C2 Nerve Root Preservation During Posterior Fixation for Instability Secondary to Congenital Craniovertebral Junction Anomalies: Feasibility Factors and Related Outcomes.

OBJECTIVE: Patients with instability because of congenital craniovertebral anomalies often have complex C1-C2 osseovascular anomalies. C2 nerve root sacrifice has been described to address such difficult anatomy during posterior C1-C2 fixation and has its own downsides. Its preservation as a recent alternative poses greater surgical challenge, and the considerations differ from other causes of craniovertebral junctional instability; the pertaining outcomes have been scarcely studied. The objective of this study was to prospectively determine the feasibility and outcomes related to C2 nerve root preservation in patients with congenital atlantoaxial dislocation (CAAD) after posterior C1-C2 fixation. METHODS: In this observational study, 63 patients (126 nerve roots) with CAAD after posterior fixation were prospectively assessed. Underlying osseovascular anomalies affecting the feasibility of C2 nerve root preservation, and C2 nerve-related dysfunction at 12 months follow-up were analyzed. RESULTS: The overall C2 nerve root preservation rate was 89.7%. Even in the presence of extreme joint obliquity/spondyloptosis and anomalous vertebral artery, it was feasible in about three fourths. After preservation, 28.3% patients developed new-onset C2 nerve root dysfunction: neuralgia in 2, dysesthesia in 6, and hypoesthesia/paresthesia in 9. The symptoms were not disabling in most patients. CONCLUSIONS: In most patients with CAAD, C2 nerve root preservation is feasible despite an aberrant bony and vascular anatomy. A few patients after nerve root preservation develop related symptoms that are conservatively manageable, with no significant adverse consequences. Given the controversy in the literature on C2 nerve sacrifice-related outcomes, we favor an attempt at C2 nerve root preservation.

Secondary anaerobic infection in a case of multidrug resistant tubercular paraspinal abscess: A rare presentation.

INTRODUCTION: Paraspinal abscesses are most commonly caused by Staphylococcus aureus and some Gram-negative bacteria. In developing countries, Mycobacterium tuberculosis (MTB) contributes to almost 50 % of cases. Even in proven cases of tubercular paraspinal abscesses, secondary infection of aerobic or anaerobic bacteria is possible and should be carefully evaluated for proper management. CASE REPORT: A type I diabetes mellitus patient presented with chronic backache and lower limb weakness and radiological investigations showed paraspinal collections suggestive of tuberculosis. The patient was then started on anti-tubercular drugs, she initially responded and then showed gradual deterioration in the form of increased pain, fever and pus discharge. Aerobic cultures of pus were sterile and anaerobic culture grew Peptoniphilus asaccharolyticus sensitive to metronidazole. Appropriate treatment had resulted in clinical improvement. CONCLUSION: Suspicion about co-infection with aerobic or anaerobic bacteria should be high even in proven cases of tubercular paraspinal abscess not improving despite proper anti-tubercular therapy.

The collateral fallout of COVID19 lockdown on patients with head injury from north-west India.

BACKGROUND: The COVID19 lockdown has altered the dynamics of living. Its collateral fallout on head injury care has not been studied in detail, especially from low- and middle-income countries, possibly overwhelmed more than developed nations. Here, we analyze the effects of COVID19 restrictions on head injury patients in a high-volume Indian referral trauma center. METHODS: From the prospective trauma registry, clinico-epidemiological and radiological parameters of patients managed during 190 days before and 190 days during COVID19 phases were studied. As an indicator of care, the inpatient mortality of patients with severe HI was also compared with appropriate statistical analyses. RESULTS: Of the total 3372 patients, there were 83 head injury admissions per week before COVID19 restrictions, which decreased to 33 every week (60% drop) during the lock phases and stabilized at 46 per week during the unlock phases. COVID19 restrictions caused a significant increase in the proportion of patients arriving directly without resuscitation at peripheral centers and later than 6 h of injury. Though the most common mechanism was vehicular, a relative increase in the proportion of assaults was noted during COVID19. There was no change in the distribution of mild, moderate, and severe injuries. Despite a decrease in the percentage of patients with systemic illnesses, severe head injury mortality was significantly more during the lock phases than before COVID19 (59% vs. 47%, p = 0.02). CONCLUSIONS: COVID19 restrictions have amplified the already delayed admission among patients of head injury from north-west India. The severe head injury mortality was significantly greater during lock phases than before COVID19, highlighting the collateral fallout of lockdown. Pandemic control measures in the future should not ignore the concerns of trauma emergency care.

Anomalous V3 Segment Aneurysm Associated with Congenital Atlantoaxial Dislocation: Case Report and Discussing the Challenges in Management.

BACKGROUND: An anomalous vertebral artery is not a deterrent for posterior C1-C2 joint manipulation and reduction of atlantoaxial dislocation (AAD). However, presence of an incidental aneurysm in the aberrant segment of artery with concurrent AAD adds to the surgical challenge. CASE DESCRIPTION: A 30-year-old woman presented with neck pain and spastic quadriparesis. Her imaging revealed atlantoaxial dislocation and bony segmentation defects. Three-dimensional computed tomography angiography showed bilateral anomalous vertebral arteries (V3 segment) and an incidental aneurysm on the arterial segment that crossed the right C1-C2 joint posteriorly. Because the artery bearing the aneurysm was nondominant, it was ligated and successful C1-C2 posterior reduction and fusion could be performed. CONCLUSION: The association of an incidental aneurysm with an anomalous vertebral artery in congenital AAD is unusual. The etiology could be an underlying collagen defect or repeated shearing trauma to the vessel wall due to C1-C2 instability. It would be less risky to proceed with endovascular embolization followed by occipitocervical fusion without opening the joints in case the aneurysm is present on the dominant aberrant V3 segment. Ventral decompression can be supplemented for irreducible AAD. On the contrary, if the aneurysm is present on the nondominant aberrant V3 segment, the C1-2 joint can be opened and manipulated following an initial endovascular treatment of the aneurysm. If the circumstances demand, the nondominant artery can be ligated and sacrificed, although there is a small risk of formation of stump aneurysm.

Bilateral persistent 'second' intersegmental vertebral arteries: illustrated with a case.

Congenital craniovertebral junction deformities can be associated with an anomalous vertebral artery (VA). At times, the artery crosses the joint posteriorly (i.e., persistent first intersegmental artery) and is at risk during posterior approach. We report a new variant, wherein the bilateral VA coursed medially after exiting the C3 transverse foramina to lie beneath C2 pars interarticularis and enter the foramen magnum (without passing through C2 transverse foramen anywhere along its course). This is possibly a result of bilateral persistent second intersegmental arteries. It is pertinent to recognize this unusual variant to avoid VA injury, especially while inserting C2 pars/transarticular screw.

Formulation of Nanoparticles Against TB--A Review.

Tuberculosis is a major public health concern. The present article reviews the current updates on the usage of nanoparticles against tuberculosis and recent patents that could develop into novel therapeutics available to the clinical armamentarium for the TB management. The drug delivery systems involving nanoparticles are suitable against chronic diseases such as tuberculosis. Polymers in many forms like liposomes, dendrimers, Nanoemulsions can be used as synthetic and natural carriers for first line and second line drugs employed for chemotherapy. Not only are the drugs sustainably released in organs and plasma, but also their dosages as well as adverse effects have been reduced, the drug interaction has increased and the drug resistant bacteria have been targeted. The hurdles in the development of anti-tuberculosis have made Nano medicines to act as a silver lining.

Plant asparaginase-based asparagine biosensor for leukemia.

The present work aims at the development of plant asparaginase-based asparagine biosensor for leukemia. It is a novel diagnostic for monitoring asparagine levels in patients suffering from acute lymphoblastic leukemia (ALL). Various immobilization strategies have been applied to improve the stability of the asparaginase. The latest and updated information including some new techniques of immobilization related to L-asparaginase such as gelatin, agarose, agar, and calcium alginate methods are described in detail along with response time studies and comparative data. Furthermore these immobilization techniques have been applied for the detection of asparagine in normal and leukemia serum samples.