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To study clinical and radiological outcomes of pediatric cervical kyphosis correction with a standalone posterior cervical approach. Cervical spine kyphotic deformity in pediatric age group is a distinct entity and the management is challenging. Pediatric cervical kyphosis is less often encountered, and literature is sparse with only few case series. Management algorithms are devised keeping the flexibility of the deformity at the core of decision making. Circumferential fusion is mostly recommended for non-flexible (rigid) kyphosis.Authors present a single center retrospective analysis of cases of pediatric cervical kyphosis managed by a standalone posterior approach. Pre- and post-operative clinical and radiological parameters were recorded and analyzed. Changes in neurological status, kyphosis correction and bony fusion were assessed. Surgical and implant related complications were noted.Seven cases (6 male, 1 female) were included. Mean age was 13.9±2.9 years, ranging from 8-17 years. Etiology was traumatic in 2 cases, developmental in 2, and syndromic, Hirayama disease and post-laminectomy in 1 case each. Mean kyphosis correction was 36.80±19.30 (87%±21%) with a mean pre-operative kyphosis angle of 37.80±15.30 and mean immediate post-operative kyphosis angle of 3.70±8.70. Mean hospital stay duration was 10±6 days. Median follow-up duration was 36 months. Myelopathy improved in 5 cases at last follow-up. Six cases demonstrated bony fusion at a mean follow-up of 8.4±1.5 months.Significant immediate correction in pediatric cervical kyphosis may be achieved with a standalone posterior approach with proper planning and technique in selected cases. Inserting pedicle screws at strategic locations of implant construct offer better corrections and pull-out strength and maintain long-term stability resulting in higher arthrodesis rates. Larger studies with longer follow up are needed to further ascertain the role of standalone posterior cervical approaches in pediatric cervical kyphosis.

Background Cervical pedicle screws (CPS) in the subaxial cervical spine (C3-C6) are faced with high incidence of perforating the lateral pedicular cortex endangering the vertebral artery (VA). The present study analyzes the pedicle width (PW) from C3 to C6 and defines the relation of VA with regard to pedicle and transverse foramen (TF) to determine the safety margin in cases of lateral pedicular breach. Methods Computed tomography angiograms of 500 patients were retrospectively studied to identify the pedicle width (PW), VA area, TF area, and the lateral pedicle to vertebral artery distance (LPVA). Occupancy ratio (OR; the percentage area of transverse foramen occupied by VA) and safety margin (SM; permissible displacement of VA in TF), along with LPVA were considered to be protective parameters against VA injury if lateral pedicle breach happens. Results PW was 4.7 mm at C3, 4.83 mm at C4, 5.26 mm at C5 and 5.41 mm at C6. Mean LPVA at different levels was between 0.97 mm and 1.15 mm, OR was around 20% at all levels, and mean SM was between 2.34 mm and 2.92 at various levels. Sex differences were statistically significant for PW but not for LPVA, SM, or OR. Conclusions This study gives us an idea about the various parameters in placement of cervical pedicle screw in subaxial cervical spine and the probable reasons there are few vertebral artery injuries despite high incidence of cervical pedicle breach. LPVA, safety margin, and OR may explain why even very significant CPS misplacement does not lead to vascular injury or neurologic deficit.

Objective Vertebral hemangiomas are benign but highly vascular lesions and are one of the most common lesions of the vertebral column. Anterior soft-tissue compression of spinal cord due to vertebral body hemangioma is challenging to manage. Our objective was to assess long-term clinical and radiologic effects of direct transpedicular absolute alcohol embolization, laminectomy, and short-segment instrumented fusion on resolution of extraosseous epidural soft tissue and improvement in myelopathy in cases of vertebral hemangioma causing anterior soft-tissue compression. Materials and Methods This was a retrospective analysis that included patients with single-level vertebral hemangioma with anterior intraspinal soft-tissue growth causing spinal cord compression and clinical features of myelopathy between June 2007 and June 2019 at authors' institute. Transpedicular vertebral body injection of absolute alcohol, laminectomy, and pedicle screw rod instrumentation was performed in all patients. Clinicoradiologic outcomes of surgery were noted. We proposed a grading system for the extent of anterior extraosseous epidural soft-tissue compression. Results In total, 14 patients were included in study. Their mean age was 28.4 ± 14.4 years. Mean follow-up duration was 67.5 ± 36.2 months. All patients had preoperative radiologic grade 4 compression. Postoperative radiologic grading improved to grade 1 in 4 (28.6%), grade 2 in 8 (57.1%), and grade 3 in 2 (14.3%). All the patients improved neurologically after surgery. Eleven patients improved to American Spinal Injury Association (ASIA) grade E, 2 improved to ASIA D, and 1 improved to ASIA C at the last follow-up visit. Conclusions Vertebral hemangiomas with anterior extraosseous epidural extension causing spinal canal compromise and myelopathy can be managed with direct transpedicular ethanol embolization, laminectomy, and short-segment instrumented fusion with resolution of the extraosseous soft tissue and improvement in myelopathy. The procedure is relatively simple, cost effective, and has a good outcome.

We aimed to study the long-term efficacy, prognostic factors and complications associated with the GKRS for trigeminal neuralgia.Prospectively created database was analyzed for these patients. We created an Artificial neural Network - using Multilayer perceptron model in SPSS 23 by including all variables whose p value were0.5 in univariate analysis.A total of 36 patients were included in the study. Patients pain free at 6 months were 25(69.44%), which reduced to 6(40 %) at 6 years. Median time to pain relief was 18.5 days. Only 5(13.88%) of them developed new onset or worsened numbness post Gamma Knife radio surgery. Median radiation dose was 80 Gy (prescribed at 100 percent isodose line). 1st GKT (P value 0.05) and post GKT numbness (P value 0.05) were the only factors favouring good outcome. Prior history of MVD was associated with poor pain relief post GKRS although p value was not significant (p = 0.136). ANN model could predict with 90.0 percent accuracy the favourable or unfavourable response on 11 Tested cases. In ANN model, a greater number of Pre GKT medications, previous MVD history, V2 dermatome involvement and negative history of post GKT numbness were negative prognostic factors.Lesser number of pre GKRS drugs used, involvement of V1 dermatome, post GKT numbness are favourable prognostic factors. Also, history of failed MVD for trigeminal neuralgia is associated with poor outcome. Repeat GKRS failed to show improvement in BNI grades.

Several scoring systems have been developed for assessment of patients with compressive cervical myelopathy. However, all of these have some shortcomings. We proposed a new modification of the modified Japanese Orthopedic Association (mJOA) score-the AIIMS cervical myelopathy score (ACMS).The aim of this study was to compare the ACMS with mJOA score and Nurick score.We prospectively studied patients with cervical compressive myelopathy. The new ACMS, mJOA, Nurick proposed by Benzel, and Nurick scores were recorded preoperatively and at three months postoperatively in patients.Sixty-two patients completed the 3-month follow-up and were included in the final analysis. The mean preoperative and postoperative Nurick, mJOA, and ACMS scores were 3.3 and 3.0, 12.3 and 13.8, and 15.1 and 17.7, respectively. High correlation (Pearson's r0.8, 95% CI: 0.94 to 0.97, P0.005) was observed between ACMS and mJOA scores for all the individual components of both scales, both in pre- and postoperative assessments. A negative correlation was observed between the occupational ability scores ACMS and the Nurick scale (r = -0.76, 95% CI: -0.83 to - 0.68). No correlation was found with cord/canal ratio on magnetic resonance imaging (MRI) with any of the three scoring systems (preoperative, postoperative, or recovery rates).The ACMS score showed a good correlation with the mJOA score for evaluation of functional disability in the setting of cervical myelopathy. The patients could themselves report the scores using the ACMS scoring chart. The occupational component of the ACMS also correlated well with the Nurick score.

Accuracy of screw placement is one of the important factors necessary for adequate union in odontoid fractures with malposition rates as high as 27.2% with standard techniques.To evaluate efficacy of intraoperative O-arm assistance in improving accuracy of anterior odontoid screw placement and clinco-radiological outcome in type II and III odontoid fractures.In this retrospective study, surgery consisted of anterior odontoid screw fixation under intraoperative O-arm assistance over 5 years. Demographical, clinical, radiological, operative details and postoperative events were retrieved from hospital database and evaluated for fusion and surgical outcome.50 patients (Mean age 34.6 years, SD 14.10, range: 7-70 years; 44 males and 6 females) with Type II and Type III odontoid fracture underwent O-arm assisted anterior screw placement. The mean interval between injury and surgery was 12 days (range 1-65 days). Mean operating time was 132.2 min ± SD 33.56 with average blood loss of 93 ml. ±SD 61.46. With our technique, accurate screw placement was achieved in 100% patients. At the mean follow-up of 26.4 month (SD13.75), overall acceptable fusion rate was 97.8% with non-union in 2.2% patients. Morbidity occurred in two patients; one patient developed fixation failure while other patient had nonunion which was managed with posterior C1-C2 arthrodesis. We had surgical mortality in one patient due to SAH. So overall our procedure was successful in 94% patients and among patients whose follow-up was available, acceptable fusion rates of 97.8% were achieved.We conclude that use of intraoperative three-dimensional imaging using O-arm for anterior odontoid screw fixation improves accuracy and leads to improved radiological and clinical outcomes. It further enables us to extend the indications of odontoid screw fixation to selected complex Type II and rostral Type III odontoid fractures.

Vertebral artery dissection (VAD) is a treatable cause of vertebrobasilar ischemic stroke and can be spontaneous or more commonly traumatic. Craniovertebral junction (CVJ) anomalies are a rare and often overlooked cause of VAD.The objective of this study was to study cases where CVJ anomaly presented as posterior circulation infarct and to conduct a relevant literature review.The medical records of seven patients who were managed for posterior circulation infarct associated with CVJ anomaly at our center from January 2009 through August 2013 were reviewed. PubMed and MEDLINE databases were also searched for similar cases, and the published case reports/series were reviewed.Seven patients met our inclusion criteria and were included in the study. The mean age was 17.4 years (range: 10-35 years). All the patients were males. The most common symptoms were headache, vomiting, and gait ataxia. Slurring of speech was seen in one patient. One patient had repeated episodes of gait ataxia with left-sided weakness with complete recovery in between the episodes. One patient presented in unconscious state. Four patients complained of vertigo. The median duration of symptoms was 7 days (range: 3 days-12 months).CVJ anomalies can present as posterior circulation infarct. One must evaluate all patients with posterior circulation stroke, especially young patients, for possible CVJ anomalies. Dynamic lateral cervical spine X-ray is an important tool to diagnose AAD. CVJ anomalies represent a treatable cause of VAD.

Cervical spondylotic myelopathy (CSM) is the commonest cause of cervical myelopathy. It contributes to high morbidity and consequent economic burden for society. Many measurement tools have been devised to quantify the disease severity, assist in decision-making, and to evaluate the outcome of surgical intervention.Most of the assessment scales are used for research purposes only and rarely in clinical practice. The purpose of this survey was to check the awareness of spine surgeons about these assessment scales and their role in the management of patients with CSM.An online questionnaire using the application "Google Forms" made consisting of 10 questions regarding the experience of treating the CSM patients and their preference for various parameters in assessing these patients. Statistical analysis was done using the statistical programming language R.One-hundred and sixty-three responses were analyzed. About 90% of the respondents were aware of the assessment tools and only 57% of them used any in management. Nurick's grade was the most well known among all groups. The commonest reason for surgeons not using any of these assessment scales despite being aware of these scales was their perception that it is very time-consuming to complete these assessment scales.Assessment scales have a role in the management and follow-up of CSM patients. While awareness regarding these tools is well spread, time constraint plays a major role in limiting its usage.

Hirayama disease (HD) is a relatively uncommon cause of lower cervical myelopathy. A number of surgical approaches have been described in patients with HD in literature. We reviewed the literature and did a systematic review and meta-analysis of the studies which presented the clinical outcome following surgical intervention in HD. A systematic search of literature was performed with the keywords “Surgical treatment in Hirayama Disease”, “Surgical approach in Hirayama Disease” and “Hirayama disease surgery”. Data related to clinical outcome following surgery was pooled to calculate the pooled proportion of clinical improvement following anterior and posterior surgical approach. Thirty-four articles met the inclusion criteria and were included in the final review. Altogether, there were 10 types of surgical procedures performed for Hirayama disease. The most commonly described surgical technique was anterior cervical discectomy and fusion with cervical plating. The pooled proportion of patients experiencing clinical improvement following all cervical approaches was 80% (95% confidence interval 76 to 84%). Pooled proportion was maximum for anterior cervical plating (96% (95% confidence interval 62 to 100%)) and minimum for ACDF without plating (57% (95% confidence interval 20 to 88%)). Subgroup analysis based on different surgical approaches was not significant (p value = 0.61). The pooled proportion of patients experiencing clinical improvement following anterior and posterior cervical approach was 80% (95% confidence interval 76 to 84%) and 81% (95% confidence interval 66 to 91%). The indications of surgical treatment in patients with HD include poor patient compliance for neck collar or rapidly progressing severe disease. Good results with more than 80% chances of clinical improvement have been reported following various anterior and posterior surgical approaches. However, there was no significant difference in the pooled outcome of different surgical approaches. Most common technique used in literature is anterior cervical discectomy and fusion with plating.

Background Conservatively managed posttraumatic acute subdural hematoma (SDH) can present with progression of the size of the hematoma with increased mass effect, necessitating delayed surgery. The factors contributing to this progression remain largely unknown. Methods A comprehensive search of the PubMed, Embase, and Scopus databases was performed to retrieve case control studies, retrospective cohort studies, and prospective studies with retrospective evaluation of risk factors until August 2, 2020. The different risk factors that were evaluated in the studies were compiled and the results were analyzed to arrive at a conclusion. Results A total of 7 studies were included in the systematic review and 6 were included in the analysis, with an aggregate of 679 patients. The following factors were found to have a relation with progression of acute SDH: age (odds ratio, 7.12; 95% confidence interval [CI], 2.52–11.72), use of antiplatelet drugs (odds ratio, 1.89; 95% CI, 1.18–2.77), use of anticoagulants (odds ratio, 3.09; 95% CI, 1.21–7.88), thickness of SDH (odds ratio, 4.13; 95% CI, 3.29–4.97), midline shift (odds ratio, 1.86; 95% CI, 0.69–3.03), hypertension (odds ratio, 2.22; 95% CI, 1.25–3.96) and ischemic heart disease (odds ratio, 3.32; 95% CI, 1.63–6.76). Conclusions The results of this analysis showed that patients with the risk factors outlined are at higher risk of developing symptomatic chronic SDH after conservatively managed traumatic acute SDH compared with those without them. It is therefore necessary to provide more intensive follow-up for these patients to avoid an adverse outcome.

Background: Day care spine surgery though practiced in many centers around the world, is still relatively an unchartered territory here in India, with very few centers performing spine surgeries in a day care setup. Our study was conducted to assess the feasibility of day care spine surgery in our setup. Materials and Methods: This is a prospective observational study in which patients who had undergone spinal surgery (lumbar discectomies, intradural-extramedullary lesions [IDEMs] and extradural space-occupying lesions [SOLs] extending up to one and a half vertebral levels, and one or two level anterior cervical discectomy and fusion [ACDF] in a day care setting) in our department from March 2018 to December 2018, were recruited. Of the 68 patients recruited, 33 were in the day care group and 35 were in the routine group. Data was collected on type of pathology, comorbidities, spinal segment involved, type of surgical procedure; visual analog scale (VAS) score in the preoperative period, immediately after surgery, 12h after the discharge, and at suture removal, length of hospital stay, cost, conversion of the day care to a routine admission, and disability/functional outcome. Results: We found comparable surgical results and postoperative pain profile in both the groups; median VAS in the immediate post-op period was found to be 5 in the day care and 4 in the routine group, at 12h after discharge, it was found to be 4 in both the groups, and at suture removal, it was found to be 2 in both the groups. There was statistically significant decrease in hospital stay and cost with a P value of 0.001 for both. Mean length of hospital stay was 1.15 ± 0.36 days in the day care and 9.66 ± 4.76 in the routine group. Mean cost was 2142.97 rupees in the day care, whereas it was 17971.94 rupees in the routine group. There were no new onset neurological deficits in the day care group. Five cases were converted from the day care group due to various reasons. Conclusion: One and two level lumbar prolapsed intervertebral discs (PIVDs)/canal stenosis, cervical PIVDs, especially single-level PIVD, IDEMs, and extradural SOLs can be performed in a day care setting.

Background The coronavirus 2019 (COVID-19) pandemic has changed the practice of neurosurgery. Significant resources have been dedicated to the disease. The pandemic in the Indian subcontinent, compared with the rest of the world, is relatively delayed. The neurosurgical practice cannot remain unaffected by hugely disruptive measures such as a lockdown. The inevitable increase in COVID infections with the gradual relaxation of lockdown continues to pose a risk for health care providers. Therefore, it is imperative to evaluate whether the pandemic has had a discernible effect on health care providers, especially in terms of practice modifications in private establishments and publicly funded hospitals, the emotional impact on the surgeon, and the influence of social media on the psyche of the surgeon. Methods An online questionnaire-based survey was prepared, with questions related to the COVID-specific themes of precautions taken in outpatient services and operating theaters, the influence of social media, the economic loss incurred, and the perceptible impact of telemedicine and webinars. The links to the survey were mailed to neurosurgeons in private and public practice countrywide. The responses were anonymized to ensure free and unbiased answers to the survey questions. Results A total of 176 responses were received from across the Indian subcontinent. The median age of respondents was 39 years (range, 32–70 years) and the postresidency experience was 7 years (range, 0–34 years). Respondents were an equitable mix of public and private practitioners. Of respondents, 46% were practicing restricted outpatient services, more in public institutions (P = 0.22) which also had a higher incidence of tele-outpatient services (26% vs. 17%). Wearing surgical masks, N95 masks, and gloves were the most commonly practiced precautionary measures in outpatient services (>60%). Although private practitioners were continuing elective cases (40%), public institutes were more cautious, with only emergency patients being operated on (29%). The greatest fear among all practitioners was passing the infection to their family (75%). Social media were helpful for brainstorming queries and updating practice modifications, but some surgeons admitted to receiving threats on social media platforms (37.5%). Depression and economic losses were palpable for approximately 30% neurosurgeons. Conclusions The survey highlights the perception of neurosurgeons toward the pandemic and the difference in public–private practice. Suspension of elective procedures, severe curtailment of regular outpatient appointments, drastic modifications of the normal outpatient department/operating room practices, and apprehensions related to inadequacy of safety provided by personal protective equipment use and financial losses of private establishments were some of the visible themes in our survey results. Although telemedicine has not been as widely adopted as expected, online education has been favorably received.

Background Locally aggressive vertebral body tumors of the axis must be treated with wide local excision for best outcome. Reconstruction of the load-bearing vertebra needs to be done after tumor resection in such a manner so as to give stable, long-term fusion in this young population. Methods We describe the management strategy of a 25-year-old acutely quadriplegic patient, with respiratory distress, with a C2 giant cell tumor. The use of a novel iliac crest graft modification used for C2 reconstruction along with a modified mesh cage used as an anterior plate has been reported. Results The patient had a good outcome at 18 months' follow-up, with neurologic improvement and a solid fusion. Conclusions Iliac crest autograft is inexpensive and easy to harvest and can be considered as a C2 prosthesis, especially in a resource-constrained setting. Modified iliac crest graft can be used for load transmission from C1 lateral mass to C3 body, and the mesh cage can be modified according to need as a plate with good results in an emergency.

Background Vertebral hemangiomas are benign, highly vascular lesions of the vertebra, rarely seen in the pediatric age group. Objective To analyze the long-term (>3 yr) outcome of patients of pediatric vertebral hemangioma presenting with myelopathy and to describe our surgical strategy to treat such cases. Methods All patients up to 18 yr of age with a symptomatic vertebral hemangioma treated at our hospital from May 2003 to August 2016, with at least 3-yr follow-up were included. Functional clinical outcomes were measured using American Spinal Injury Association (ASIA) score. Results There were 7 male and 7 female patients. All hemangiomas were located in the thoracic spine with single-level involvement. Upper thoracic spine involvement was more common (12 cases: 85.71%) than lower thoracic spine involvement (2 cases: 14.29%). All patients had features of myelopathy. The mean age was 14.57 yr, ranging from 10 to 18 yr. The mean follow-up was 62.21 mo, ranging from 36 to 90 mo. All patients had improvement in motor strength of both lower limbs postoperatively. Local pain, which was present in 1 patient, resolved, and the bladder symptoms present in 5 patients also resolved. Conclusion Our experience in treating symptomatic pediatric vertebral hemangiomas, along with the long-term follow-up data, suggests that good postoperative results can be achieved with minimal complications in carefully selected patients.

The purpose of the study was to analyze single fraction Gamma Knife stereotactic radiosurgery (SRS) for uveal melanoma (UM). In the treatment of UMs, the dose distribution exhibited by an irregular eye surface has more calculation uncertainty. A tissue-equivalent bolus was placed on the left eye surface of a human head-shaped phantom. It was assumed that the treated eye is fixed using retrobulbar anesthesia and suture on extraocular muscles for phantom study. Leksell stereotactic frame was fixed around phantom’s head and the stereotactic computed tomography (CT) was performed. Two sets of scans were acquired (a) without bolus and (b) with a bolus of 1.0 cm thickness. These scans were transferred into a treatment planning system (TPS). The skull contouring was performed using stereotactic CT images. The target, visual pathways, and eye lens were delineated in stereotactic CT space created on TPS. A clinical relevant plan was designed on the CT study set “a” to deliver a radiation dose of 30Gy at tumor margin. The plan superimposed over CT study set “b” and compiled for convincing treatment strategy. The tumor coverage was 95% at 50% prescription isodose line. The conformity index, selectivity and the gradient index were 1.27, 0.80 and 3.28 respectively. The left optic nerve and eye lens received a maximum dose of 11.1 Gy and 11.0 Gy respectively. The treatment plan overlay showed similar planning indices and critical organ doses. The plan comparison showed: an irradiated volume received the radiation dose > 15 Gy varies < 1.0% whereas the volume received < 15 Gy were larger (> 1.0%) in the study set “b”. The distant lateral points from the target volume which describe the phantom’s eyelid showed a radiation dose of 3.2 Gy - 2.5 Gy. The doses to these points were misled and ignored in the CT study set “a”. The eye bolus provides better dosimetric information in the estimation of low dose areas which is commonly misled on TPS in SRS planning for UMs.

Drug-induced gingival overgrowth (DIGO) secondary to chronic phenytoin intake for seizure control is a well-recognized phenomenon. Phenytoin-induced gingival overgrowth (PIGO) usually resolves gradually following cessation of phenytoin intake. It is usually seen throughout the dentate regions of the maxillary and mandibular dental arches, but more severely affect their anterior portions exposed to atmosphere. We report a rare case of PIGO predominantly involving hard palate and floor of oral cavity, which has not been reported in English literature till date.

Laminoplasty causes destruction of the posterior musculoligamentous complex, which may result in cervical kyphosis, or more commonly loss of cervical lordosis (LOCL). In this study, we evaluated the role of various preoperative radiologic parameters in predicting not only the LOCL/kyphosis but also the functional outcomes in the form of change in Oswestry Disability Index (ODI) score following laminoplasty.Patients were evaluated both clinically and radiologically with dynamic cervical spine radiograph, noncontrast-enhanced computed tomography, and magnetic resonance imaging of the cervical spine preoperatively as well as at 1 year follow-up.One hundred twenty-one patients who underwent laminoplasty for cervical spondylotic myelopathy/ossified posterior longitudinal ligament from 2011 to 2018 at our center were included in final analysis. In multivariate analysis, preoperative Cobb angle (P = 0.001), T1 slope (TIS; P = 0.001), and dynamic extension reserve (P0.001) were found to have an independent effect on LOCL. The receiver operating characteristic curve using the regression model significantly predicted LOCL10° with an area under the curve of 88.3% (P0.001). Similarly, preoperative T1S (P = 0.036) and SVA (P0.001) were found to be independent predictors of significant improvement in ODI after laminoplasty. The receiver operating characteristic curve using the regression model significantly predicted change in ODI with an area under the curve of 83.7% (P0.001). Based on these findings, classification and scoring systems with good accuracy have been proposed for prediction of LOCL and improvement in ODI.We have found that the chances of significant LOCL is determined by an interplay of preoperative Cobb angle, T1S, and dynamic extension reserve.

A novel agar-based phantom was developed and assessed for ultrasonography (USG)-guided brain biopsy training. The phantom provides visual cues combined with sonologic cues, allowing multimodal training. Impact of multimodal training is evaluated through pretraining and posttraining trials.Twenty-five participants were divided based on experience with USG-based procedures into familiar (≥3 procedures performed in the past) (n = 14) and unfamiliar (3 procedures performed) (n = 11). Agar phantoms with an opaque top and transparent middle layer were constructed in transparent glass bowls, each having 12 embedded targets. Participants underwent 2 supervised trials of USG-guided biopsy with aluminum foil covering the glass bowls, eliminating visual cues. Between 2 trials, participants underwent unsupervised self-training on a phantom without foil cover, providing visual cues. Performance was measured through insonation efficiency (EfI), biopsy efficiency (EfB), efficiency score (Ef), error score (Er), and performance score (PS). Scores were compared between and within the 2 groups before and after training. Impact of the self-training session on subjective comfort levels with the procedure was assessed through feedback forms.Familiars had better pretraining EfB, Ef, Er, and PS (P0.001) compared with unfamiliars. After training, both performed similarly on all metrics. After training, familiars improved only in EfI (P = 0.001), with the unfamiliars showing significance in all metrics except EfI.Simulation and phantom-based models can never supplant training through supervised skill application in vivo but our model supplements training by enabling technical skill acquisition, especially for beginners in USG-guided brain biopsy.

Intraoperative trans-esophageal migration of pulled-out screws, especially while using the zero-profile implant system, has been rarely reported in the literature.In this technical note, we are describing a simple technique to retrieve a trans-esophageally migrated pulled-out screw using a suction catheter.A 32-year-old female presented with spastic quadriparesis. She underwent C5-C6 anterior cervical discectomy and fusion (ACDF). Nine months following the surgery, X-ray cervical spine showed implant loosening and failure of fusion across the instrumented disc space. However, during revision surgery, the loosened screw could not be located visually in the initial attempts, though it could be felt by probing the prevertebral space with the index finger. Intraoperative X-rays showed that the screw migrated curiously in the cranial direction as the surgical field was probed further manually. The screw was then finally retrieved using Magill's forceps assisted by video laryngoscopy assisted by intermittent negative pressure application via a blunt-tipped suction catheter.She was discharged home on a Philadelphia collar, and at 1 year of follow-up, she was completely asymptomatic.Perforation of the aerodigestive tract by a displaced cervical spine implant is an uncommon complication. Manipulation during surgery may cause the implants embedded into the wall of the aerodigestive tract to become dislodged and then migrate into the pharyngeal lumen. In resource-constrained situations or when intraoperative endoscopy is not available, a trial of screw retrieval using a suction catheter may be attempted.

During the COVID-19 pandemic, a multitude of surveys have analyzed the impact virus spreading on the everyday medical practice, including neurosurgery. However, none have examined the perceptions of neurosurgeons towards the pandemic, their life changes, and the strategies they implemented to be able to deal with their patients in such a difficult time.From April 2021 to May 2021 a modified Delphi method was used to construct, pilot, and refine the questionnaire focused on the evolution of global neurosurgical practice during the pandemic. This survey was distributed among 1000 neurosurgeons; the responses were then collected and critically analyzed.Outpatient department practices changed with a rapid rise in teleservices. 63.9% of respondents reported that they have changed their OT practices to emergency cases with occasional elective cases. 40.0% of respondents and 47.9% of their family members reported to have suffered from COVID-19. 56.2% of the respondents reported having felt depressed in the last 1 year. 40.9% of respondents reported having faced financial difficulties. 80.6% of the respondents found online webinars to be a good source of learning. 47.8% of respondents tried to improve their neurosurgical knowledge while 31.6% spent the extra time in research activities.Progressive increase in operative waiting lists, preferential use of telemedicine, reduction in tendency to complete stoppage of physical clinic services and drop in the use of PPE kits were evident. Respondents' age had an impact on how the clinical services and operative practices have evolved. Financial concerns overshadow mental health.

We aim to evaluate the role of frailty and inflammatory markers in predicting the short-term outcomes after catheter-associated urinary tract infections (CAUTI) and central line-associated bloodstream infections (CLABSI).Data regarding the patients' characteristics, isolates on CAUTI and CLABSI, antibiotic susceptibility, frailty (11-point Modified Frailty Index), and inflammatory markers were retrospectively collected. Their impact on the short-term outcomes was assessed using regression modeling response.One hundred and one patients with CAUTI (n = 71) and CLABSI (n = 30) between January 2018 and December 2019 were included in this study. The pooled incidence rates for CAUTI were 5.50 and for CLABSI 3.58 episodes/1000 catheter-days. We observed 74.7% drug resistance in our CAUTI isolates and 93.3% in CLABSI. In the multivariate analysis, frailty (P = 0.006), neutrophil/lymphocyte ratio (NLR) (P = 0.007) and the presence of sepsis (P = 0.029) were found to be significant predictors of in-hospital mortality in CAUTI. In patients with CLABSI, frailty (P = 0.029) and NLR (P = 0.029) were found significant and along with sepsis (P = 0.069) resulted in a regression model with good accuracy in predicting mortality. The receiver operating characteristic curve showed that 11-point Modified Frailty Index and NLR as well as the regression model significantly predicted mortality with an area under the curve of 86.1%, 81.4%, and 95.4%, respectively, in CAUTI, and 70.9%, 77.8%, and 95.2%, respectively, in CLABSI.

High-speed drilling during neurosurgical procedures lead to aerosol generation. Contaminated particles when dispersed can lead to transmission of disease in healthcare workers via air-borne route. We designed and validated the utility of an innovative microscope drape, in mitigating the dispersion of aerosol, while drilling on an ex-vivo model.Two consecutive high-speed drilling operative simulations were performed using a dry-model under operative-microscope with and without drape, respectively, to demonstrate the degree of particulate dispersion while high-speed drilling using a 10% Povidone-Iodine solution for irrigation.There was significantly lower particulate dispersion and soiling of surgeon's gown, mask, and surrounding drapes outside the immediate operative field using the customized microscope mounted drape.Customized microscope mounted drape is effective in containing the widespread particulate dispersion associated with high-speed drilling under a microscope. The benefits of this specialized drape can translate into a safer micro-environment for operating surgeons during drilling procedures.

Cushing's disease (CD) is a spectrum of clinical manifestations due to adrenocorticotropic hormone-secreting pituitary adenoma. Transsphenoidal adenomectomy remains the standard treatment. There has been a paradigm shift from microscopic to endoscopic transsphenoidal surgery in recent years. However, the efficacy of endoscopic transsphenoidal surgery has not been established. Therefore, it is of interest to determine the superiority of endoscopic transsphenoidal surgery, if any, over microscopic surgery.To assess the efficacy of endoscopic endonasal transsphenoidal surgery for the treatment of CD and to determine the factors affecting remission.Patients undergoing surgery for CD from 2009 to 2017 were analyzed retrospectively. Transsphenoidal resection was the preferred treatment, with recent trends in favor of the endonasal endoscopic skull base approach. Postoperative cortisol level of2 μg/dL was taken as remission and value between 2 and 5 μg/dL as possible remission.In total, 104 patients operated primarily for CD were included for analysis; 47 patients underwent microscopic surgery, 55 endoscopic surgery, and 2 were operated transcranially. Remission was achieved in 76.47% of patients. In univariate analysis, factors significantly associated with remission were 1) type of surgery (P = 0.01); remission in endoscopy surgery (88.23%) is better than microscopy (56.6%); 2) postoperative day 1 morning cortisol (P = 0.004); and 3) postoperative day 1 morning ACTH (P = 0.015). In multivariate analysis, only postoperative day 1 cortisol was found to be significant predictor of remission (P = 0.02).Postoperative plasma cortisol level is a strong independent predictor of remission. Remission provided by endoscopy is significantly better than the microscopic approach.

Background: Laminoplasty is a method of posterior cervical decompression which indirectly decompresses the spinal column. Unfortunately, many patients undergoing laminoplasty develops postoperative loss of cervical lordosis (LCL) or kyphotic alignment of cervical spine even though they have sufficient preoperative lordosis which results in poor surgical outcome. Objective: We would like to highlight the relationship between various radiological parameters of cervical alignment and postoperative LCL in patients undergoing laminoplasty. Methods: We performed extensive literature search using PubMed, Google Scholar, and Web of Science for relevant articles that report factors affecting cervical alignment following laminoplasty. Results: On reviewing the literature, patients with high T1 slope have more lordotic alignment of cervical spine preoperatively. They also have more chances of LCL following laminoplasty. C2–C7 sagittal vertical axis (SVA) has no role in predicting LCL following laminoplasty though patients with low T1 slope (≤20°) and high C2–C7 SVA (>22 mm) had correction of kyphotic deformity following laminoplasty. C2–C7 lordosis, Neck Tilt, cervical range of motion, and thoracic kyphosis has no predictive value for LCL. Lower value of T1 slope (T1S-CL) and CL/T1S has more incidence of developing LCL following laminoplasty. The role of C2–C3 disc angle has not yet been evaluated in patients undergoing laminoplasty. Dynamic extension reserve determines the contraction reserve of SPMLC and lower dynamic extension reserve is associated with higher chances of LCL following laminoplasty. Conclusions: Cervical lordotic alignment is important in maintaining cervical sagittal balance which ultimately is responsible for global spinal sagittal balance and horizontal gaze. Among various radiological parameters, T1 Slope has been reported to be the most important factor affecting cervical alignment following laminoplasty.

Aim:The purpose of this study was to estimate technical treatment accuracy in fractionated stereotactic radiosurgery (fSRS) using the Extend™ system (ES) of Gamma Knife (GK).Methods and materials:The fSRS with GK relies on a re-locatable ES where the reference treatment position is estimated using repositioning check tool (RCT). A patient surveillance unit (PSU) monitors the head and neck movement of the patient during treatment and imaging. The quality assurance test of RCT was performed to evaluate a standard error (SE) associated with a measurement tool called digital probe. A ‘4-mm collimator shot’ dose plan for a head–neck phantom was investigated using EBT3 films. CT and MR distortion measurement studies were combined to evaluate SEimaging. The combined uncertainty from all measurements was evaluated using statistical methods, and the resultant treatment accuracy was investigated for the ES.Results:Four sets of RCT measurements and 20 observations of associated digital probe showed SERCT of ±0·0186 mm and SEdigital probe of ±0·0002 mm. The mean positional shift of 0·2752 mm (σ = 0·0696 mm) was observed for 20 treatment settings of the phantom. The differences between radiological and predefined isocentres were 0·4650 and 0·4270 mm for two independent experiments. SEimaging and SEdiode tool were evaluated as ±0·1055 and ±0·0096 mm, respectively. An expanded uncertainty of ±0·2371 mm (at 95% confidence level) was observed with our system.Conclusions:The combined result of the positional shift and expanded uncertainty showed close agreement with film investigations.

Aim To evaluate clinical outcomes, radiological findings (displacement and angulation), and bony fusion in cases of unstable hangman’s fracture. Introduction Hangman fracture, also known as traumatic spondylolisthesis of axis vertebra, is classically defined as bilateral pars interarticularis fracture of axis vertebra. Opinions vary regarding optimal treatment of unstable hangman’s fractures. Some authors have recommended use of rigid orthosis, whereas others have recommended internal fixation. The peculiar anatomy of the upper cervical spine is highly variable, and presence of surrounding neurovascular structures makes axis pedicle screw fixation even more technically challenging. The advent of intraoperative three-dimensional navigation systems facilitates safe and accurate instrumentation. Materials and Methods This article analyzes patients operated for type II and IIa hangman’s fractures during the period from September 2011 to August 2018 by two neurosurgeons. The patients’ age, sex, mechanism of injury, associated injuries, and neurologic status were noted. The authors retrospectively assessed the clinical outcome, radiological findings (displacement and angulation), and bony fusion. Result Eighteen patients with age ranging from 17 to 81 years, were operated using computed tomography-based (O-arm) navigation. Accuracy of screw insertion, preoperative and postoperative displacement, and angulation of C2 over C3 were evaluated. Bony fusion was assessed in all patients. A total of 92 screws were inserted: 36 screws in C2 pedicle, 34 in C3 lateral mass, 20 in C4 lateral mass, and 2 in C5 lateral mass. Of these 92 screws, 36 C2 pedicle screws were inserted under O-arm guidance. The mean preoperative C2–C3 displacement was 4.5 ± 2.1 mm, and the mean postoperative displacement was 1.8 ± 1.1 mm with a mean reduction of 2.7 ± 1.4 mm. The mean preoperative C2–C3 angulation was 10.2 ± 7.6 degrees and the postoperative angulation was 2.52 ± 4.62 degrees with a mean reduction of 8.2 ± 11.6 degrees. Screw malplacement was seen in two C2 pedicle screws (2/36, 5.5%). All C2 pedicle screw breaches were of grade 2. Excellent anatomical reduction in all cases could be achieved as established by the improvement in morphological parameters of fracture. Conclusion This series using O-arm in unstable hangman fracture demonstrates that intraoperative O-arm-based navigation is a safe, accurate, and effective tool for screw placement in patients with unstable hangman fracture.

Background: Screw diameters are currently available based on the literature available for the Western population. No data are available in such a large number of patients for the Indian population. Objective: The aim of this study was to define the average pedicle size available and to determine the angulation for placement of screws for C2 pedicle in the Indian population. We also try to determine the pedicle screw diameter which can be used universally in most Indian patients, considering the pedicle dimensions. Material and Methods: Retrospective morphometric analysis of CT scans of 247 patients (152 M, 95 F) was done to calculate the C2 pedicle width (PW), pedicle height (PH), pedicle length (PL), pedicle transverse angle (PTA) and the craniocaudal angulation (CCA) of the C2 pedicle. Results: Mean PW in females was 5.3 mm and in males it was 5.9 mm. This difference was statistically significant. The mean PH in the study population was 8.9 mm, while the mean PL was 29.7 mm. The mean PTA was 40.0 degrees and the CCA was 28.4 degrees. Conclusion: This is a morphometric analysis of the C2 pedicle which provides information for the surgeons to determine the safe site of entry and trajectory for the screw implantation. We conclude that a screw diameter of 2.7 mm can be safely implanted in a vast majority of the patient population.

External ventricular drain (EVD) is one of the most commonly performed neurosurgical procedures. EVD can be associated with high rates of complications like misplacement, iatrogenic hemorrhage, and CSF infection. Several modifications have been proposed in the EVD insertion techniques to decrease the risk of these complications. Bolt-connected EVD, one of these modifications which involves insertion of a bolt in the burr hole, has been proposed to have better chances of optimal placement of EVD tip, lesser risk of CSF infection, and accidental pullout. A comprehensive search of different databases was performed to retrieve studies comparing the bolt-connected EVD with tunneled EVD and meta-analysis was done. Seven studies met inclusion criteria and were included in the meta-analysis. Our analysis revealed that bolt-connected EVD is associated with significantly better chances of optimal placement than traditional tunneled EVD (MH OR-1.65, 95% CI 1.14 to 2.40, p = 0.008). We also observed that bolt-connected EVD is associated with significantly decreased risk of CSF infection (MH OR-0.60, 95% CI 0.39 to 0.94, p = 0.026), EVD malfunction (MH OR-0.31, 95% CI 0.16 to 0.58, p = 0.0003), and accidental disconnection (MH OR-0.09, 95% CI 0.03 to 0.26, p

Background Vasospasm and delayed ischemic neurologic deficits are the leading causes of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). Several therapeutic agents have been assessed in randomized controlled trials for their efficacy in reducing the incidence of vasospasm and improving functional outcome. The aim of this network meta-analysis is to compare all these therapeutic agents for their effect on functional outcome and other parameters after aSAH. Methods A comprehensive search of different databases was performed to retrieve randomized controlled trials describing the effect of various therapeutic approaches on functional outcome and other parameters after aSAH. Results Ninety-two articles were selected for full text review and 57 articles were selected for the final analysis. Nicardipine prolonged-release implants were found to be the best treatment in terms of favorable outcome (odds ratio [OR], 8.55; 95% credible interval [CrI], 1.63–56.71), decreasing mortality (OR, 0.08; 95% CrI, 0–0.82), and preventing angiographic vasospasm (OR, 0.018; 95% CrI, 0.00057–0.16). Cilostazol was found to be the second-best treatment in improving favorable outcomes (OR, 3.58; 95% CrI, 1.97–6.57) and decreasing mortality (OR, 0.41; 95% CrI, 0.12–1.15). Fasudil (OR, 0.16; 95% CrI, 0.03–0.78) was found to be the best treatment in decreasing increased vessel velocity and enoxaparin (OR, 0.25; 95% CrI, 0.057–1.0) in preventing delayed ischemic neurologic deficits. Conclusions Our analysis showed that nicardipine prolonged-release implants and cilostazol were associated with the best chance of improving favorable outcome and mortality in patients with aSAH. However, larger multicentric studies from other parts of the world are required to confirm these findings.

Objective Management of pediatric odontoid fractures is tricky and controversial. This study will enrich world literature with intricacies of anterior odontoid screw (OS) fixation in the pediatric population learned over the last decade. Methods In this retrospective study, all patients with pediatric odontoid fracture who underwent anterior odontoid screw fixation from January 2010 to December 2019 were included and evaluated for surgical outcome. Results Thirteen patients were included in this study (mean age, 15 years; range, 6–18 years; male/female, 11:2; type II, 10; type IIA, 1; type III, 2). Common causes of injury were motor vehicle accidents (61.5%) followed by fall from height (38.5%) and all were acute fractures (2–30 days). Five patients had neurologic deficits. Accurate placement of screw was achieved in 92.3% of patients, including all 9 patients who used intraoperative O-arm. K wire migration during bicortical drilling resulted in neurovascular injury, with 1 mortality (7.7%). The remaining 12 patients were available for follow-up (mean, 36 months; range, 20–72 months) and all had preservation of neck movements. Successful OS fixation was achieved in 84.6% of patients, including 1 patient (7.7%) who had a fibrous union. One patient (8.3%) had nonunion because of migration of the screw head in the C2 body. Conclusions Anterior odontoid screw fixation in the pediatric population provides good functional outcomes with instant fixation by direct osteosynthesis. However, the surgeon should be meticulous in the surgical approach and should achieve a lag effect. The surgeon should stop after engaging the outer cortex of the odontoid peg with K wire to avoid cranial migration. Intraoperative O-arm guidance is useful.

Objective We present the unique administrative issues as well as specific patient-related and surgeon-related challenges and solutions implemented while treating neurosurgical patients during the coronavirus disease 2019 (COVID-19) pandemic vis-à-vis pre-COVID-19 times at our tertiary-care center. Methods This is a retrospective study comparing the outcome of the neurosurgical patients treated from the beginning of lockdown in India on March 25, 2020 to November 30, 2020 with that of same period in the previous year, 2019. Results There were 687 neurosurgery admissions during the study period compared with 2550 admissions in 2019. The total number of surgeries performed in neurosurgery also showed a similar trend, with only 654 surgeries in 2020 compared with 3165 surgeries in 2019. During COVID-19 times, 474 patients were operated on including both trauma and nontrauma cases. Of the 50 patients with suspected/indeterminate COVID-19 who were operated on, 5 turned out to be positive for COVID-19. Significant differences were seen in the mortality (P < 0.01) and morbidity (P

OBJECTIVE The longer learning curve and smaller margin of error make nontraditional, or "out of operating room" simulation training, essential in neurosurgery. In this study, the authors propose an evaluation system for residents combining both task-based and procedure-based exercises and also present the perception of residents regarding its utility. METHODS Residents were evaluated using a combination of task-based and virtual reality (VR)–based exercises. The results were analyzed in terms of the seniority of the residents as well as their laboratory credits. Questionnaire-based feedback was sought from the residents regarding the utility of this evaluation system incorporating the VR-based exercises. RESULTS A total of 35 residents were included in this study and were divided into 3 groups according to seniority. There were 11 residents in groups 1 and 3 and 13 residents in group 2. On the overall assessment of microsuturing skills including both 4-0 and 10-0 microsuturing, the suturing skills of groups 2 and 3 were observed to be better than those of group 1 (p = 0.0014). Additionally, it was found that microsuturing scores improved significantly with the increasing laboratory credits (R2 = 0.72, p < 0.001), and this was found to be the most significant for group 1 residents (R2 = 0.85, p < 0.001). Group 3 residents performed significantly better than the other two groups in both straight (p = 0.02) and diagonal (p = 0.042) ring transfer tasks, but there was no significant difference between group 1 and group 2 residents (p = 0.35). Endoscopic evaluation points were also found to be positively correlated with previous laboratory training (p = 0.002); however, for the individual seniority groups, the correlation failed to reach statistical significance. The 3 seniority groups performed similarly in the cranial and spinal VR modules. Group 3 residents showed significant disagreement with the utility of the VR platform for improving surgical dexterity (p = 0.027) and improving the understanding of surgical procedures (p = 0.034). Similarly, there was greater disagreement for VR-based evaluation to identify target areas of improvement among the senior residents (groups 2 and 3), but it did not reach statistical significance (p = 0.194). CONCLUSIONS The combination of task- and procedure-based assessment of trainees using physical and VR simulation models can supplement the existing neurosurgery curriculum. The currently available VR-based simulations are useful in the early years of training, but they need significant improvement to offer beneficial learning opportunities to senior trainees.

The aim was to study surgical outcomes in hangman’s fractures in paediatric and adolescent patients and to demonstrate evolution in posterior surgery from C1-C2-C3 fusion to C1 sparing techniques. Patients (aged ≤ 18 years) operated at a tertiary level centre between September 2011 to February 2018 with more than 1 year of follow-up were included. Neurological status, type of fracture, operating time, blood loss, follow-up, and complications were assessed. Nine patients were included, with mean age mean of 16.45 years, with a mean follow-up of 42.78 months. Six patients having neurological deficit showed improvement. Two patients, one having undergone C1-C3 lateral mass screw rod fixation (LMSF) and other had C2 pedicle screw with C3 LMSF, developed kyphosis for which fixation was further extended caudally. One patient with an old hangman’s fracture with reabsorbed axis pedicle underwent C2 body screw along with C3-C4 pedicle screw rod fixation and C2 pedicle reconstruction. All patients showed evidence of postoperative fusion. Hangman’s fractures in young patients can be successfully managed via posterior fixation. In our centre, we have evolved in the direction of motion preservation at C1 C2 joint, along with 3 column stable fixation of the C2 pedicle. C2 pedicle reformation has allowed motion preserving surgery in complex fracture types. Extension of construct till C4 in selected cases is important to prevent postoperative kyphosis.

Describe the pre-operative and post-operative stages of physical therapy examination, rehabilitation interventions and outcomes in craniopagus conjoined twins (CCT).27-months old total vertical types III CCT were admitted for surgical treatment. A structured rehabilitation program (functional mobility, balance training, sensory stimulation, communication, orthotic management, and caregiver education) was delivered post-operatively at different stages of surgery. The total duration of post-separation rehabilitation was 15 months for Twin A and 23 months for Twin B.Pre-operative WeeFIM was 67/126 for both the twins. Post-separation, Twin A improved to a state of complete independence in walking, step climbing, and hand function with a discharge WeeFIM score of 84/126. However, Twin B was completely dependent in bed mobility and transfer activities during discharge (WeeFIM-18/126). Minimal change in functional status was noted in Twin B (discharge FSS score-19/30). Both the twins were transferred to a regional hospital for long-term care. At 67 months of age, Twin B lost his life due to chest infection.Vestibular based therapies, balance, and postural control may be prioritized in the rehabilitation process of CCT. Greater communication and coordination among physical, occupational therapists and other rehabilitation professionals are recommended for successful outcome in these unique cases.

Background Global use of telemedicine has increased rapidly during the coronavirus disease 2019 (COVID-19) pandemic to bridge the gap in existing health care services. Intercontinental trends in neurosurgeons' perception and practices of telemedicine have been sparingly reported. Methods We conducted an online anonymized and validated survey using a structured questionnaire to gain insight into neurosurgeons' experience with telemedicine across various continents and rated its usefulness on a 5-point Likert scale. Results We received 286 responses across 5 continents. There was a trend to support a major paradigm shift favoring teleconsultations during the COVID-19 pandemic in respondents from North America (P = 0.06). Signed prescriptions were e-mailed along with video-based teleconsultations preferentially in Europe and North America. In comparison, audio- or text-based teleconsultations along with unsigned prescriptions were prevalent in Asia and Africa (P = 0.0005). Acceptability and perceived usefulness for telemedicine during the pandemic were similar across the globe, regardless of neurosurgeons' experience (mean satisfaction score 3.72 ± 1.09; P = 0.62). A majority of neurosurgeons from Asia and South America complained of difficulties during teleconsultations owing to lack of appropriate infrastructure, internet connectivity/prescription-related issues, and potential risk of litigation (P = 0.0005). Approximately 46% of neurosurgeons, predominantly from Europe and North America, thought that telemedicine could play a vital role in clinical practice even after the COVID-19 pandemic subsides (mean satisfaction score 3.26 ± 1.16; P = 0.007). Conclusions Telemedicine in neurosurgery is a viable alternative to physical outpatient services during the COVID-19 pandemic and could potentially play a vital role after the pandemic.

Background Opinions vary regarding optimal treatment of unstable hangman's fractures. Recent technological advances have allowed short segment, motion preserving fixation, even in complex cases. The aim of the study was to demonstrate C1-C2 motion-preserving short-segment fusion in hangman's fracture and the evolution of technique from pedicle realignment to pedicle reformation in complex fractures with resorbed/destroyed C2 pedicles. Methods This was a retrospective study. Patients operated by a single surgeon at a tertiary level center from 2012 to 2018 were included. The type of fracture, operating time, and blood loss was recorded. Neurologic deficits were recorded using the American Spinal Injury Association scale with regular clinicoradiologic follow-up. Results Nine patients (8 male), with a mean age of 36 ± 16.9 years were included. In the initial 7 patients, C2 pedicle screw, C3-C4 lateral mass screw, and rod fixation was done. The last 2 patients were complex neglected injuries, with 1 having severe angulation and displacement and the other having spondyloptosis with C2 body placed anterior to C4 body. In both these patients, direct C2 body screw were placed and pedicle reconstruction was done. Mean follow up was 41.4 ± 29.8 months. All 5 patients with preoperative neurologic deficits had improvement in power. C1-C2 joint motion was preserved in all. All patients had bony fusion. Conclusions Preservation of motion at the C1-C2 joint should be the goal in all surgically managed hangman's fracture patients. The technique of C2 pedicle reconstruction can be utilized for the same in old neglected hangman's fractures.

Cervical split cord malformations are extremely rare with less than 75 cases reported in the literature worldwide. The widely different terminologies used to describe the same pathoanatomy make the documentation of all reported cases a difficult task. We conducted a systematic review of 71 cases documented over 38 reports from 1889 to 2016. The controversy regarding prophylactic surgery in asymptomatic individuals remains. We advocate prophylactic surgery in all asymptomatic individuals to preclude severe neurological deficit following trivial trauma in future. The results of surgery in asymptomatic individuals are excellent while those in symptomatic individuals are good as well.

OBJECTIVEExtracorporeal telescopes (exoscopes) have been the latest addition to the neurosurgeons’ armamentarium, acting as a bridge between operating microscopes and endoscopes. However, to the authors’ knowledge there are no published preclinical laboratory studies of the accuracy, efficiency, and dexterity of neurosurgical training for the use of 2D or 3D exoscopes compared with microscopes.METHODSIn a controlled experimental setup, 22 participating neurosurgery residents performed simple (2D) and complex (3D) motor tasks with three visualization tools in alternating sequence: a 2D exoscope, 3D exoscope, and microscope, using a block randomization model based on the neurosurgeons’ prior training experience (novice, intermediate, and senior: n = 6, 12, and 4, respectively). Performance scores (PS; including error and efficiency scores) and dexterity scores (DS) were calculated to objectify the accuracy, efficiency, and finesse of task performance. Repeated measures ANOVA analysis was used to compare the PS, DS, and cumulative scores (CS) of candidates using the three visualization aids. Bland-Altman plots and intraclass correlation coefficients were generated to quantify intraobserver and interobserver agreement for DS. Subgroup analysis was performed to assess the impact of participants’ prior training. A postexercise survey was conducted to assess the comfort level (on a 10-point analog scale) of the participants while using each visualization tool for performing the suturing task.RESULTSPS, DS, and CS were significantly impacted by the visualization tool utilized for 2D motor tasks (p < 0.001 for each), with the microscope faring better than the 2D exoscope (p = 0.04) or 3D exoscope (p = 0.008). The PS for the 3D object transfer task was significantly influenced by the visualization aid used (p = 0.007), with the microscope and 3D exoscope faring better than the 2D exoscope (p = 0.04 for both). The visualization instrument used significantly affected the DS and CS for the suturing task (p < 0.001 for both), with the microscope again scoring better than the 2D exoscope (p < 0.001) or 3D exoscope (p = 0.005). The impact of the visualization aid was more apparent in participants with a shorter duration of residency (novice, p = 0.03; intermediate, p = 0.0004). Participants also felt the greatest operational comfort while working with a microscope, 3D exoscope, and 2D exoscope, in that order (p < 0.0001).CONCLUSIONSCompared with 3D and 2D exoscopes, an operating microscope provides better dexterity and performance and a greater operational comfort level for neurosurgeons while they are performing 2D or 3D motor tasks. For performing complex 3D motor tasks, 3D exoscopes offer selective advantages in dexterity, performance, and operational comfort level over 2D exoscopes. The relative impact of visualization aids on surgical proficiency gradually weakens as the participants’ residency duration increases.

Background and Introduction: Donning and doffing of personal protective equipments (PPE) has become relevant especially during COVID-19 pandemic and neurosurgeons operating upon COVID-19 positive or suspect patients should be aware of proper technique of donning and doffing of PPE.[1] Surgeries involving direct exposure of anterior nasal spaces/paranasal sinuses carry significantly more risk of infection and it may be prudent to use PPE while operating all such cases.[2] Objective: In this video, we present our extensive protocol of donning and doffing of PPE which we have devised for our operating room. Technique: Donning consists of wearing of the PPE in a proper sequence so as to afford maximal protection from viral infection while conducting the surgical procedure. Various components of PPE and procedure of donning is shown followed by doffing, the sequential and safe removal of the PPE. Results: A meticulous method of donning and doffing PPE for neurosurgeons handling COVID-19 positive / suspect cases has been shown . Conclusion: Proper sequence of donning and doffing of PPE gear is of crucial importance during the COVID pandemic to prevent infection to the health care workers while handling COVID-19 positive/suspect cases and this video demonstrates the protocol we use at our institute.