Endoscopic Management of Chronic Subdural Hematoma Using a Novel Brain Retractor.

BACKGROUND: Endoscopic procedures are useful in chronic subdural hematoma especially when there are septations, solid/organized hematoma, and the presence of bridging or neovessels in the cavity. Visualizing the distal hematoma cavity by a rigid scope is challenging in large and curved ones due to the hindrance by the brain surface. Combining rigid endoscopy and brain retractor can overcome this limitation. METHODS: A retrospective study of 248 patients managed by endoscopic technique was performed and the relevant literature was reviewed. RESULTS: The brain retractor was used in all patients. Average operative time, subgaleal drainage duration, and hospital stay were 56 minutes, 3.1 days, and 4.6 days, respectively. The average preoperative Glasgow coma scale (GCS) score was 12, which improved to 14 and 15 in 223 and 23 patients, respectively at discharge. There were solid clots, septations, bridging vessels, curved hematoma cavities, rapid expansion of the brain after partial hematoma removal, and recurrences in 59, 52, 15, 49, 19, and 2 patients, respectively. There were 2 deaths, without any procedure-related mortality. CONCLUSIONS: Endoscope was very effective and safe in the management of chronic subdural hematoma, especially in about 51% patients with solid clots, septations, and bridging vessels which could have been difficult to treat by conventional burr hole. It can avoid craniotomy in such patients. Good visualization and complete hematoma removal were possible with the help of an endoscope and brain retractor in about 27% of patients which could have been difficult with a rigid endoscope alone.

A Model with Feedback Mechanism for Learning Hand-Eye Coordination: A Pilot Study.

BACKGROUND: Practicing neuroendoscopic skills like hand-eye coordination is mandatory before embarking on actual surgeries. Synthetic models are able alternatives for cadavers and animals. Presently available models in the literature are either very costly or lack a feedback mechanism, which makes training difficult. OBJECTIVE: We aimed to make a basic low-cost neuroendoscopic hand-eye coordination model with a feedback mechanism. METHODS AND MATERIALS: An electronic circuit in series was designed inside a clay utensil to test inadvertent contact of the working instrument with implanted steel pins, which on completion lighted a light-emitting diode (LED) and raised an alarm. Two exercises-moving-a-rubber exercise and passing copper rings of multiple sizes were made and tested by 15 neurosurgeons. RESULTS: The moving-a-rubber exercise was completed by 6/15 (40%) neurosurgeons in the first attempt, 6/15 (40%) in the second, and 3/15 (20%) in the third attempt. For the 1.5 cm copper ring passing exercise, 12/15 (80%) successfully performed in the first attempt; for 1 cm copper ring, 6/15 (40%) performed in the first; and for the 0.5 cm copper ring, 1/15 (6.6%) performed in the first attempt. The time to finish all the exercises significantly decreased in the third successful attempt compared to the first. CONCLUSION: The model gave excellent feedback to the trainee and examiner for basic neuroendoscopic hand-eye coordination skills.

A Novel Brain Retractor for Endoscopic Evacuation of Chronic Subdural Hematoma.

Background: Endoscopic chronic subdural hematoma (CSDH) evacuation is a safe and effective alternative to the conventional burr hole technique. Although a rigid endoscope has the advantage of good visualization, there are risks of brain damage due to limited space to accommodate the scope and frequent lens soiling. Objective: This technical note describes a novel brain retractor to overcome the limitations of rigid endoscopy. Methods: The novel brain retractor (by senior author) was made by dividing a silicon tube longitudinally into two halves, and tapered for easy introduction in the operative cavity. Sutures were placed at the outer end of the retractor to prevent migration and to assist in angulation. Results: The novel retractor along with endoscopic assistance was used in 362 CSDH procedures. Endoscopy combined with this retractor provided additional help in complete removal of hematoma in organized/solid clots, septa, bridging vessels, and rapid expansion of brain in 83, 23, 21, and 24 patients, respectively (n = 151, 44%). Although there were three deaths (due to poor preoperative status), and two recurrences, there were no retractor-induced complications. Conclusions: The novel brain retractor assists endoscope in proper visualization of complete hematoma cavity by gentle and dynamic brain retraction, helps in thorough irrigation of hematoma cavity, protects the brain, and prevents lens soiling. It allows easy insertion of the endoscope and instruments using bimanual technique even in patients with a small width of hematoma cavity.

Seventh Cervical Nerve (C7) Transection for Spastic Arm Paralysis After Cerebral Injury.

BACKGROUND: Spastic limb paralysis because of cerebral injury can cause long-term disability. Its treatment varies from conservative to operative; however, the optimum treatment is yet to be found. OBJECTIVE: To test the hypothesis that patients with spastic arm paralysis who receive C7 nerve transection to their paralyzed side might have reduction in spasticity, pain, and improvement in arm function. METHODS: Four patients with spastic hemiparesis that had ceased to improve after 1 year of rehabilitation, having pain and poor function, were included. All 4 patients underwent C7 nerve transection plus rehabilitation. The outcome was assessed at 1, 3, and 6 months by the Fugl-Meyer upper extremity scale for motor recovery, by the Modified Ashworth Scale score for spasticity, and by the visual analogue score for pain. Functional use of the limb was also assessed by performance of activities such as dressing, tying shoe laces, wringing a towel, and operating a mobile phone. RESULTS: At the end of 6 months, there was a significant improvement in mean Fugl Meyer score, reduction in Modified Ashworth score, and Visual Analogue scale for pain. At the beginning of the study, none of the patients could perform any day-to-day activities; however, at the end of 6 months, 3/4 of the patients could perform at least 1 activity. CONCLUSION: C7 neurectomy leads to improved motor function, reduction of spasticity and pain, and improvement in function in patients with spastic arm paralysis because of cerebral injury.

Effect of Vaccination on COVID-19 Severity and Outcome: A Comparative Study in a Tertiary Care Hospital.

INTRODUCTION: Vaccination is an important aspect of preventing/decreasing the severity of any viral disease including severe acute respiratory syndrome coronavirus 2 (SARS-CoV2). This disease being very new in the experience of mankind has very little data on the effect of vaccination on the severity of this disease. We conducted this study with the primary objective to assess the severity and clinical outcome of COVID-19 infections among nonvaccinated and vaccinated individuals. MATERIALS AND METHODS: This was a hospital-based retrospective cohort study including all individuals developing microbiologically confirmed COVID-19 over 5 months from February to 31st July 2021. A questionnaire was used to acquire demographic details, history of vaccination with dates, severity of COVID-19 infection, comorbidities, and outcome. Patients found positive microbiologically for SARS-CoV-2 before any dose of its vaccine were considered nonvaccinated, while patients developing SARS-CoV-2 infection even after a single dose or both doses of vaccine were considered "vaccinated." The outcome and mortality among the vaccinated and nonvaccinated patients were evaluated and compared. RESULTS: The study included 2,879 patients, but complete data were obtained only from 1,500 patients. A total of 1,500 patients were analyzed, out of which 880 are male and 620 are female. The severity of the disease was categorized into mild, moderate, and severe in the age-group of <60 years and >60 years with urban (1051, 70.07%) and rural (449, 29.93%) populations. A total number of recovered patients (n = 245), died patients (n = 215) in the age-group of >60 years while the total recovered patients (n = 823) and dead patients (n = 217) in the age-group <60 years with p = 0.001. Total vaccinated patients in the age-group >60 years (n = 204) and not vaccinated (n = 256) while in the age-group of <60 years total vaccinated n = 229 and not vaccinated n = 811. The outcome of disease in the age-group of >60 years in nonvaccinated 50% recovered and 50% died during the course of illness while in the vaccinated 57.3% recoverd and 42% died p-value 0.14, while in the age-group of <60 years recovery in nonvaccinated 77.6% and death in nonvaccinated was 27.32% while in vaccinated patients 82.28% were recovered and 15% died with significant p-value 0.04. Disease outcome was not found significantly associated with a number of doses with p-values of 0.84 and 0.507 in the age-group of >60 years and <60 years, respectively. A total number of 56 patients received Covaxin and 377 patients received Covishield and disease outcome was not found significantly associated with the type of vaccine. CONCLUSION: Vaccination against COVID-19 was significantly effective in terms of hospitalization and disease severity. Vaccinated persons were less among patients with COVID-19 hospitalization and with severe disease progressing to death. These findings indicate vaccination is helpful in reducing the development of severe COVID-19 infection as compared to nonvaccinated status.

Rotational Occipital Scalp Flap for Occipital Pressure Ulcer.

Occipital pressure ulcers and wound gaping may occur in unconscious and malnourished patients. Most of the time, a large defect requires wound coverage by scalp flaps. This video describes a rotational occipital scalp flap for occipital pressure ulcer and wound gaping in a patient of operated midline posterior fossa mass & ventriculoperitoneal shunt. The defect measured 2.25 × 2.5 cm with exposed inion. The wound was included in an imaginary triangle, and the horizontal and vertical incision lengths were about four times the base of the triangle. The flap was based on the left occipital artery and raised in an avascular plane above the periosteum. The wound margins were freshened and undermined. The flap was rotated to bring it over the defect, and suturing was done in the standard manner. The flap had good healing, and the patient continued to be under care for his cerebellar medulloblastoma.

Endoscope-controlled Access to Thalamic Tumors using Tubular Brain Retractor: An Alternative Approach to Microscopic Excision.

BACKGROUND: Surgery for thalamic lesions has been considered challenging due to their deep-seated location. Endoscopic excision of deep-seated brain tumors using tubular retractor has been shown to be safe and effective in prior studies; however, there are limited reports regarding its use for thalamic tumors. We present our experience of endoscope-controlled resection of thalamic tumors using a tubular retractor. MATERIAL AND METHODS: This was a prospective observational case series done at a tertiary center specialized for endoscopic neurosurgery during the period from 2010 to 2019. Surgeries were performed under the endoscopic control using a silicon tubular retractor. Lesions were approached transcortically or trans-sulcally. Data were collected for the extent of resection, amount of blood loss, operative time, need for conversion to microscopy, and complications. RESULTS: Twenty-one patients of thalamic masses of 14- to 60-year age underwent the surgeries. Pathologies ranged from grade I to IV gliomas. Gross total and near-total resection could be done in 42.85% of cases for each group. The average blood loss and operative time were164.04 ± 83.63 mL and 157.14 ± 28.70 minutes, respectively. Complications included a small brain contusion, two transient hemipareses, and one transient speech deficit. CONCLUSION: Endoscopic excision of thalamic tumors using a tubular retractor was found to be a safe and effective alternative to microscopic resection.

Endoscopic-Assisted C2 Transverse Process Mass Excision.

BACKGROUND AND INTRODUCTION: C2 transverse process exostoses are rare lesions. Due to critical structures surrounding them, their excision is challenging. There are sparse reports of anterior retropharyngeal approach (ARPA) for high-cervical transverse process mass and none for endoscopic ARPA approach. OBJECTIVE: A step-by-step technical report with its video is presented. SURGICAL TECHNIQUE: A 14-year-old girl presented with chronic right-sided neck pain. The computed tomography scan revealed a 6.5 cm3 mass in the right transverse process extending into the lateral mass of the C2 vertebra. The mass was anterior and in direct contact with the vertebral artery. She underwent a minimally invasive endoscopic ARPA. RESULTS: The mass could be excised along with its cartilaginous cap without any complications. The patient's symptoms resolved completely. The biopsy came out as osteochondroma. CONCLUSION: Endoscopic ARPA is a minimally invasive option for high-cervical tumors and was found safe and effective for C2 transverse process osteochondroma.

Lumboperitoneal Shunts - Patient Selection, Technique, and Complication Avoidance: An Experience of 426 Cases.

BACKGROUND: Lumboperitoneal shunt is a known procedure for communicating hydrocephalus. Being an extracranial procedure, it can also be utilized in normal-sized ventricles. OBJECTIVE: To report our experience of lumboperitoneal shunt done with a minimal follow-up of 12 months with an emphasis on patient selection, technique, and complication avoidance. METHODS: This was a retrospective analysis of patients who underwent LP shunt during October 2014-October 2019 at the authors' institute. Inclusion criteria were patients with communicating hydrocephalus due to tubercular meningitis, normal pressure hydrocephalus, idiopathic intracranial hypertension, and postoperative refractory cerebrospinal fluid leaks. Data were collected for demographics, Glasgow coma scale and Glasgow outcome scale, vision, gait, memory, urinary incontinence, failed attempts, and complications. RESULTS: A total of 426 patients underwent the LP shunt procedure. The commonest indication was tubercular meningitis followed by idiopathic intracranial hypertension and normal pressure hydrocephalus. Age ranged from 16 to 72 years. There were 255 male and 171 female patients. The mean follow-up was 41 ± 8 months. Overall, 301 patients (70.6%) had neurological improvement. Shunt-related complications occurred in 112 (26.29%) patients, of which shunt block was the commonest. Other complications were infection in 17 (3.9%) patients and extrusion in four (0.9%) patients. Transient postural headache was seen in 46 (10.7%) patients, which gradually improved. CONCLUSION: Lumboperitoneal shunt was found to be a safe and effective treatment in appropriately selected communicating hydrocephalus patients. A meticulous technique reduces the complication rate.

Endoscopic Third Ventriculostomy - A Review.

BACKGROUND: Endoscopic third ventriculostomy (ETV) has become a proven modality for treating obstructive and selected cases of communicating hydrocephalus. OBJECTIVE: This review aims to summarize the indications, preoperative workup, surgical technique, results, postoperative care, complications, advantages, and limitations of an ETV. MATERIALS AND METHODS: A thorough review of PubMed and Google Scholar was performed. This review is based on the relevant articles and authors' experience. RESULTS: ETV is indicated in obstructive hydrocephalus and selected cases of communicating hydrocephalus. Studying preoperative imaging is critical, and a detailed assessment of interthalamic adhesions, the thickness of floor, arteries or membranes below the third ventricle floor, and prepontine cistern width is essential. Blunt perforation in a thin floor, while bipolar cautery at low settings and water jet dissection are preferred in a thick floor. The appearance of stoma pulsations and intraoperative ventriculostomography reassure stoma and basal cistern patency. The intraoperative decision for shunt, external ventricular drainage, or Ommaya reservoir can be taken. Magnetic resonance ventriculography and cine phase-contrast magnetic resonance imaging can determine stoma patency. Good postoperative care with repeated cerebrospinal fluid drainage enhances outcomes in selected cases. Though the complications mostly occur in an early postoperative phase, delayed lethal ones may happen. Watching live surgeries, assisting expert surgeons, and practicing on cadavers and models can shorten the learning curve. CONCLUSION: ETV is an excellent technique for managing obstructive and selected cases of communicating hydrocephalus. Good case selection, methodical technique, and proper training under experts are vital.

Endoscopic Anterior Cervical Discectomy (Disc Preserving).

BACKGROUND AND INTRODUCTION: Endoscopic anterior cervical approach has several advantages compared to conventional anterior cervical discectomy and fusion (ACDF). OBJECTIVE: This video demonstrates a step-by-step procedure for endoscopic anterior cervical discectomy. PROCEDURE: The patient is placed supine with the neck extended. A standard anterior cervical approach using about 3 cm skin incision is made and under "Easy Go" (Karl Storz, Tuttlingen, Germany) endoscopic vision, the uncinate process and uncus are drilled. Only a small portion of the normal disc, posterior longitudinal ligament (PLL), and compressing disc is removed. The closure is done in a standard manner. RESULTS: In 240 patients, the average postoperative reduction in disc height, operating time, and blood loss were 1.1 ± 0.2 mm, 110 ± 17 min, and 30 ± 11 mL, respectively. The average postoperative VAS score and Nurick grading improved significantly. There were no permanent complications or any mortality. CONCLUSION: Endoscopic technique is an effective and safe alternative to ACDF after attaining the learning curve.

Teaching Glasgow Coma Scale Assessment by Videos: A Prospective Interventional Study among Surgical Residents.

Objective Glasgow Coma Scale (GCS) assessment is vital for the management of various neurological, neurosurgical, and critical care disorders. Learning GCS scoring needs good training and practice. Due to limitation of teachers, the new entrants of the clinical team find it difficult to learn and use it correctly. Training through videos is being increasingly utilized in the medical field. This study aimed to evaluate the efficiency of video teaching of GCS scoring among general surgery residents. Materials and Methods A prospective study was done utilizing the freely available video at glasgowcomascale.org. The participants (general surgery residents, 1st-3rd year) were asked to assess and record their responses related to GCS both before and after watching the video. A blinded neurosurgeon recorded the correct responses separately. Statistical Analysis The difference between correct responses of the residents before and after watching the video was calculated using the "chi-square test." p -Value ≤ 0.05 was taken as significant. Results There was a significant improvement in GCS scoring by residents after watching the videos ( p < 0.05). On estimating the responses separately, all the three responses (eye, verbal, and motor) improved significantly for 1st-year residents while only the motor response improved significantly for 2nd- and 3rd-year residents. The mode subjective improvement for the 1st-, 2nd-, and 3rd-year residents was 5, 4, and 3, respectively. Conclusion Training GCS scoring through videos is an effective way of teaching the surgery residents with maximum benefit to the junior-most ones.

The Effect of Aerosolized Chlorpheniramine Maleate on Exercise Induced Bronchospasm and Gas Exchange in Asthmatics.

INTRODUCTION: Exercise induced asthma (EIB) is an acute, reversible, usually selflimiting airways obstruction which sets in after exercise in patients with asthma. One popular mechanism of EIA is the increase in histamine and its metabolites in circulation after exercise, which leads to bronchoconstriction via histamine receptors in bronchi. Chlorpheniramine Maleate is potent, less sedative antihistaminic drug, which acts by inhibiting histamine release from mast cells. It is also said to have anticholinergic properties. The aerosol route of administration of a drug has the advantages of a faster onset of action, fewer side effects, and greater protection against EIB with respect to small airways function. This study was conducted to evaluate the effect of Chlorpheniramine Maleate aerosol inhalation on flow volumes and gas exchange. MATERIALS AND METHODS: 25 established patients of stabilized bronchial asthma (18 to 44 years) with history of EIA attending Allergy OPD, Medical OPD or Chest clinic were included in the present study. Patients were studied for 3 days in a week at the same time of day. Baseline spirometry was done to know test parameters, i.e. FEV1, PEFR and FEF50%. Gas exchange study during rest including minute ventilation (VE), oxygen consumption (VO2), Carbon dioxide produced per minute (VCO2), Respiratory quotient (R) was carried out. Patient was asked to perform exercise on bicycle ergometer. During exercise VE, VO2, VCO2 and R were recorded every 30 seconds. FEV1, PEFR and FEF50% were recorded immediately after and 5 min after completion of exercise. On day 2, same procedure was repeated with saline nebulisation before the exercise. On day 3, aerosolized Chlorpheniramine Maleate was used instead of saline for nebulisation. Values obtained were tabulated and analysed. OBSERVATIONS AND RESULTS: After exercise FEV1, PEFR, FEF50% decreased on all three days, but the fall in these parameters was less on Day III (prior nebulisation with Chlorpheniramine maleate) compared to previous days. There was significant increase in FEV1, PEFR and FEF50% (P<0.01, 0.05 and 0.05 respectively) which was seen 30 mins after inhalation of Chlorpheniramine maleate aerosol compared to placebo. Resting and exercise values of Minute Ventilation (VE), oxygen uptake (VO2) carbon dioxide expired, on all the three days were comparable and statistically not significant by the end of exercise. On day 2 and 3, 'R' as compared to that of day1 was slightly significant during rest and initial minutes of exercise but became insignificant after that till the end of exercise. CONCLUSION: This study shows that Chlorpheniramine causes bronchodilation during resting period by acting on the circulating or tissue histamine in asthmatics which contributes to an increase in resting bronchomotor tone. As there is incomplete inhibition of EIA by Chlorpheniramine, there may be some other associated mediator release for pathogenesis of EIA.

Computerized Tomography-Based Morphometric Analysis of Cervical Spinal Canal in Central Indian Population.

Objective Normal cervical spine canal morphometry is critical for understanding the pathology of certain diseases and for proper preoperative planning. Computerized tomography (CT) scan can replace older conventional radiography techniques by providing more accurate morphometric measurements. This study was aimed to find out various dimensions of the cervical spinal canal of central Indian population. Materials and Methods A prospective study was conducted including 100 consecutive cervical spine CT scan of asymptomatic adult subjects. The anteroposterior sagittal canal diameter (SCD), transverse canal diameter (TCD), canal surface area (CSA), and Pavlov-Torg Ratio (PTR) from C2 to C7 were calculated. Statistical Analysis Data were entered in Microsoft Excel Sheet 2007 and statistical analysis was performed by IBM SPSS statistics 2.0 version. p -Value < 0.05 was considered as significant. Results Age ranged from 18 years to 77 years with mean age 39.5 years. There was no significant difference in all the dimensions (SCD, TCD, CSA) in male and female except at C2 level, where SCD, TCD, and CSA were significant larger in male. The mean SCD, TCD, and CSA is largest at C2 level (14.4 ± 1.63 mm, 21.57 ± 1.59 mm, and 156.20 ± 24.98 mm 2 , respectively) and smallest at C4 level (12.77 ± 1.48 mm, 20.37 ± 1.72 mm, and 130.42 ± 21.20 mm 2 ). PTR showed very little variation. Conclusion Normal values of cervical spinal canal could serve as a future reference. CT scan provides more accurate measurement. More studies are needed as there could be variations in dimensions in different regions in India.

Endoscopic Management of Chronic Subdural Hematoma.

BACKGROUND: Twist drill evacuation, burr hole aspiration, mini-craniotomy, and craniotomy are some of the surgical methods to remove chronic subdural hematoma (CSDH). Endoscopic treatment was also recently found to be useful. METHODS: We conducted a prospective study of 72 hematomas in 68 patients. Computed tomography was performed in all cases. Endoscopic surgery was performed in all CSDH patients. SURGICAL PROCEDURE: A 4-cm skin incision was performed at the most curved part of skull with the CSDH. A mini-craniotomy or enlarged burr hole was made. The inner and outer table of the burr hole margin was drilled to provide a straight trajectory to the hematoma cavity. An endoscope supported by a telescope holder was used. A modified silicone brain retractor was used in five patients. A subgaleal drain was left in all patients for 3 to 5 days. RESULTS: There were 42 male and 26 female patients. The age ranged from 45 to 79 years (average: 69 years). All patients had a history of head trauma. Preoperative average Glasgow Coma Scale Score was 14. The procedure was effective in hematoma evacuation and a good visualization of the whole cavity in all patients. The endoscopic technique helped in complete hematoma removal in organized/solid clot, septations, and bridging vessels in 17, 2, and 2 cases, respectively. Duration of surgery ranged from 35 to 80 minutes. One death occurred. There was no recurrence, infection, fresh bleed, or injury to the brain or membrane. CONCLUSION: The endoscopic technique is an effective alternative technique for treating CSDH. Although the study has limitations because of the small number of patients with a short follow-up, the study indicated that thick and vascular membranes, septations, and organized and solid clots can be removed effectively using this technique.