Comparison of midpoint transverse process to pleura (MTP) block and erector spinae plane block (ESP) for postoperative analgesia in modified radical mastectomy patients: A double-blinded, randomized control trial.

Background and Aims: Modified radical mastectomy (MRM) is associated with moderate severity of postoperative pain. Besides intravenous (IV) analgesics, various nerve blocks are being described for pain relief of MRM patients. We compared erector spinae plane (ESP) block with midpoint transverse process to pleura (MTP) block in these patients for postoperative analgesia. Material and Methods: After receiving ethical committee approval from the institutional ethics committee (AIIMS, Jodhpur) and written informed consent from study participants, 66 patients who were assigned American Society of Anesthesiologists (ASA) physical status I and II, aged 18-75 years, and were scheduled to undergo MRM were enrolled and randomly allocated into two groups. Unilateral block was given before surgery at T3 or T4 level and with 15 ml of 0.5% ropivacaine in both the groups. Infusion of 0.5% ropivacaine (Neon laboratories limited, Mumbai, India) and 0.2% ropivacaine at a rate of 5 ml/h was maintained intraoperatively and postoperatively, respectively. Pain was assessed using the Visual Analogue Scale (VAS) for the next 24 hours. The total number of patients needing rescue analgesia, the total amount of rescue analgesics consumed in the next 24 hours, and patient satisfaction score were also compared between groups. Results: Demographics and baseline vitals were comparable in the groups. On comparing VAS scores in both the groups during rest and movement at different time intervals, there was no difference in pain scores during the initial two hours. From the third hour, there was a statistically significant difference (P < 0.001) in pain VAS scores in both groups. The ESP group had lower VAS scores compared to the MTP group when followed for the next 24 hours. There was a statistically significant difference in patient satisfaction. Conclusion: ESP block is more efficacious when compared to MTP block for postoperative analgesia in MRM patients.

Comparison of neuraxial acoustic target window of the spine among rider sitting, cross leg, hamstring stretch, and classical sitting position: An observational study.

Background and Aims: To compare ultra-sonographic dimensions of acoustic target window of the spine in the participants at four different sitting positions namely cross leg sitting (CLP), hamstring stretch (HSP), classical sitting (CSP) and riders sitting position (RSP). The primary objective of this study was to measure the neuraxial acoustic target window (defined as interlaminar distance between L3-L4 lamina). The secondary objective was to compare ultra-sonographic measurements of the depth of ligamentum flavum from the skin, and to compare the diameter of intrathecal space and comfort score in the four different sitting positions. Material and Methods: This study is a prospective observational study. Eighty participants were included and positioned in four different sitting positions to perform an ultra-sonographic scan and measure various parameters of the acoustic neuraxial window. The interlaminar distance, the distance of skin from the ligamentum flavum, and the diameter of the spinal canal or intrathecal space was measured in the L3-L4 intervertebral space in different positions. Results: The mean value of interlaminar distance among four sitting positions was ranging from 1.40 cm to 1.44 cm (P value 0.725.) The distance of ligamentum flavum from skin and diameter of intrathecal space was also comparable in all the groups. The comfort score in CSP was significantly better when compared to other groups with a median score of 4 (P value < 0.001). Conclusions: There is no statistically significant difference in interlaminar distance in various sitting positions. All four positions are equally effective and can be used as an alternative to spinal/epidural intervention, but the CSP came out to be the most comfortable and more emphasis should be given to the comfort as it increases the chance of success rate of the procedure.

Optochiasmatic Cavernomas: Updated systematic review and proposal of a novel classification with surgical approaches.

Cavernomas are histologically benign vascular malformations found at different sites in the brain. A rare site for such cavernomas, however, is the anterior optic pathway, comprising the optic nerve, chiasma, and optic tract-called optochiasmatic cavernomas (OCC). These lesions usually present with sudden onset or progressive vision loss, headache, and features mimicking pituitary apoplexy. In this paper, we describe a case of OCC operated at our center. We carry out an updated review of literature depicting cases of OCC, their clinical presentation, management, and postoperative complications. We also propose a novel classification system based on lesion location and further analyze these cavernoma types with respect to the surgical approach used and visual outcome. A 30-year-old lady had presented with a 3-week history of progressive bilateral vision loss and headache. Based on imaging, she was suspected to have a cavernous angioma of the chiasma and left optic tract. Due to progressive vision deterioration, the lesion was surgically excised using pterional craniotomy. Postoperatively, her visual symptoms improved, but she developed diabetes insipidus. Clinical and radiological follow-up has been done for 18 months after surgery. A total of 81 cases have been described in the literature, including the present case. Chiasmal apoplexy is the most common presentation. Surgical excision is the standard of care. Our analysis based on lesion location shows the most appropriate surgical approach to be used for each cavernoma type. Visual outcome correlates with the preoperative visual status. Visual outcome is good in patients presenting with acute chiasmal apoplexy, and when complete surgical excision is performed. The endonasal endoscopic approach was found to provide the best visual outcome. In addition to preoperative visual status, complete surgical excision predicts favorable visual outcomes in OCC. Our proposed classification system guides the appropriate surgical approach required for a particular location of the cavernoma.

Mucous Extractor for Tumor Tissue Sampling in Neurosurgery.

Objective Collection of sample for histopathological analysis is highly important during any surgical procedure. The histopathology report helps determine the diagnosis, prognosis further management, and follow-up plan. The use of a reliable sample collection technique is doubly important in neurosurgical procedures because lesions are often deep-seated and difficult to access. Materials and Methods Conventional techniques of sample collection, such as use of tumor-grasping forceps and collection of material from the ultrasonic aspirator device suffer from limitations of access and unreliability. We propose a novel technique of sample collection using readily available mucous aspirator device. Results This device is economical, sterile, and disposable. It can be used even in low-resource settings because it is easily available. It can also be connected to suction cannula and the negative pressure settings can be adjusted as required. Conclusion The use of this device for neurosurgical procedures has been tried in the transcranial and transnasal neurosurgical procedures and found to be effective. The sample collected in the canister of the mucous aspirator can be directly sent to the laboratory for histopathological analysis.

Comparison of Binaural Tone Music vs Patient Choice Music vs Midazolam on Perioperative Anxiety in Patients Posted for Surgery Under Spinal Anaesthesia: a Randomized Control Trial.

Background Perioperative anxiety affects patients' hemodynamics by increasing stress levels, leading to delayed recovery. In this study, we compared the anxiety-reducing effect of music (patient choice and binaural tone music) with midazolam for perioperative anxiolysis in patients undergoing surgery under spinal anaesthesia. Methods After obtaining institutional ethical clearance and informed written consent, a total of 225 patients classified as ASA grades 1 and 2 (American Society of Anesthesiologists) were enrolled and randomised into three groups of 75 patients per group. Group A patients received research-selected music (binaural tone) via noise-cancelling headphones, Group B received intravenous midazolam (minimum of 1 mg to 2 mg maximum) as per clinical judgement, and Group C participants provided patient-preferred music via noise-cancelling headphones. The patient's perioperative anxiety was assessed using a visual analogue anxiety scale at regular time intervals. Results Anxiety scores were significantly reduced in the patient's choice music group (Group C) and binaural tone music group (Group A) as compared to the midazolam group (Group B). Postoperative pain scores were statistically significantly lower in Group C, followed by Group A and Group B. On comparing patient satisfaction scores, using numerical rating scores, 96% of patients in Group C achieved excellent scores with a p-value of 0.007. Conclusion Binaural tone music and patient choice music can be suitable alternatives to pharmacological therapies for perioperative anxiolysis.

Conscious sedation and electroporation: A new perspective.

Tumor-specific electroporation (TSE) is a technique involving the application of high voltage pulsed electric impulses to the tumor lesions. We performed TSE in four patients with different indications and airway scenarios. We kept all four patients under conscious sedation using trans-nasal humidified rapid-insufflation ventilatory exchange (THRIVE) and dexmedetomidine infusion. This case series reflects those various untoward effects of general anesthesia that can be avoided by oxygenating the patient with THRIVE and dexmedetomidine infusion, which provide analgesia, sedation, and amnesia.

The Yin and Yang of Operating on a Posterior Fossa Meningioma: The Schmahmann Syndrome.

The cerebellum is classically linked with control of motor function, such as coordination, balance, and regulation of movement. There is an increasing awareness, now, of the non-motor functions of the cerebellum, and the occurrence of behavioral anomalies with cerebellar disorders. We present the first report of Schmahmann syndrome (cerebellar cognitive affective syndrome [CCAS]) occurring secondary to posterior fossa meningioma excision. A 35-year-old lady with a posterior fossa meningioma developed an infarct of the right posterosuperior cerebellar hemisphere and ipsilateral superior vermis, following suboccipital craniotomy and tumor resection. Few days after the surgery, she presented with aggressive and emotional behavior, irrelevant talk, and emotional lability. The CCAS scale was administered, and she scored poorly on almost all parameters. A neuropsychological evaluation was also done. The occurrence of CCAS, posterior fossa syndrome (PFS), and behavioral abnormalities like abnormal pathological laughter/crying provides further clinical evidence of the "affective" functions of the cerebellum, modulated mainly by the posterior lobe and vermis of the cerebellum.