Surgical Management of Spinal Tuberculosis - A Retrospective Observational Study from a Tertiary Care Center in Karnataka.

CONTEXT: Tuberculosis (TB) is a common infectious disorder in developing countries. A significant load of patients with extrapulmonary TB are diagnosed in our institute, mostly involving the spine. AIM: We aimed to present our experience in the surgical management of spinal TB. SETTING AND DESIGN: This was a retrospective observational study. MATERIALS AND METHODS: Seventy patients (year 2016-2018) who underwent surgical management with minimum of 1-year follow-up (17 patients lost during follow-up) were graded as per the American Spinal Injury Association (ASIA) grading system for neurological deficits. All were surgically treated with laminectomy and epidural abscess drainage/transpedicular debridement of granulation with/without spinal stabilization. Thoracic and lumbar cases were managed by posterior approach; among them, 12 patients who had no significant cord compression and good ASIA grade with facet involvement (requiring fusion) underwent minimally invasive pedicle screw fixation. Cervical cases were managed mostly by anterior approach. All patients received Anti-tubercular treatment (ATT) post operatively as per protocol postoperatively, following which magnetic resonance imaging (MRI) spine was done. STATISTICAL ANALYSIS: Data were analyzed using SPSS software version 18.0 (SPSS Inc. Released in 2009. PASW Statistics for Windows, version 18.0. Chicago, IL, USA: SPSS Inc.). The continuous variables were analyzed using descriptive statistics using mean and standard deviation. RESULTS: The average age was 42.5 years. The most common location was thoracic (28 patients), followed by lumbar (20 patients), cervical (16 patients), and thoracolumbar (6 patients). Twenty patients had epidural abscess with cord compression. All patients who presented within 4 weeks of onset of symptoms showed a statistically significant improvement postsurgery. Sixteen patients with epidural abscess had good neurological recovery immediately after surgery (ASIA B to ASIA D/E). Four patients with epidural abscess with late presentation remained ASIA A after surgery. All patients had good fusion rates (follow-up X-ray) at 1 year. After ATT course completion, all patients had complete eradication of disease (MRI spine). CONCLUSION: Surgical treatment for spinal TB, if performed early (within 4 weeks) with good decompression, results in satisfactory clinical outcome with early improvement in the neurological deficits. Posterior approach to the spine with decompression and fixation gives good results, and minimally invasive procedures further help lessen muscle dissection, less pain, and early mobilization.

Far lateral approach without occipital condylar resection for intradural ventral/ventrolateral foramen magnum tumors and aneurysms of V4 segment of vertebral artery: Review of surgical results.

BACKGROUND: Controversies exist regarding the need and extent of condylar resection for safe surgical management of intradural ventral/ventrolateral foramen magnum (VFM) tumors and aneurysms of V4 segment of vertebral artery (VA) by far lateral approach. This retrospective study was conducted to evaluate the results of basic far lateral approach(retrocondylar approach) without upfront occipital condylar resection. METHODS AND RESULTS: Twenty one patients underwent surgery via far lateral approach for intradural VFM tumors and aneurysms of V4 segment of VA at Sri Sathya Sai Institute of Higher Medical Sciences during 9 years(2008-2016) study period. Eight patients had VA aneurysms and 13 patients had intradural VFM tumors. After basic far lateral approach(retrocondylar approach), dura was opened and checked if the exposure was adequate for safe surgery. Retrocondylar approach provided adequate exposure for all these lesions and resection of occipital condyle/jugular tubercle was not required in any of these cases. Skeletonization or transposition of VA was not done in any of these cases. Gross total resection of the tumor could be done in 9 patients(9/13-69.2 %) and near total excision (>95 %) in 4 patients (4/13-30.8 %). Seven of the 8 VA aneurysms were successfully clipped. Outcome at a final follow up of 3 months or more was good(mRS<2) in 19 patients(19/21-90.5 %) and poor in 2 patients. Complications included lower cranial nerve deficits [transient-2/21(9.5 %), persisting-2/21(9.5 %)], motor deficits(2/21-9.5%), seventh nerve paresis(1/21-4.8%), sixth nerve paresis(2/21-9.5%) and pseudomeningocele(1/21-4.8%). CONCLUSION: Basic far lateral (retrocondylar) approach provides excellent exposure for majority of VFM tumors and aneurysms of V4 segment of VA. Condylar resection(transcondylar approach), drilling of jugular tubercle (transtubercular approach), skeletonization/transposition of VA might not be required for safe surgical management of majority of these lesions.

Extrapontine Myelinolysis and Reversible Parkinsonism After Hyponatremia Correction in a Case of Pituitary Adenoma: Hypopituitarism as a Predisposition for Osmotic Demyelination.

BACKGROUND: Osmotic demyelination syndrome commonly follows rapid correction of hyponatremia. Although pons is a common location, extrapontine locations, such as striatum and thalamus, have been reported. CASE DESCRIPTION: A 48-year-old woman presented with masked facies, shuffling gait, and pill-rolling tremors suggestive of acute-onset parkinsonism. Hyponatremia was diagnosed following a bout of diarrhea, which was corrected with hypertonic saline. Magnetic resonance imaging of the brain showed a giant pituitary adenoma. Hyperintensities on T2-weighted imaging were also seen at the level of pons and bilateral striatum. Central pontine myelinolysis and extrapontine myelinolysis were diagnosed. Hormonal assay showed hypocortisolism, secondary hypothyroidism, and hypogonadism. The patient was started on levodopa-carbidopa, steroids, and thyroxine. She underwent transnasal pituitary adenoma excision. At 6 months postoperatively, she had recovered completely with normal gait. Repeat imaging showed complete resolution of myelinolysis. At 36 months, she continued to have hypocortisolism and hypothyroidism requiring replacement. CONCLUSIONS: Extrapontine myelinolysis with parkinsonism and asymptomatic central pontine myelinolysis is rare with few cases described in the literature. Our patient had a pituitary adenoma with hyponatremia requiring sodium correction, and we believe that hypopituitarism might have predisposed her to osmotic demyelination. We reviewed relevant literature on extrapontine myelinolysis in suprasellar tumors and the pathophysiology. Hypopituitarism is an underrecognized cause of hyponatremia. When treating a patient with hyponatremia, knowing the pituitary function status is a prerequisite for the physician to prevent osmotic demyelination syndrome.

How I do it : anterior clinoidectomy and optic canal unroofing for microneurosurgical management of ophthalmic segment aneurysms.

BACKGROUND: Power drilling commonly used for anterior clinoidectomy and optic canal unroofing can result in thermal injury to the optic nerve. METHODS: The authors describe an intradural "limited drill" technique of anterior clinoidectomy and optic canal unroofing for microneurosurgical management of ophthalmic segment aneurysms, where optic canal unroofing is done with 1 mm Kerrison punch and the use of the power drill is restricted to anterior clinoidectomy to avoid thermal injury to the optic nerve. The optic nerve, internal carotid artery (ICA), and aneurysm are covered with wet gelfoam pieces to prevent any inadvertent contact with the drill. CONCLUSION: "Limited drill technique" is a safe and effective technique of anterior clinoidectomy and optic canal unroofing. KEY POINTS: • Anterior clinoidectomy and optic canal unroofing is an important skull base technique required for safe clipping of the majority of ophthalmic segment aneurysms • Power drilling commonly used for optic canal unroofing can cause thermal injury to optic nerve • More than 2 mm free space is available around the optic nerve in the optic canal • Foot plate of 1 mm Kerrison punch can be safely introduced within a normal optic canal without causing mechanical injury to the optic nerve • Reflection of posteriorly based dural flap acts as a dural barrier, preventing direct contact of drill bit to optic nerve, internal carotid artery and aneurysm during drilling • Entanglement of cottonoids to rotating drill bit is a major problem in intradural anterior clinoidectomy • Wet gelfoam pieces do not get entangled to the rotating drill bit • Structures surrounding the area of drilling can be covered with wet gel foam pieces to prevent direct contact of the drill to neurovascular structures • Opened cisterns can be covered with wet gelfoam pieces during drilling to prevent deposition of bone dust in the subarachnoid space • "Limited drill technique" of anterior clinoidectomy and optic canal unroofing is a safe and effective technique for the exposure of ophthalmic segment aneurysms.

Surgical management of thalamic gliomas: case selection, technical considerations, and review of literature.

This study aimed to identify (1) the thalamic gliomas suitable for surgical resection and (2) the appropriate surgical approach based on their location and the displacement of the posterior limb of the internal capsule (PLIC). A retrospective study over a 5-year period (from 2006 to 2010) was performed in 41 patients with thalamic gliomas. The mean age of these patients was 20.4 years (range, 2-65 years). Twenty (49 %) tumors were thalamic, 19 (46 %) were thalamopeduncular, and 2 (5 %) were bilateral. The PLIC, based on T2-weighted magnetic resonance axial sections, was displaced anterolaterally in 23 (56 %) cases and laterally in 6 (14 %) cases. It was involved by lesion in eight (20 %) cases and could not be identified in four (10 %) cases. Resection, favored in patients with well-defined, contrast-enhancing lesions, was performed in 34 (83 %) cases, while a biopsy was resorted to in 7 (17 %) cases. A gross total resection or near total resection (>90 %) could be achieved in 26 (63 %) cases. The middle temporal gyrus approach, used when the PLIC was displaced anterolaterally, was the commonly used approach (63.5 %). Common pathologies were pilocytic astrocytoma (58 %) in children and grade III/IV astrocytomas (86 %) in adults. Preoperative motor deficits improved in 64 % of the patients with pilocytic lesions as compared to 0 % in patients with grade III/IV lesions (P value, 0.001). Postoperatively, two patients (5 %) had marginal worsening of motor power, two patients developed visual field defects, and one patient developed a third nerve paresis. Radical resection of thalamic gliomas is a useful treatment modality in a select subset of patients and is the treatment of choice for pilocytic astrocytomas. Tailoring the surgical approach, depending on the relative position of the PLIC, has an important bearing on outcome.