Lumbar canal stenosis in "young" - How does it differ from that in "old" - An analysis of 116 surgically treated cases.

OBJECTIVE: Patients treated for lumbar canal stenosis (LCS) were retrospectively analyzed to evaluate the differences in clinical management in those below (Group A) and those above (Group B) the age of 50 years. All patients were treated with the premise that instability is the nodal point of the pathogenesis of LCS and "only-stabilization" is the surgical treatment. MATERIALS AND METHODS: During the period June 2014 to June 2020, 116 cases were diagnosed to have LCS and surgically treated by the Goel modification of Camille's transarticular screw fixation technique. RESULTS: Twenty-four patients in Group A and six patients in Group B had a history of "significant" injury to the back at the onset of clinical symptoms. The indices suggested that the intensity of symptoms was relatively more severe in Group A than in Group B. Unilateral leg symptoms were more common in Group A (68%) than in Group B (31.8%). Neurological motor deficits were more common in Group A (28%) than in Group B (12%) patients. Spinal segments surgically treated in Group A ranged from 1 to 4 (average 2 levels) and in Group B it ranged from 2 to 5 (average 3 levels). During the follow-up period that ranged from 6 to 72 months (average 37 months), 100% of patients had varying degrees of relief from symptoms. CONCLUSIONS: LCS is confined to a lesser number of spinal segments in the Group A patients. The symptoms were radicular in nature and relatively severe in Group A than in Group B patients.

Rotatory atlantoaxial dislocation presenting as spinal kyphoscoliosis.

A 16-year-old male presented with primary complaint of worsening dorsal spinal kyphoscoliosis (SKS) for 3 years. More recently, he developed spasticity in legs, breathlessness on mild exertion, and sleep apneas. Apart from SKS, investigations revealed rotatory atlantoaxial dislocation. Atlantoaxial fixation resulted in rapid recovery from all symptoms including from spinal deformity. Observations in this patient suggest that rotatory dislocation can be a cause of spinal deformity.

Silent stellate ganglion paraganglioma masquerading as schwannoma: A surgical nightmare.

A 28-year-old normotensive female presented with Horner's syndrome and paresthesia over the left side of the chest. Imaging study showed a large heterogeneous enhancing lesion in short-T1 inversion recovery sequence with flow voids in T2W sequence of magnetic resonance imaging. The lesion was located in the left-sided D1 and D2 regions extending into the neural foramina and apical part of the lung. During surgery, even minimal dissection of the tumor resulted in marked fluctuation in hemodynamic parameters, requiring temporary suspension of the surgery multiple times until hemodynamic parameters were brought under control by the anesthesiologist with drugs. The massive fluctuation in hemodynamic parameters in an unprepared and unanticipated scenario was a challenge for the anesthetist and surgeon. The tumor was radically excised with improvement of paresthesia in the immediate postoperative period, but Horner's syndrome persisted. After 18-months of follow-up, she was relieved of all symptoms including Horner's syndrome. Histopathological examination confirmed our suspicion as paraganglioma.

Optimizing Burr Hole Placement for Craniotomy: A Technical Note.

Objective Usually, burr holes are placed along the line of a craniotomy. We describe a novel technique of burr hole placement to obtain smooth and beveled bony margin without any troughs and crests. Dural separation is obtained by minimizing the number of burr holes required. Methods Fifty craniotomies of diameter ranging from 3.5 to 11.5 cm were accomplished by placing burr hole in the center of bone flap rather than along the craniotomy line permitting 360 degrees of dura separation dependent on the length of dura separator. Craniotomy < 9  cm in diameter was performed by placing a single burr hole and a larger size craniotomy was performed with two burr holes. Parasagittal craniotomy was performedby placing burr hole not > 2.5  cm away from expected craniotomy site, namely superior sagittal sinus area enabling separation of adhered dura and venous sinuses. The bone cutter was used in a particular fashion to create smooth margin and beveled edges. Results Craniotomy < 9  cm in diameter was possible with single burr hole in 34 cases. Craniotomy larger than 9  cm in size was performed in 16 cases with double burr hole by strategically placing burr in the center of the desired bone flap. The craniotomy was achieved in all cases without damaging dura and venous structures. Conclusions An optimally placed single burr hole is sufficient for small to moderately large size craniotomy. Larger size craniotomy is possible with minimum numbers of burr holes. This achieves good cosmesis and avoids sinking of the bone flap.

Volume change theory for syringomyelia: A new perspective.

BACKGROUND: The etiopathogenesis of syringomyelia is still an enigma. The authors present a novel theory based on fluid dynamics at the craniovertebral (CV) junction to explain the genesis of syringomyelia (SM). The changes in volume of spinal canal, spinal cord, central canal and spinal subarachnoid space (SSS) in relation to the posterior fossa have been analysed, specifically during postural movements of flexion and extension. The effect of fluctuations in volume of spinal canal and its contents associated with cerebrospinal fluid (CSF) flow dynamics at the CV junction have been postulated to cause the origin and propagation of the syringomyelia. The relevant literature on the subject has been reviewed and the author's theory has been discussed. CONCLUSION: Volume of spinal canal in flexion is always greater than that in extension. Flexion of spine causes narrowing of the ventral subarachnoid space (SAS) and widening of dorsal SAS while extension causes reverse changes leading to fluid movement in dorsal spinal SAS in flexion and ventral spinal SAS in extension. Cervical and lumbar spinal region with maximum bulk hence maximum area and volume undergo maximum deformation during postural changes. SSS CSF is the difference between the volume of spinal canal and spinal cord, varies in flexion and extension which is compensated by changes in posterior fossa (CSF) volume in normal circumstances. Blocked SAS at foramen magnum donot permit spinal SAS CSF exchange which during postural changes is compensated by cavitatory/cystic (syrinx) change at locations in cervical and lumbar spine with propensity for maximum deformation. Augmentation of posterior fossa volume by decompression helps by normalization of this CSF exchange dynamics but immobilizing the spinal movement theoretically will cease any dynamic volume changes thereby minimizing the destructive influence of the fluid exchange on the cord. Thus, this theory strengthens the rational of treating patients by either methodology.

Potential of aerosolized rifampicin lipospheres for modulation of pulmonary pharmacokinetics and bio-distribution.

The aim of the present study was to establish the potential of rifampicin loaded phospholipid lipospheres carrier for pulmonary application. Lipospheres were prepared with rifampicin and phospholipid in the ratio of 1:1 using spray drying method. Further, lipospheres were evaluated for flow properties and surface area measurement. The formulated lipospheres were evaluated in vitro for aerodynamic characterization and in vivo for lung pharmacokinetics and biodistribution studies in Sprague Dawley rats. Powder flow properties finding suggested the free flowing nature of the lipospheres. In-vitro aerosol performance study indicated more than 80±5% of the emitted dose (ED) and 77.61±3% fine particles fraction (FPF). Mass median aerodynamic diameter (MMAD) and geometric standard deviation (GSD) were found to be 2.72±0.13 µm and 3.28±0.12, respectively. In-vitro aerosol performance study revealed the higher deposition at 3, 4 and 5 stages which simulates the trachea-primary bronchus, secondary and terminal bronchus of the human lung, respectively. The drug concentration from nebulized lipospheres in the non-targeted tissues was lesser than from rifampicin-aqueous solution. The pulmonary pharmacokinetic study demonstrated improved bioavailability, longer residence of drug in the lung and targeting factor of 8.03 for lipospheres as compared to rifampicin-aqueous solution. Thus, the results of the study demonstrated the potential of rifampicin lipospheres formulation would be of use as an alternative to existing oral therapy.