L2 Burst fracture - Transpedicular screw and rod stabilisation

20 year old man had sustained injury to the back when he fell from a height of 20 feet from a coconut tree. MRC grade 2/5 paraparesis L1 downwards. The severely compressed neural elements were decompressed by a laminectomy and then stabilised with transpedicular screw [D12 to L3 since L1 body was also fractured] and rod [titanium, GESCO [Tm]] and fused with bone grafts.

intraop problems: getting the c-arm to behave!

improved significantly and quite swiftly to 4+/5 just by relief of compression. Able to walk with a walker.

Fourth ventricular ependymoma [WHO grade II] - Total excision.

Two and a half year old boy had increasing headache, unsteadiness of gait. He had features of raised ICP and truncal ataxia. Ciss-3D images [my favourite MR sequence -shows such exquisite details of cisternal anatomy!] clearly show the extension of tumor into the right foramen of Lushka. Tumor showed patchy enhancement.

Midline suboccipital craniotomy and complete excision was possible since tumor attachment to the floor of the fourth ventricle was small and well circumscribed.

Surgeons:I and VS Hari

Intraop problems: Difficulty visualising and excising the extension of the tumor into the right foramen of lushka [since our microscope does not have turnable eyepiece]. The lower cranial nerves were preserved intact and were visualised after excision of tumor from the foramen of Lushka. Lack of self retaining Leyla retractors was not much of a problem.

Post op complication - developed CSF leak, and high cell counts in ventric CSF, following superficial surgical site infection. Organism was sensitive to vancomycin and patient quickly responded and recovered completely from this potentially life threatening complication.

A VP shunt, although not desirable, was inserted since an early operation theatre slot was not available.

Close follow up is planned. No adjuvant treatment as of now.

Pondy night

L>R: Roopeshkumar VR, M.S. Gopalakrishnan, Arveen, Gomathy shankar, V.S. Hari, Randhir

Equipment wish list for 2007-08

Equipment [priority / approved or not]

Operating microscope [top priority/yes ]
Stereotactic frame [needed/deferred ]
Neuroendoscope [top priority/yes]
Image intensifier [high priority/deferred ]
Neuronavigation [ needed/ deferred ]
CUSA [ needed/deferred ]
Jet irrigating system for diathermy [ needed/deferred ]
Mayfield head clamps [ high priority/yes ]
Radiolucent operating table [ needed/deferred ]
Nerve stimulator [ needed/deferred ]
Deep brain stimulator [ needed/deferred ]
Image viewer [ large LCD screen with video editing][ needed/deferred ]
Intraoperative Ultrasound [ needed/deferred ]
Controlled suction [ needed/ deferred ]
Syringe infusion pump [ needed/deferred ]
Alpha bed [air bed] [ needed/deferred ]
Sequential compression bandage [anti-DVT][ needed/ deferred ]
Special instruments [ needed/deferred ]
Diathermy [ needed/ deferred ]

Equipment purchase almost done: waiting for purchase order

Pneumatic drill

Diathermy

Leyla retractor system

More instruments

Ulnar nerve injury at distal forearm - split sural nerve graft

40 yr old with defence wound to ulnar aspect of distal forearm when assaulted with a knife 3 months back. 0/5 power of ulnar innervated muscles (some atrophy +) . Absent CMAPs and SNAPs.



anesthesia - supraclavicular block and epidural anesthesia for graft harvesting.
Surgery: Split sural nerve graft after neurolysis. Some fascicles were intact in the deeper aspect of the nerve.
Surgeons - I and hari.

Problems: Intraop NAP recordings could not be done as the equipment is currently unavailable. transcluscent 80 ethilon suture is much harder to use compared to silk. Dont underestimate the value of icecream sticks and shaving blades when it come to trimming nerve ends. Cling drapes are good.

Endoscopic trans-nasal transphenoidal decompression of sellar supra-sellar cystic craniopharyngioma

Two patients with almost identical lesions on mri.

Very elegant minimally invasive surgery.
Problems: Some part of the capsule may be left behind although not readily apparant on post op scan. Planned for close follow up for recurrence. Gammaknife/ reexcision then?
both patients had transient diabetes insipidus.
surgeons: Roopesh, Prof S Gopalakrishnan [Otorhinolaryngology dept], Somnath.

Anterior third ventricular colloid cyst - transcallosal approach

25 yr old lady with one episode of hydrocephalic attack/seizure [history not very discriminating] and attacks of headaches since 10 days.
CT scan - hyperdense anterior third ventricular lesion.

MRI - looked like a colloid cyst to me. Roops thought it could be cranio

Surgery - Right frontal parasagittal craniotomy[not crossing midline], interhemispheric transcallosal approach, transforaminal excision of lesion. Intraop impression: craniopharyngioma?! The viscid liquid contained white specks similar to that in some cranios.

Surgeons: I, VS Hari, Gomathy Shankar.

problems encountered:

1. change of plan - wanted to use right lateral position with head flexed up laterally to take advantage of gravity dependant retraction since self retaining retractors are currently unavailable but gave up fearing disorientation. May be next time. [Ability to operate with horizontal hand position should be a significant advantage]


2. Had difficulty finding foramen of monroe [? lifted up and adesions], and some difficulty orienting in the ventricle entered [left]. [grade 3/4 frust!] Initial attempted septal fenestration resulted in a small area of injury to left caudate ependymal surface.
   
3. End op hyperthermia [39.4 deg] and tachycardia [145/mt] due to occlusive drapes and air conditioning malfunction.

Post op - No deficits.

Final histopathology: Colloid cyst.

• Craniotomy need not be across midline - avoids sinus injury, saves a couple of burr holes. but has to be really reach midline - expose lateral edge of sinus.
• interhemispheric entry was precoronal as planned on preop mri and veins.

Intradural lesion [neurofibroma] excision in emergency OT

35 yr old lady with 15 day history of numbness and weakness of lowerlimbs. Relatively rapid progression to paraplegia with loss of bladder control over last 2 days.

OT slot at 2 am atlast! D6-8 neurofibroma was excised.

Operating surgeons - VS Hari and Gomathy Shankar.

Fourth ventricular epidermoid

Thought I'd post a few images of what we operate here. This 65 year old was bed ridden because of severe cerebellar ataxia for last six months. Due to lack of support from family she didnt undergo treatment despite a CTscan diagnosis 3 months back.

Surgery- midline suboccipital craniotomy and subtotal excision. [actually intraop impression was gross total excision, but some tumor stuck to the obex and that exiting beyond the foramina of Lushka were left behind to avoid unacceptable deficits.] *surgeons:I and Hari.

intraoperative events and problems encountered: Blood pressure rose to 200/160 as the tumor was decompressed although no significant maniulation of the floor of the fourth ventricle occurred. Controlled with propofol infusion. Bp remined high in immediate postop period. [NTG patch now].

operating microscope [the chinese make borrowed from plastic surgery] malfunctioned and surgery was done without it!

outcome: no new deficits except mild gag tolerence. however she experienced near aspiration on attempted feeding. Indirect laryngoscopy showed fixed left vocal cord. So she was maintained on ryles tube feeds until the right cord started compensating. Relatives refused the option of gastrostomy.

We did start the fire…

We did start the fire…

This is just a beginning. Everything starts small. Even the giant sequoia.

I’d say this is a log on how we went about constructing this department. Just to remind ourselves the possibilities that keeps shining through.

June 2006 – Dr Roopesh VR and I get appointed as Asst Profs in Neurosurgery. We are however under administrative control of Dept of Surgery since Aps cannot be given administrative control of a dept.

June 2006 – first neurosurgery – L4-5 disc prolapse with cauda equine syndrome. Many thanks to the director Prof KSVK Subbarao , Prof AK Das [MS], Prof Karoon Agarwal [plastic surgery hod] , Prof Jagdish [Hod Surgery] for their support.

July 2006 – 2 beds in CTVS ICU and two more in ward 44.

OT days are Fridays and alternate Tuesdays. That’s too few. Buts that’s life!

OP days - Mondays and Wednesdays [10 am , 83 A, 2nd floor]

Feb 2007 after months and months of toiling on “specifications” on excel files, the first instruments have landed. Our tenure almost got over before that happened! [Just as Dr Ananthakrishnan had warned]

March 2007 – Surgical diathermy, instruments, Leyla retractor system, pneumatic drill are in the purchase pipeline. [a very long one that ]