Ritesh Kansal

An intradural–extramedullary gas-forming spinal abscess in a patient with diabetes mellitus

Spinal infections are commonly reported to be located in the extradural or intramedullary spaces. Infection involving the intradural-extramedullary space are uncommon. We report a patient with uncontrolled diabetes mellitus and an infected foot ulcer who presented with a cervical cord abscess and intradural gas. Early diagnosis and aggressive treatment are necessary for a favourable outcome in gas-forming intradural spinal abscesses. To our knowledge, a gas-forming intradural spinal abscess has not been reported previously and we discuss the relevant literature.

Jarcho-Levin syndrome with diastematomyelia : A case report and review of literature

Jarcho–Levin syndrome (JLS) is a type of segmental costovertebral malformation. It is a congenital disorder characterized by a variety of vertebral and costal anomalies. Only four cases of Jarcho–Levin syndrome with diastematomyelia have been reported in the literature. We report the fifth case of Jarcho–Levin syndrome with diastematomyelia and review the literature. A one-and-half-year-old male child born of full-term normal delivery was brought with complaints of progressively increasing weakness in lower limbs with inability to stand since 1 month. Radiological examination revealed irregular fusion of ribs, spina bifida, and diastematomyelia at L2–L3 vertebral level. The patient underwent L1 to L3 laminectomy. A large bony spur was identified and excised with microrongeurs. Spondylocostal dysplasia may be associated with diastematomyelia or other surgically correctable occult intraspinal anomalies which may be diagnosed in early asymptomatic stage by magnetic resonance image screening of spine.

Cervical intradural disc herniation and cerebrospinal fluid leak

Cervical intradural disc herniation (IDH) is a rare condition and only 25 cases of cervical have been reported. We report a 45-year-old male who presented with sudden onset right lower limb weakness after lifting heavy weight. Magnetic resonance imaging of the cervical spine showed C5/6 disc prolapse with intradural extension. The patient underwent C5/6 discectomy through anterior cervical approach. Postoperatively, the patient improved in stiffness but developed cerebrospinal fluid leak and the leak resolved with multiple lumbar punctures.

Dolichoectasia of vertebrobasilar arteries as a cause of hydrocephalus

Dolichoectasia of vertebrobasilar artery is a condition in which the vertebral/basilar artery is elongated, distended and tortuous. It is usually asymptomatic. It may present with compressive or ischemic symptoms. Hydrocephalus as a complication of vertebrobasilar dolichoectasia is rare. We present a case of a 60-year-old male with dolichoectasia of the basilar artery causing compression of the third ventricular outflow and, thus, presenting with noncommunicating hydrocephalus.

An anterior high cervical retropharyngeal approach for C1-C2 intrafacetal fusion and transarticular screw insertion.

Craniovertebral instability is a significant challenge to neurosurgeons. We describe an alternative anterior high cervical retropharyngeal approach for C1-C2 intrafacetal fusion and transarticular screw insertion. We dissected 10 cadaveric specimens and fixed the atlantoaxial joint with C1-C2 intrafacetal fusion and transarticular screw insertion. We achieved good surgical exposure and fixation in all cadavers with this technique. The anterior high cervical retropharyngeal approach for C1-C2 intrafacetal fusion and transarticular screw insertion may provide an alternative fusion technique for craniovertebral fusion.

Fat graft migration causing recurrent cervical cord compression.

AIM Fat graft migration following spinal cord surgery is an uncommon problem. Only few cases of fat graft migration causing cauda equine syndrome, recurrent sciatica, and root compression following lumbar spine surgery have been reported. We report a case of fat graft migration causing symptomatic cervical cord compression. MATERIAL AND METHODS A 45-years-old male with cervical spondylosis underwent anterior C4-5 discectomy and excision of hypertrophied ligament. A dural tear that occurred during the procedure was repaired with fat graft harvested from thigh. Significant improvement in stiffness was noted postoperatively. After 15 days, the patient presented again with worsening lower limbs stiffness. Magnetic resonance imaging of spine was done which revealed displacement of the fat graft causing cervical cord compression. RESULTS Re-exploration was done and the migrated fat graft was removed. Post operatively patient noticed significant improvement in stiffness in both lower limbs. CONCLUSION Autologous fat graft is one of the best materials used in sealing the dural cerebrospinal fluid leak during spinal surgery. However sometimes it may migrate and cause compression of cord and roots with relative symptoms. This complication should be kept in mind as removal of migrated fat graft will relieve these symptoms.

Giant intramedullary epidermoid extending from the brain stem to the upper thoracic spinal cord.

Epidermoid cysts are benign tumors originating from ectoderm remnants. Most epidermoid cyst cases are intracranial. Spinal epidermoid cysts are uncommon and most of the reported cases are in the thoracic and lumbar spine. Occurrence of intramedullary epidermoid cysts in the cervical spine is extremely rare. An 18-year-old male with a giant intramedullary tumor extending from the brain stem to the upper thoracic spinal cord presented at our outpatient department. The patient underwent total excision of a silvery white lesion through a midline myelotomy. Histopathological examination was suggestive of an epidermoid cyst. We present a brief report of the case and discuss the relevant literature.

Cerebrospinal fluid rhinorrhea after ventriculoperitoneal shunt in a patient with tectal plate glioma

Cerebrospinal fluid (CSF) rhinorrhea due to a remote tumor is a rare but increasingly reported condition, where it is usually a presenting complaint. CSF rhinorrhea occurring after tumor decompression has also been reported. We report a patient with tectal plate glioma that caused CSF rhinorrhea following insertion of ventriculoperitoneal shunt. The pathophysiology of CSF rhinorrhea is also discussed.

Right cerebellar peduncle neurocysticercois presenting with bradycardia

Dear editor, Bradycardia in neurosurgical practice is usually attributable to raised intracranial tension. Rarely bradycardia may occur due to the direct involvement of the vasomotor center within the brainstem [5]. Brain stem lesions are known to cause cardiovascular autonomic dysfunction [3]. Neurocysticercosis a parasitic disease of central nervous system commonly presents with seizures, headache or focal neurological deficit. Bradycardia is known in neuricysticercosis with raised intracranial pressure. We present a case of neurocysticercosis of right cerebellar peduncle with bradycardia for 5 years and no evidence of increased intracranial pressure. Surgical excision of the cyst cured the bradycardia. A 32-year-old male, diagnosed as sick sinus syndrome since 5 years presented with headache, giddiness, and imbalance for the past 20 days. The patients pulse was regular, normal volume and 50/min at rest. The examination of the patient was normal except for cerebellar signs. Fundus examination was normal. MRI of the brain showed a smooth walled cyst within the right middle cerebellar peduncle (Fig. 1) with no obvious solid portion. The cyst did not enhance on contrast administration. In view of the progressive cerebellar deficits and ambiguous nature of the cyst etiology, the cyst was excised. The patient had a rapid recovery from the headaches and cerebellar deficits. It was noted that the patients bradycardia had resolved and the pulse rate was in the normal range. Histopathology confirmed neurocysticercosis. The patient was treated with a course of albendazole. The patient was symptom free with a normal pulse at follow-up at 3 months. A cardiac review of the patient was normal. Brainstem is an essential region in the regulation of the autonomic cardiovascular functions. Bradycardia is a classic sign of the Cushings reflex denoting raised intracranial tension [1]. Central or uncal herniation due to intracranial pressure leads to compression and stretching of the brainstem, responsible for bradycardia. The vasomotor area in the medulla may be responsible for this. The importance of this region in parasympathetic and sympathetic cardiovascular functions is known. Manipulation of the medulla is known to cause bradycardia during surgery [2, 7]. Activation of sublobule IX-b of the cerebellar vermis has been shown to evoke hypotension, bradycardia, and decrease of phrenic nerve activity in anesthetized animal

Cemento-ossifying fibroma presenting as a posterior fossa mass lesion.

Cemento-ossifying fibromas are benign lesions of the jaw, which arise from the periodontal membrane. Histopathologically these are composed of fibrous tissues with calcified structures resembling bone and cementum. Surgical resection is the treatment of choice. They have rarely been reported in the ethmoid sinus, maxillary sinus and sphenoid sinus Mastoid bone is an extremely rare site of such tumors. Only one case of cemento-ossifying fibroma of petromastoid bone has been reported before. We present a case of cementoossifying fibroma involving the petromastoid bone, with the large intracranial component causing compression on the cerebellum. This unique case may provide insight into the etiopathogenesis of these tumors.