tissue contamination, bacteremia, or transfacetal migration of microbes. Chronic/recurrent sinus is usually a harbinger of deeper infection and can be cured with implant removal.

Remote cerebellar hemorrhage: Report of 2 cases and review of literature

Remote cerebellar hemorrhage (RCH) is an extremely rare and potentially devastating complication of supratentorial and spinal surgeries. While there are numerous postulates explaining the patho-physiology behind this phenomenon, including the most popular CSF over drainage theory, the exact cause for the same is still largely unknown. In this report, we present 2 cases of remote cerebellar hemorrhage encountered following 2 different surgical procedures. One patient had preceding pterional craniotomy for ruptured anterior communicating artery aneurysm while the other one developed RCH after placement of EVD. Both of them had history of poorly controlled hypertension, contrary to most reports where hypertension has not been found to be commonly associated with it. Moreover, while most cases have been reported to occur following supratentorial craniotomies and spinal surgeries, one of our patients developed the same after placement of the EVD, which, to the best of our knowledge, has not been reported earlier.

Evaluating Atlantoaxial Dislocation Based on Cartesian Coordinates: Proposing a New Definition and Its Impact on Assessment of Congenital Torticollis

BACKGROUND Conventional 2-dimensional (2-D) definition of atlantoaxial dislocation (AAD) is inadequate for coexisting 3-D displacements. OBJECTIVE To prospectively classify AAD and its related abnormalities along 3 Cartesian coordinates and assess their association with torticollis. METHODS One hundred and fifty-four patients with congenital AAD were prospectively classified according to their C1-2 displacement along 3 Cartesian coordinates utilizing 3-D multiplanar CT. The impact of this 3-D dislocation on occurrence of clinically manifest torticollis was also evaluated and surgical treatment was planned. RESULTS Three dimensional CT assessment detected the following types of C1-2 dislocations: I:translational dislocation (along Z coordinate, n = 37 [24%]); II: central dislocation (along Y coordinate, n = 10 [6.5%]); III: translational+central dislocation (along Z+Y coordinates, n = 42 [27.3%]); IV: translational dislocation+ rotational dislocation+coronal tilt (along Z+X coordinates, (n = 6 [3.9%]); V: central dislocation (basilar invagination)+rotational dislocation+coronal tilt (along Y+X coordinates, n = 11 [7.1%]); VI: translational dislocation+ central dislocation+ rotational dislocation+ coronal tilt (along all 3 axes, n = 48 [31%]). Assessing degree of relative C1-2 rotation revealed that 27 (37%) of 85 patients with <50 rotation and 54 (78%) of 69 patients with >5° rotation had associated torticollis. Translational dislocation had negative association (odds ratio [OR] 0.1, 95% confidence interval [CI; 0.47-0.32], P = .00), while type VI (OR 5.0, 95% CI [2.2-11.19], P = .00), type V (OR 4.44, 95% CI [0.93-21.26], P = .04), and type IV (OR 1.84, 95% CI [0.32-10.38], P = .48) dislocations had strong positive association with torticollis. Sixty-two (40%) patients improved, 68 (44%) remained unchanged, and 24 (16%) patients worsened postoperatively. Twenty-eight patients required second-stage transoral decompression following posterior distraction-fusion due to neurological nonimprovement. CONCLUSION Three-dimensional assessment of AAD including evaluation of culpable C1-2 facet joints addresses anomalous displacements in 3 Cartesian planes. This provides targets for adequate cervicomedullary decompression-stabilization, and helps in the management of accompanying torticollis.

Spinal intradural hydatid cyst causing arachnoiditis: A rare etiology of cauda equina syndrome

This study aims to focus on a rare presentation of spinal hydatid cyst as cauda equine syndrome and misdiagnosed as intradural extramedullary (IDEM) benign lesion on magnetic resonance imaging. In this article, we report a case of spinal hydatid cyst masquerading as IDEM tumor, and intraoperatively, we accidently find clumped granuloma with severe arachnoiditis and hydatid cyst in lumber region, which was present as bilateral S1 radiculopathy with cauda equina syndrome. An 11 year old boy who presented with symptoms and signs of cauda equina syndrome and planned for surgical excision. His radiological impression was IDEM possibly neurofibroma. To our surprise, we found multiple intradural cystic lesions with arachnoiditis. Dissecting in plane cyst was flushed out, and surgical cavity was irrigated with 3% saline. Postoperatively histopathology and serum tests confirmed the diagnosis of hydatid cyst. Hydatid disease is rare cause of cauda equine syndrome which can be miss diagnosed on radiological investigations. A high index of suspicion should be kept especially in a young patient from the Indian subcontinent.

Cervicomedullary intramedullary peripheral primitive neuroectodermal tumor with intratumoral bleed: Report of one case and review of literature

Primitive neuroectodermal tumors (PNET) are highly malignant, yet relatively uncommon neoplasms of the central nervous system. Although a host of different parts of the nervous system can be affected, intramedullary location of PNET is extremely rare. Most reports on intramedullary PNET have reported central PNET (cPNET); peripheral PNET (pPNET) affecting intramedullary spinal location is extremely rare. Till now, seven such cases of intramedullary pPNET have been described in medical literature in English. Here, we report an 11-year-old boy with cervicomedullary junction intramedullary pPNET who presented with intratumoral bleed, wherein the clinical presentation and radiological features gave us no clue preoperatively about the underlying diagnosis. In this report, we additionally review certain salient aspects of this dreaded disease in light of the existing evidence.

Bilateral Cervical Lymphangioma of The Neck In An Adult: A Rare Case with Review of Literature

Lymphangiomas of the head and neck are sometimes referred to as cystic hygromas and result from abnormal growth of the lymphatic vessels. Lymphangiomas are most commonly found in children and very rarely observed in adults. Most lymphangiomas are congenital, but they have also been reported secondary to infections, neoplasms, trauma, and iatrogenic injuries. The authors report the case of an adult female with a slowly enlarging neck mass that was resected and identified by pathology as a lymphangioma. The literature is reviewed and the classification, symptoms, diagnosis, and treatment of lymphangiomas are discussed. Observation is recommended for small, non-expanding lesions. Surgical resection is recommended for lesions that persist, enlarge, or produce obstructive symptoms. Careful surgical planning is critical to avoid injury to

A low-lying, solitary, bihemispheric PICA with an associated spontaneous vertebral-PICA dissecting aneurysm

Sir, The unique variation of a low-lying, solitary, bihemispheric posterior inferior cerebellar artery (PICA)with vertebral artery (VA)-PICA dissection that resulted in VA luminal compromise as well as subarachnoid haemorrhage (SAH) due to an associated PICA dissecting aneurysm is described. This 26-year-old male patient presented with two episodes of sudden-onset severe holocranial headache with recurrent vomiting within 2 weeks. He progressively deteriorated to complete unresponsiveness and an extensor posturing within 12 h. His computed tomographic (CT) scan showed Fischer grade IV subarachnoid with intraventricular hemorrhage with moderate ventriculomegaly. An external ventricular drainage improved his neurological status to following simple commands but disoriented and possessing purposeful movements (modified Hunt and Hess grade IV). His CT-angiogram showed a low-lying origin of right PICA in close proximity to the occipital condyle at the foramen magnum. The segment of VA just before the origin of right PICA had excessive tortuosity and an abrupt and irregular luminal narrowing. There was also a laterally directed aneurysm in the anterior medullary segment of PICA (Fig. 1a, b and c). His digital subtraction angiogram (DSA) confirmed that the right PICA emerged just proximal to the neck of the aneurysm at the level of foramen magnum and was supplying both cerebellar hemispheres. There was an irregular and abrupt, short-segment dissection of the right VA with decreased blood flow in the distal right VA beyond the origin of PICA. The narrowing due to the dissection extended for a short distance into the anterior medullary segment of right PICA and was associated with an irregular, bilobed aneurysm with an ill-defined neck (Fig. 1d, e and f). The contralateral VA was supplying the basilar artery with a dominant left anterior inferior cerebellar artery (AICA) and absence of right PICA. The internal carotid artery (ICA) injections also revealed a good bilateral posterior cerebral artery (PCA) as well as a retrograde basilar artery supply through the posterior communicating arteries At surgery (Fig. 2), in lateral position, using the extreme lateral transcondylar approach, the extradural VA (along lateral upper border of C1 posterior arch) was traced to its intradural segment. The distal VA and a small part of proximal anterior medullary PICA were narrow. A large partially thrombosed anterior medullary segment PICA aneurysm was lying anterolateral to the lower medulla. Two straight, permanent 7-mm Yasargil titanium clips were applied to clip the neck of the aneurysm and its thrombosed fundus excised. The patient also underwent a ventriculoperitoneal shunt for postoperative hydrocephalus and improved to modified Hunt and Hess grade II status. The low-lying, solitary PICA in our patient had a bihemispheric supply. The PICA originates most frequently from the intracranial portion of the VA, approximately 15 mm proximal to the vertebrobasilar junction, along the lateral aspect of medulla [2, 6, 7]. During development, at the upper cervical level, a lateral spinal longitudinal artery (LSA), lying lateral to the cord and ventral to the posterior cervical nerve roots ends into the intradural portion of VA at C1 and or joins the PICA. A low-lying PICA may occur if a longitudinal continuity is established between the PICA and the LSA with the PICA eventually originating from the J. Sardhara : S. Behari (*) :A. K. Jaiswal :R. N. Sahu Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226014, India e-mail: sbehari27@yahoo.com

A device for three-dimensional quantitative assessment and alignment of C1-2 vertebrae during posterior distraction and fusion technique for atlantoaxial dislocation and/or basilar invagination

The most common type of congenital C1-2 dislocation is a combined type in which atlanto-axial dislocation (AAD) and basilar invagination (BI) are often associated with a rotational dislocation and coronal tilt. An optimal surgical treatment involves reduction of AAD and BI with simultaneous correction of the rotation and coronal tilt to achieve an optimal cervical canal decompression, sagittal and coronal realignment and bony fusion. The most acceptable technique to facilitate this correction is the C1-C2 distraction technique, which is accomplished by the manual joint manipulation. In this study, the authors describe an instrument that accomplishes distraction of the C12 joint space along with its quantitative assessment, permits the easy installation of a joint spacer without damage to the articular surfaces, brings about reduction of AAD and BI, while simultaneously also helping in the correction of the coexisting coronal tilt and rotational dislocation. This distractor not only achieves a multi-planar three-dimensional correction of the displacements at the C1-2 vertebral level, but may be used for the quantitative assessment of the correction and is compatible with the related surgical instruments of all standard companies utilized in this operative procedure.

Technical pearls and surgical outcome of early transitional period experience in minimally invasive lumbar discectomy: A prospective study

Background: There is growing indications of minimally invasive spine surgery. The inherent attitude and institutive learning curve limit transition from standard open surgery to minimally invasive surgery demanding understanding of new instruments and correlative anatomy. Materials and Methods: In this prospective study, 80 patients operated for lumbar disc prolapse were included in the study (between January 2016 and March 2018). Fifty patients (Group A) operated by various minimally invasive spine surgery (MISS) techniques for herniated disc disease were compared with randomly selected 30 patients (Group B) operated between the same time interval by standard open approach. Surgical outcome with Oswestry Disability Index (ODI) and patient satisfaction score was calculated in pre- and postoperative periods. Results: Mean preoperative ODI score in Group A was 31.52 ± 7.5 standard deviation (SD) (range: 6–46; interquartile range [IQR]: 8; median: 32.11) and postoperative ODI score was 9.20 ± 87.8 SD (range: 0–38; IQR: 11; median: 6.67). Mean preoperative ODI score in Group B was 26.47 ± 4.9 SD (range: 18–38; IQR: 4; median: 25) and postoperative ODI score was 12.27 ± 8.4 SD (range: 3–34; IQR: 12; median: 10.0). None of the patients was unsatisfied in either group. On comparing the patient satisfaction score among two groups, no significant difference (P = 0.27) was found. Discussion: On comparing the change in ODI and preoperative ODI among both groups, we found a significant difference between the groups. It is worth shifting from open to MISS accepting small learning curve. The satisfaction score of MISS in early transition period is similar to open procedure. Conclusion: The MISS is safe and effective procedure even in transition period for the central and paracentral prolapsed lumbar intervertebral disc treatment. The results are comparable, and patient satisfaction and symptomatic relief are not compromised.

Surgical outcome in cortical ependymoma: A single centre experience of 18 cases

Cortical ependymomas (CE) are rare subset of supratentorial ependymoma which are located in the peripheral cortical rim without any connection to the ventricular lining. With limited cases previously reported, current knowledge on diagnosis and management of tumors is lacking. We present the largest single center experience on CE reported so far and highlight their clinico-radiological aspects, histopathological features as well the results of their surgical excision. We studied 18 CE patients undergoing surgical excision at our center between September 2009 to November 2017. Clinical, radiological, histopathological and operative data was obtained from hospital records. Functional assessment of our patients were done using the Karnofskys performance score (KPS). Survival analysis was done using Kaplan-Meier method and log rank test. Mean age of patients in our study group was 19 ± 11.1 years. Frontal lobe was the most frequently involved region. Features of raised intracranial pressure like holocranial headache (n = 15, 83.33%) and vomiting (n = 9, 50%) were most common presenting complaints in our study. Gross total resection of tumor was achieved in eleven patients (61.11%). Histopathology showed equal number (n = 9) of WHO grade 2 and 3 ependymoma. During 111 months follow-up, four patients (22.22%) developed recurrence and three patients (16.66%) died. Five years overall survival (OS), progression-free survival (PFS) rate were 74.3% and 70.7%. In view of higher risk of progression to higher histo-pathological grade and local recurrence years after surgical excision, a long clinical and radiological follow-up is advised.