Management of cervical monoradiculopathy due to prolapsed intervertebral disc, an institutional experience.

BACKGROUND: Cervical radiculopathy is the common clinical entity, often caused by "wear and tear" changes that occur in the spine. In the younger population, cervical radiculopathy is a result of a disc herniation or an acute injury causing foraminal impingement of an exiting nerve, whereas in the older individuals, it is due to foraminal narrowing from osteophyte formation, decreased disc height, and degenerative changes of the uncovertebral joints anteriorly and of the facet joints posteriorly. In most (75%-90%), cervical radiculopathy responds well to conservative treatment, whereas the remaining patients, who fail to achieve acceptable recovery with conservative modalities, alone need surgical decompression of the nerve root. Surgical interventions can be categorized into anterior and posterior approaches to the spine. Our study is focused on the surgical outcome of anterior discectomy with fusion versus posterior cervical discectomy with foraminotomy for cervical monoradiculopathy. MATERIALS AND METHODS: Ours is a retrospective study including patients of one level unilateral posterolateral cervical disc prolapse with radiculopathy operated in Department of Neurosurgery, Bangalore Medical College and Research Institute between 2012 and June 2016. The hospital records, imagings, operation notes, and follow-up records were reviewed and analyzed. One hundred and fourteen patients of cervical monoradiculopathy were investigated and operated, 76 operated by anterior cervical discectomy with fusion (ACDF), and 38 operated by posterior cervical laminoforaminotomy (PCL). RESULTS: The average operation time in 76 patients of ACDF group was 178 min and in 38 patients of PCL group was 72 min. Sixty-nine (91%) patients of ACDF and 38 (100%) patients of PCL had symptomatic relief but statistically (P > 0.5) was not significant. Three patients in ACDF group had hoarseness of voice due to recurrent laryngeal nerve palsy and there were no fresh permanent neurological deficits in any patients of PCL group over a follow-up period of 36 months. The average postoperative hospital stay was 5 days in ACDF group and 3 days in PCL group. The average intraoperative blood loss was <50 ml in ACDF group and 650 ml in PCL group. The need of analgesic for pain arising from bone graft site in ACDF group was comparable with operative site pain in PCL group. CONCLUSIONS: PCL is a simple approach, yields gratifying results, and is a promising alternative in selected cases of cervical monoradiculopathy due to disc prolapse.

Intraoperative angiography in aneurysm surgery: an initial experience.

BACKGROUND: Intraoperative angiography (IOA) assumes an important role in the prevention of complications such as aneurysmal neck remnant or compromise of adjacent cerebral vasculature during surgery for cerebral aneurysms. Aims : To determine the feasibility, efficacy and safety of IOA in aneurysmal surgery. SETTINGS AND DESIGN: Prospective study of IOA in patients undergoing aneurysmal surgery. MATERIALS AND METHODS: IOA was performed using digital subtraction angiography (DSA) compatible C-arm, radiolucent operating table and appropriate femoral sheath, guiding catheters and guide wires in 20 consecutive patients after surgical clipping of the cerebral aneurysm. The post-clipping IOA was compared with preoperative angiogram. RESULTS: Complete aneurysmal obliteration was confirmed in all the patients. In two patients compromization of adjacent vessels was noted, which could be rectified by repositioning of the clip. Some degree of vasospasm was noted in all the patients. Intra-arterial nimodipine was administered in four patients with severe vasospasm. There was improvement in two patients. Time taken for performing IOA varied from 30 to 45 min. No complications attributable to IOA were encountered in this study. CONCLUSION: IOA is a safe and effective adjunctive tool for aneurysm clipping. Routine use of IOA in all cases of aneurysmal surgery is recommended.

Morphometric analysis of the thoracic pedicle: an anatomico-radiological study.

BACKGROUND: Knowledge of the morphometric anatomy of the pedicles in thoracic spine is essential for the surgeon attempting thoracic pedicle screw placement. AIM: To study the morphometry of the pedicles in the thoracic spine in Indian subjects and note the anatomical landmarks required for safe and accurate pedicle screw placement. SETTINGS AND DESIGN: An anatomico-radiological study with cadaveric confirmation was conducted in a medical college and tertiary care center. MATERIALS AND METHODS: Morphometric anatomy of 720 pedicles from T1-T12 was studied. The study consisted of 15 separated thoracic vertebral cadavers and 15 computed tomographic scans of undiseased thoracic spine. Transverse and sagittal pedicle diameters, transverse pedicle angle, chord length and the pedicle entry point landmarks were studied. Using the results, accuracy of the pedicle screw placement was confirmed in 120 pedicles from five unseparated cadavers. RESULTS: Transverse pedicle diameter was narrowest at T4 and gradually increased craniocaudally. Twenty-two percent of the pedicles from T4 to T6 were less than 4.5 mm, but none were less than 3.5 mm. The transverse pedicle angle was widest at T1 (26.50) and decreased caudally to T12 (8.10). The chord length gradually increased caudally from a minimum of 30.4 mm at T1 to a maximum of 43.3 mm at T12. Landmarks (transverse and vertical distance) for the pedicle entry point were measured from the reference point taken as the center of the junction of lamina and the transverse process. The pedicle entry point was always superolateral to this reference point. CONCLUSION: Knowledge of the pedicle diameter and chord length is essential for choosing the appropriate pedicle screw, whereas the pedicle angle and the entry point are important for accurate screw placement.

Microsurgical anatomy of the posterior circulation.

CONTEXT: The microsurgical anatomy of the posterior circulation is very complex and variable. Surgical approaches to this area are considered risky due to the presence of the various important blood vessels and neural structures. AIMS: To document the microsurgical anatomy of the posterior circulation along with variations in the Indian population. MATERIALS AND METHODS: The authors studied 25 cadaveric brain specimens. Microsurgical dissection was carried out from the vertebral arteries to the basilar artery and its branches, the basilar artery bifurcation, posterior cerebral artery and its various branches. Measurements of the outer diameters of the vertebral artery, basilar artery and posterior cerebral artery and their lengths were taken. RESULTS: The mean diameter of the vertebral artery was 3.4 mm on the left and 2.9 mm on the right. The diameter of the basilar artery varied from 3-7 mm (mean of 4.3 mm). The length varied from 24-35 mm (mean of 24.9 mm). The basilar artery gave off paramedian and circumferential perforating arteries. The origin of the anterior inferior cerebellar artery (AICA) varied from 0-21 mm (mean 10.0 mm) from the vertebrobasilar junction. The diameter of the AICA varied from being hypoplastic i.e., CONCLUSIONS: The authors have documented the various anomalies as well as the differences of the anatomy in this area in the Indian population as compared to the Western literature.