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Study Design: Retrospective observational study.Purpose: To share our experience of multimodal intraoperative neurophysiological monitoring (IONM) used in Sakra World Hospital, Bengaluru in various spine surgeries.Overview of Literature: The development of new onset postoperative neurological deficits can be completely avoided. In order to avoid these, IONM has become a standard of care in recent times for early detection and manipulation of the surgical procedure to prevent postoperative neurological deficits.Methods: This retrospective study was performed on 408 patients who had undergone spine surgeries with IONM during April 2014 to March 2020 at a single center. The operative report, anesthesia record, and IONM were reviewed. All the patients were reassessed for postoperative neurological deficits in the postoperative period and followed up based on the intraoperative findings and neurological deficits for 4 weeks. Signal changes in IONM were reviewed, and the obtained results were further categorized into true positive, true negative, false positive, or false negative. If changes were observed during the IONM, the patients were managed as per the algorithm.Results: Of the 408 patients being monitored continuously during the intraoperative period, 38 showed changes in recordings, 28 developed postoperative neurological deficits, and one developed neurological deficit without any change in the IONM. Nine patients had transient neurological deficits, and the other 20 had permanent neurological deficits. Overall, the multimodal IONM used in our study had a sensitivity of 96.6%, specificity of 97.4%, a positive predictive value of 73.7%, and a negative predictive value of 99.7%.Conclusions: Use of decision algorithm and multimodal neuromonitoring consisting of motor evoked potentials, somatosensory evoked potentials, and electromyography complement each other in the detection of neurological injury during the course the surgery, improve intraoperative care, and prevent further damage and morbidity in patients.

Intradural extramedullary spinal metastasis is rare, representing 6% of all spinal metastasis. Indeed, intradural metastasis from a Renal Cell Carcinoma to the cauda equina is extremely rare with only 11 case reports present in the past. We present a patient with Cauda equina syndrome with an intradural extramedullary lesion causing compression of the nerve roots. He was subjected to a surgical decompression of the cauda equina with excision of the mass. The pathological examination displayed metastatic clear cell RCC with infiltration of the cauda equina. Thus, metastatic tumors constitute an important differential diagnosis for all lesions of the spine irrespective of level or location. Keywords: Metastatic, Renal cell carcinoma, Intradural, Extramedullary, Cauda equina.

A 73-year-old male patient suffered from recurrent strokes over 2 years. An angiogram revealed a giant cervical ICA aneurysm located in the retromandibular region with a tortuous loop of redundant artery anterior to it. He was taken up for surgery where the aneurysm was resected and the free ends anastomosed under shunt cover. The patient recovered well and was discharged without deficits. Another 70-year-old lady presented with a swelling in the retro mandibular region of the neck associated with fainting episodes every time she opened her mouth wide or chewed. Angiographic studies showed a giant retro mandibular ICA aneurysm, which was treated with an EC-IC bypass with ligation of the aneurysmal sac. The patient was discharged without deficits and has hence been living normally. Cervical aneurysms are rare and challenging modality to treat for the vascular neurosurgeon. These reports highlight the variability of presentation and the choice of modalities available for treatment. Selection of the appropriate modality can be challenging. Hence, we suggest a treatment algorithm for diagnosing as well as treating the disease successfully. Keywords: Giant, Cervical aneurysm, Coiling, Surgery.

Introduction and objective: Craniosynostosis is a pathological condition resulting from premature closure of cranial sutures. Open cranial vault reconstruction has been the standard of care for isolated non-syndromic craniosynostosis. The current centre introduced the endoscopic craniosynostosis surgery in 2015. The aim of the study is to compare safety outcomes of endoscopic versus open surgery in craniosynostosis within the context of a developing healthcare system, with a focus on anterior synostosis. Methods: This was a retrospective study of all patients undergoing surgery for anterior craniosynostosis from 2012 to 2018 at a single institution. Data on age at surgery, demographics, sutures, surgery duration and complications, including follow up information was obtained. We excluded syndromic patients and patients with pan-synostosis. Statistical analysis was undertaken with P value set at

Introduction and Objectives: The present study was undertaken with the objective to study the functional outcome with Oswestry Disability Index and VAS in patients with degenerative lumbar canal stenosis who underwent unilateral laminotomy and bilateral decompression of the canal. Materials and Methods: The cases were the patients who underwent microsurgical treatment for degenerative lumbar canal stenosis, between the age group of 40 to 60 during 2008 – 2010 were taken for the study. Patients with a history of low back pain, neurogenic claudication, radicular pain with single level canal stenosis and without spinal instability were included in the study. The patients underwent a thorough preoperative clinical and radiological examination at the department. VAS- Visual Analog Scale and Oswestry Disability Index and Neck Disability Index (0-10 scale) were used to assess the functional outcome. Results: 45 patients were included in our study. 42.2% were between 60-70 yrs. Males were more compared to females, 82 % people presented with neurogenic claudication pain and the pain was bilateral in 70 %. The duration was ranging from 6 months to 1 year. The functional outcome analyzed with VAS and ODI which showed progressive improvement in the values at the end of 1 year follow up the difference showed a p- value of had recurrence of the symptoms and did not develop any spinal instability. Conclusion: The functional outcome measured with VAS and ODI showed strongly significant as well as analysis showed immediate improvement with bilateral symptoms, canal stenosis at the L4-5 level. However good results noted in follow -up with a female who was having bilateral symptoms and stenosis at L5 S1 level. Keywords: Lumbar Canal Stenosis, ODI Scores, VAS scale, Neurogenic Claudication, Laminotomy

Introduction: Cervical radiculopathy is a neurological disfunction wherein a nerve root in the cervical spine becomes inflamed with disc herniation and uncovertebral osteophytes accounting for the majority of cases. The standard surgical treatment for this cervical radiculopathy till now is posterior lamino foraminotomy and anterior discectomy with or without fusion. This study describe the outcome of a minimally invasive anterior cervical disc preserving technique of upper vertebral transcorporeal anterior microforaminotomy to treat cervical radiculopathy Cervical. Objective: To Evaluate the clinical and radiological outcome of disk preserving functional cervical disk surgery. Material and Methods: This is a prospective non randomised hospital based study. The study population included 11 patients operated for cervical radiculopathy with the new technique at the department of Neurosurgery, Manipal Hospital, Bangalore during July 2007 to June 2010. The patients were followed up from 8 to 30 months with a mean follow up of 17 months for clinical and radiological outcome. Results: The mean age of the patient was 40.099.71 years. The majority of the patients (five) were in 31-40 age groups. Male patients (63.6%) were more as compared to females. All patients in this study had neck pain, radicular pain and weakness. Clinical symptoms were between 1 to 3months. The mean preoperative visual analogue scale score was 8.55 and postoperative score was 1.18. The VAS score reduced significantly postoperatively and it was statistically significant. There was no significant reduction in the disc height postoperatively. Conclusion: The Disk preserving functional cervical disk surgery is a minimal invasive procedure with the least complications and adequate motion at the operated site. Keywords: Cervical Disk Surgery, Cervical radiculopathy, Disk preserving, Disk Herniation

Context Autologous bone is the most commonly used flap in cranioplasty to repair the defect; however, synthetic materials are available. Poly methyl methacrylate (PMMA) is an effective polymer owing to its thermoplastic and radiolucent properties comparable to bone strength. Three-dimensional (3D) printing combined with computer-assisted design (CAD) is a simple, low-cost method to print molds that ensure surgical success. Materials and methods A total of 114 patients underwent cranioplasty (July 2015-April 2018), and 25 of them using 3D printed template molds due to unavailability of autologous bone. The clinical features, patient demographics, and surgical parameters were analyzed. The visual analog score for cosmesis (VASC) and Odom's score was obtained pre and post-op. Results The mean age of the patients is 38.4 ± 14.6 years (Range, 9-66). The primary pathology for undergoing craniectomy is stroke (n = 13; 52%), traumatic brain injury (10; 40%) and tumor (2; 8%). The reason for nonavailability of flap was infection (n = 14;56%), flap resorption (4;16%), and trauma or tumor (7;28%). The mean time for manufacturing the 3D printed template is 13.2 ± 2.1 h. On follow-up, median Odom's score is excellent in 52% of cases, good in 40%, and fair in 8%. The mean VASC score on follow up is 8.2 ± 1.3. Three patients developed minor postoperative complications. Conclusion This is the first study from a single tertiary care center in India to systematically evaluate the outcomes in 3D cranioplasty using CAD and 3D printing technology. This method would be optimal especially in developing countries since PMMA is cost effective and also gives an ideal cosmetic effect.

The concepts of consciousness, coma and wakefulness have fascinated man from the ages. The explanation and thereby, understanding of different states of altered consciousness vary from mystic, spiritual to anatomic and scientific. The advent of experimental neurology and anatomy gradually expanded the scientific horizons of man allowing observations and measurements to be made and interpreted. Keywords: Coma, Conciousness.

Background: The treatment of atlantoaxial instability (AAI) involves stable fixation and fusion with adequate decompression of spinal cord. After the advent of the Goel posterior joint manipulation technique, most of the once irreducible atlantoaxial dislocations (AAD) could be reduced and the need for transoral odontoidectomy became almost nil. Here we tried to iterate the indications of anterior transoral odontoid surgery for AAI in the current scenario. Methods: A retrospective study compiling the clinical, radiological, and surgical characteristics of 6 cases (5 scenarios). These patients underwent anterior transoral surgery alone or in combination with a posterior approach. Results: Two patients had a well-formed occipito-cervical fusion mass, with a displaced odontoid and unreduced C1-C2 joint causing cervical myelopathy. A middle-aged woman presented with unreduced AAD following failed C1-C2 joint distraction technique. A displaced dystopic os odontoideum ossicle was found in an adolescent boy, prohibiting the reduction of AAD. A young man had displacement of the fractured odontoid segment with intact transverse alar ligament and C1-C2 joint complex. One patient had a rare scenario of abnormal orientation of the C1-C2 joint. All 6 patients were successfully treated with adequate spinal cord decompression achieved by the anterior transoral route and stabilization by either the anterior approach itself or in combination with posterior surgery. All had significantly better postoperative outcomes except for 1 patient who expired due to poor respiratory reserve. Conclusion: We tried to emphasize the indications for using transoral anterior odontoid surgery over the posterior approach in the management of AAI. This will prevent the surgical technique of anterior odontoidectomy from becoming an obsolete procedure in the current practice.

Pyogenic Spondylodiscitis is a common affliction of the spine in which microorganism can spread by either direct or indirect route destroys the disc and vertebral end plates. Contiguous spread from nearby structures like mediastinum, oesophagus, intestines, penetrating injuries are well known. We report one such case where Self-expanding metallic [SEM] stenting done for Boerhaave syndrome lead on to T3-4 Spondylodiscitis with pathological fracture resulting in acute paraplegia as a complication. Spinal complications related to oesophageal stents are rarely reported in literature. We present our experience in managing this catastrophic presentation with a review of literature of similar cases. Keywords: Spondylodiscitis, Self-expanding metallic esophageal stent, Boerhaave syndrome

Highlights • Decerebrate rigidity unreported complication of pseudomeningocoele. • Mechanism of developing such rigidity discussed. • Management of pseudomeningocoele highlighted., Introduction Spinal pseudomeningoceles are extradural collections of cerebrospinal fluid that result following a breach in the dural-arachnoid layer and is reported as one of the complications of lumbar disc surgery. Although they are often self subsiding and asymptomatic, they may occasionally cause low-back pain, headaches, and even nerve root entrapment. The purpose of this case report is to present an unreported presentation of pseudomeningocele Presentation of case A 34 year obese male presented one month post lumbar discectomy with symptoms suggestive of raised intra cranial pressure presenting as repetitive decerebrate rigidity and altered sensorium lasting for few minutes when there is pressure on the pseudomeningocele sac and subsiding with change in position of the patient. He underwent surgical repair of the dural tear and was improved symptomatically with no recurrence of symptoms at five years follow up. Discussion Radiological investigation helped in ruling out the other causes of decerebrate rigidity and the possible mechanism of development of such symptom in pseudomeningocele is discussed. Conclusion To the best of our knowledge, this is the first reported case of pseudomeningooele presenting as decerebrate rigidity. Spinal pseudomeningocele can present in varied ways and earliest detection is the key to avoid such complications.

Sacral chordomas are locally aggressive tumors that grow slowly and often involve the sacral nerve roots leading to bladder disturbances. The treatment of these tumors involves utmost care as it can lead to tumor recurrence and neurological morbidity. We present our experience of 6 patients with sacral chordomas out of 17 patients with sacral lesions, where we have treated them with partial sacrectomies. In all of our cases, we have preserved at least one S2 root and postsurgery 83.33% of patients had intact bowel and bladder function. The lumbopelvic fixation was done in one of the cases as we have preserved the stability of the sacroiliac (SI) joint, as all osteotomy was done below S1. None of the patients had recurrence with an average follow-up of 4.1 years. This study aims at describing the surgical steps in managing a sacral chordoma.

Purpose:To report a case of silicone oil migration into optic chiasm with resultant visual field defect in the fellow eye. We also summarize the risk factors and pathogenic mechanisms responsible f...

Background Rosette-forming glioneuronal tumour [RGNT] is a relatively rare entity first identified as a separate entity in 2002. We are reporting the second case of RGNT in the opticochiasmatic region. Case Description We report a case report and literature review of RGNT with syndromic association. Conclusions Although initial reports were predominantly in the fourth ventricle, many recent reports have identified the possibility of its occurrence outside fourth ventricle in pineal gland, spinal cord, septum pellucidum, lateral ventricle, and suprasellar region. To date, only 1 case of RGNT involving the opticochiasmatic region has been reported in a patient with neurofibromatosis type 1. Genetic analysis of this rare tumor identified 3 hotspots involving somatic mutations of FGFR-1 and PIK3CA and a germline mutation involving PTPN11, which can be targets for therapeutic intervention in cases where complete resection is not possible. To the best of our knowledge, we report the first case of RGNT involving the opticochiasmatic region without any syndromic association. Other cases of RGNT with syndromic associations provide us with insight into possible therapeutic interventions.

First decribed by Sir Goeffrey Jefferson in London in 1924, the term Jefferson’s fracture has become an eponym for all fractures of the Atlas. Complex Jefferson fractures and unstable Jefferson fractures require surgical fusion to maintain stability of the spinal axis. This however results in debilitating loss of movement at the crucial C1C2 joint, the most versatile of spinal joints where stability and mobility are intricately balanced into a complex yet supremely agile structure. The desire to attempt in some way to preserve a degree of movement and to spare the patient the crippling loss of movement at this joint has led to many attempts at innovation, both surgical and technological. This has led to the discovery of C1 osteosynthesis. This revolutionary technique enables the anatomical fixation of the defect thus allowing motion preservation without compromising on stability, which is a major advantage given the extreme importance of both to the proper functioning of the C1C2 and C1C0 joints. We present a case report of a 54 year old man with an isolated Jefferson’s fracture which was treated successfully by this technique. We also present an overview of the biomechanics of C1 injury and the relevant review of literature regarding options for management of complex C1C2 injuries.

Concomitant ruptured intracranial aneurysm and severe contralateral internal carotid artery (ICA) stenosis pose a surgical dilemma. There are no guidelines. Most reports suggest an ipsilateral association. The outcome depends on planning and strategy. This 49-year-old male with ruptured C6 segment ICA aneurysm had 90% calcific carotid stenosis contralaterally. He underwent simultaneous surgery for both. The surgical steps involved and the reason behind the sequence of steps are unique to this situation and led to a good outcome. The strategy and the technicalities involved are discussed in this report.

Objective: Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome caused by small endocrine tumors that secrete fibroblast growth factor 23 (FGF23), a phosphaturic hormone.Abbreviations: CT = computed tomography; FGF23 = fibroblast growth factor 23; Ga68-DOTANOC = (68)Galliumlabeled (1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid)-1-NaI(3)-octreotide; MRI = magnetic resonance imaging; PET = positron emission tomography; PMTMCT = primitive appearing mixed connective tissue tumors; SSR = somatostatin receptor; TIO = tumor-induced osteomalaciaMethods: A 44-year-old male was evaluated following complaints of progressive leg pain, difficulty walking, and muscle pain over the previous 9 years. Biochemical evaluation showed low serum phosphorus, high urine phosphorus, and elevated FGF23 levels. These findings were suggestive of TIO. A whole-body (68)Gallium-labeled (1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid)-1-NaI(3)-octreotide positron emission tomography–computed tomography scan revealed a large vascular lesion in the anterior squamous portion of the right temporal lobe and right greater wing of the sphenoid bone, involving the posterolateral wall of the right orbit. Axial T1-weighted magnetic resonance imaging revealed isointense lesions containing multiple vascular channels. The histomorphologic feature of the excised tumor was compatible with a phosphaturic mesenchymal tumor, mixed cell type. Serum phosphorus and FGF23 levels normalized after excision of the tumor and resulted in healing of the fractured femur.Results: We report a large vascular lesion in the anterior squamous portion of the right temporal lobe and right greater wing of the sphenoid bone, involving the posterolateral wall of the right orbit as a cause of TIO.Conclusion: TIO is a fascinating paraneoplastic syndrome and is an important cause of adult-onset hypophosphatemia. Localization of tumors in cases of TIO is difficult and a stepwise approach with functional and anatomic imaging is usually successful in 90% of the cases. Excision of the tumor cures this debilitating disease, although recurrence is possible.

Introduction: Arteriovenous fistulae (AVF) are rare lesions. Patients typically present with slowly progressive myelopathy that is often mistaken for degenerative cervical or lumbar stenosis. Cranial presentations are even more innocuous ranging from seizures to tinnitus. The purpose of this study is to present a series of cases to aid in the assessment, diagnosis and treatment of this unusual pathology. Case Series: We present 11 cases of AVFs treated at our centre over an 4-year period. Seventy percent of patients were male. The mean age of presentation was 62.6 years. The most common lesion was a dural AVF emanating from the craniovertebral junction with single feeder. All patients underwent either microsurgical correction or endovascular embolization as the primary procedure. Eight patients showed improvement following treatment as graded by the Nurick system. Two patients failed to improve. None of the patients worsened. One patient had a cortical venous thrombosis after embolization that resolved well with anticoagulants. Conclusion: The successful treatment of AVF requires a detailed understanding of clinical presentation and imaging findings to allow for precise treatment. Owing to the rarity of the condition, clinicians must continue to share their experiences to advance our knowledge.

Intracranial aneurysms are a subject of controversy. Anterior circulation aneurysms are usually considered surgical territory, yet endovascular prowess can affect good results with minimal morbidity and comparable long-term results. We present a complex anterior cerebral artery aneurysm that would require either a bypass or a complex vessel reconstructive procedure. Instead, we proceeded to perform a stent-assisted coiling trapping the coils inside the aneurysm through a covered stent, thereby ensuring vascular continuity and complete aneurysm control. A brief review of the literature is also added to put this report in perspective.

Introduction: Craniosynostosis is an uncommon disorder affecting the growing skull. Timely surgery and physical therapy can give excellent results restoring neurological function and cosmesis. However, miss the appropriate juncture, and severe consequences will follow. Concerns include late presentation, surgical morbidity. Case Series: We present our institutional experience of varied syndromes who presented to a tertiary care institution between 2016 and 2018 along with the course in hospital complete with surgery and rehabilitation. We also supplement this with a short review of literature. The article stresses on the need to differentiate syndromic and simple craniosynostosis as well as in their specific management strategies complete with procedure assessment and complications. Result: A series of syndromic and simple craniosynostosis operated early lead to optimal cosmetic results with minimal or no long-term neurological deficits. The approach emphasises the need for early treatment to ensure excellent cosmesis and to avoid neurological and developmental disorders.

Background Giant cell tumors (GCTs) are benign tumors with a predilection for the epimetaphyseal region of the long bones. GCTs involving the skull base are rare, and only a few available cases have been reported. Surgical gross total resection is the recommended method of treatment for GCTs. In the case of skull base tumors, it is very difficult to achieve such a result by direct surgical resection alone without any morbidities. Denosumab is a fully humanized monoclonal anti-receptor activator of nuclear factor-κB ligand antibody that has been recently approved by the Food and Drug Administration for the treatment of GCTs that are surgically unresectable, metastatic, and have a high risk of progression and recurrence. Denosumab has been used in many cases involving the long bones. However, in cases of skull base GCTs, only a limited number of cases have been reported. In addition, in such cases, it was used as postoperative chemotherapy owing to subtotal resection. Case Description For the present patient, we adopted a unique approach in which denosumab was administered as neoadjuvant chemotherapy to reduce the size of the tumor to a resectable level. Subsequently, surgical resection was performed with good functional and histopathological outcomes. Conclusions Our findings emphasize the use of denosumab as a neoadjuvant treatment routinely for all cases of skull base GCTs to achieve safe and complete excision of the tumor.

Introduction: Craniosynostosis is a congenital pathological condition resulting from premature fusion of sutures of the cranial vault and leads to an abnormal head shape with a significant risk of raised intracranial pressure. Surgical correction techniques have seen a constant evolution from an extensive open procedure to the relatively new minimally invasive craniosynostosis technique. The current center introduced this new procedure in India since 2015. Aims and Objectives: This article documents our experience as the first team in the country to correct craniosynostosis endoscopically with emphasis on planning, surgical techniques, and helmet therapy to achieve the optimum result. Materials and Methods: This is a prospective case series of six patients with anterior craniosynostosis corrected endoscopically and followed up with postoperative custom-made cranial helmet. All patients were nonsyndromic with no associated anomalies. The mean age of surgical intervention was 92.6 days (84–100 days), mean duration of surgery was 61.7 min (54–74 min), mean blood loss was 55 ml (50 ml–60 ml), and mean duration of hospital stay was 2 days (2–3 days). No complications and mortality were reported. Conclusion: This case series has demonstrated that endoscopically assisted craniosynostosis correction is a safe, effective, and reliable technique in the armamentarium of a craniofacial surgeon. The minimally invasive nature allows early intervention in children. Parental compliance is important in helmet therapy which forms an integral part of this surgery for correction of the abnormal head shape. We believe that every patient with nonsyndromic single-suture craniosynostosis should be offered endoscopic correction before the age of 6 months.