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.

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.