The post spinal surgery syndrome: A review.

Post spinal surgery syndrome(PSSS) has always been considered only for the pain it causes. However, many other neurological deficits do happen after lower back surgery. The aim of this review is to look into the various other neurological deficits that could happen after a spinal surgery. Using the keywords, foot drop, cauda equina syndrome, epidural hematoma, nerve and dural injury in spine surgery, the literature was searched. Out of the 189 articles obtained, the most important were analyzed. The problems associated with spine surgery have been published in the literature but are much more than the failed back surgery syndrome and cause more discomfort to the patients. To bring about a more sustained and collective awareness and understanding of these complications following spinal surgery, we encompassed all these complications under the heading of PSSS.

Spontaneous Resolution of Chiari 1-Associated Syringomyelia: A Report of Two Cases.

BACKGROUND: Traditional teaching is that Chiari 1 malformations with syrinx should be operated as soon as possible. We present 2 cases of a radiologically proven Chiari 1 malformation with syrinx which were treated nonoperatively and improved radiologically. METHODS: Two children with an MRI-proven Chiari 1 malformations were followed up nonoperatively for 7 years (2010-2017). One was a boy aged 8 years and the other a girl aged 9 years at first presentation. Their parents were not interested in a surgical option and so it was decided to adopt a wait-and-watch policy. Both patients were followed up with a regular half-yearly clinical examination and yearly MRI studies (2010-2017). RESULTS: It was found that, in both of them, the initial cough during swallowing and the headache improved. Serial MRI showed that the hind-brain protrusion was reduced and syrinx diminished or resolved well. CONCLUSIONS: Some children with Chiari I and syringomyelia may show spontaneous resolution of symptoms and syringomyelia. Large registry studies will be needed to determine how likely it is that Chiari-associated syringes will resolve, and whether there are particular anatomic or neurologic differences between those who require surgery and those who don't.

An unusual extra-axial hypodense lesion mimicking a chronic subdural haematoma.

A 59-year-old man was found on the road with multiple injuries. CT scan showed a hypodense extra axial lesion in the left fronto-temporal region suggestive of chronic subdural haematoma. He was treated conservatively but did not improve. He underwent craniectomy after lesion was shown to be increasing in size, only solid tissue was seen which was not biopsied. Patient made good recovery after steroids were put on. He deteriorated again 6 weeks later and radiology showed the frontal lesion without involvement of the brain and with minimal enhancement and mass effect. He underwent biopsy decompression of the lesion with steroids, post-operatively he improved well, but deteriorated when the steroids were tapered. Histopathology report was Non-Hodgkin's lymphoma. No primary was found and the patient died during oncology treatment. This illustrates manifestation of primary dural lymphoma radiologically mimicking chronic subdural haematoma, another common disorder.

Postpartum cerebral angiopathy mimicking hypertensive putaminal hematoma: a case report.

OBJECTIVE: To present an emerging clinical entity which may mimic another common entity. METHODS: A 31 year-old woman complained of sudden severe headache and collapsed. She had delivered by Cesarean section one week previously. She had a normal antenatal history and did not have any evidence of hypertension. RESULTS: Clinical examination revealed her to be in altered sensorium, GCS E2V2M5 with reduced movements on the left side. CT scan showed a large right putaminal hematoma with mass effect and midline shift. MRI also showed the hematoma but the MRV was normal. Despite antiedema measures and hyperventilation, the patient continued to deteriorate and so underwent right hemicraniectomy. MRA was done postoperatively and showed diffuse spasm of both middle cerebral arteries. A diagnosis of postpartum cerebral angiopathy was made and she was put on methylprednisolone and other antiedema measures were continued. With this she improved significantly. At one year she had residual hemiparesis but had returned to work. Four-vessel angiogram repeated 1 year later showed no arterial spasm. She later had cranioplasty to cover the defect. CONCLUSIONS: This case is presented to show that in a postpartum patient, if she presents with putaminal hematoma, postpartum angiopathy needs to be suspected and appropriate investigations and treatment, including steroids, should be given as the overall prognosis is good.

Decompressive hemicraniectomy in large putaminal hematomas: an Indian experience.

OBJECTIVE: The treatment of large putaminal hematomas is predominantly medical and the role of surgery is debated. Decompressive hemicraniectomy in large hemispheric infarctions has been reported to lower mortality and improve outcomes. Decompressive hemicraniectomy may also have a role in putaminal hematomas. METHODS: In all, 23 patients with putaminal hematoma who underwent decompressive craniectomy in the last 4 years were analyzed. Parameters investigated included clinical presentations, radiologic profile, time interval from ictus to surgery, and Glasgow outcome score at 1 month. RESULTS: There were 13 men and 10 women with ages ranging from 31 to 68 years. All of them presented with neurologic deficits. Seven patients had a Glasgow Coma Scale (GCS) score of 3 to 8, 12 had a GCS score of 9 to 12, and GCS score was above 13 in 4. Seventeen patients had known hypertension. Computed tomography scan was done in all. The hematoma was less than 3 cm in 5 cases, 3 to 5 cm in 11, and larger than 5 cm in 7; and was 30 mL or less in 3, 30 to 60 mL in 13, and more than 60 mL in 7. All patients underwent hemicraniectomy on the side of the lesion and dura was left open. At 3 months, 13 patients had a good outcome and 10 had a poor outcome (including 3 deaths). CONCLUSIONS: Decompressive hemicraniectomy can be a useful alternative surgical procedure in moderate to large putaminal hematomas.

Twist drill craniostomy with closed drainage for chronic subdural haematoma in the elderly: an effective method.

OBJECTIVE: Chronic subdural haematoma is a disease of the elderly and surgery in these patients carries a much higher risk. The common surgical procedures for chronic subdural haematoma include twist drill craniostomy, burr hole evacuation or craniotomy. The aim of this study was to analyse the results of twist drill craniostomy with drainage in elderly patients with chronic subdural haematoma. METHODS: Forty-two elderly patients (>65 years) with radiologically proven chronic subdural haematoma were analysed. All the patients underwent twist drill craniostomy and continuous drainage of the haematoma under local anaesthesia and total intravenous anaesthesia (TIVA). RESULTS: There were 24 males and 18 females. Headache and cognitive decline was seen in 50% and weakness of limbs in 60% of patients. CT scan was done in all cases. All patients underwent twist drill 2-3 cm in front of the parietal eminence under local anaesthesia. The drain was left for 24-72 h depending on the drainage. At 1 week, 88% of patients had a good outcome. CONCLUSION: Twist drill craniostomy with drainage under local anaesthesia is a safe and effective procedure for chronic subdural haematoma in the elderly and could be used as the first and only option in these people.

Chiari 1 malformations: an Indian hospital experience.

INTRODUCTION: A consensus on the ideal surgical procedure for Chiari 1 malformation has not been achieved. The purposes of the study were to report on the experience of treating this condition in an Indian hospital, and to look into the management of this not too uncommon condition with a view to improve the treatment and prognosis. METHODS: A retrospective case note study of all cases of Chiari 1 malformations operated over a ten-year period from 1989 to 1999 and followed-up for another two years, were analysed for clinical and radiological features. All patients who underwent posterior fossa decompression were included. Patients who underwent other procedures like shunts were excluded. The data obtained included clinical and radiological features. RESULTS: A total of 51 cases were analysed. All patients had posterior fossa decompression with duroplasty in the majority. Many patients had a delayed improvement noticed during the follow-up period. Headache, neck pain and motor features showed an improvement in the majority of the patients but sensory deficits did not. CONCLUSION: This study showed the effectiveness of posterior fossa decompression with duroplasty as a procedure, which benefited most patients with Chiari 1 malformations.

Delayed postoperative extradural hematoma.

Postcraniotomy complications include various types of intracranial hematomas and systemic complications like cardiac and renal failure. This is a report of a patient who underwent a reexploration of a previous craniotomy and then went into status epilepticus, which was controlled, but the patient developed acute renal failure and then a delayed extradural hematoma.

Congenital spinal dermal sinuses: poor awareness leads to delayed treatment.

OBJECTIVE: Congenital spinal dermal sinuses are relatively uncommon congenital abnormalities that result from abnormal neurulation. Lack of awareness about this problem, especially at the primary care level, results in these patients not being managed appropriately. This issue is highlighted in this case series of nine patients. MATERIALS AND METHODS: The nine patients--six males and three females--were treated over a 3-year period in two centres in the UK and India. The age varied from 212 months to 19 years. Clinical presentations included meningitis or neurological deficits. One was asymptomatic. MRI was done in all cases and showed the sinus tracts in all cases. In five cases, there were intramedullary dermoids and in the others the sinus tract ended either on the dura or blindly. All cases were treated surgically by excision of the sinus and tumour if any. In terms of the neurological status, one became normal, four improved and four remained the same. Of the four who remained the same, two had had normal neurological examination preoperatively. The mean duration from first assessment by a medical practitioner to correct diagnosis and referral to a neurosurgeon was 5 years (range 2 months to 18 years). Proper diagnosis and appropriate management was delayed in these cases because professionals were not aware of this condition. CONCLUSIONS: Primary care physicians should be made more aware about congenital spinal dermal sinuses. This will facilitate early diagnosis and referral to specialist services.