Yatin Kher

Introduction Several different surgical techniques have been used in the treatment of patients with symptomatic Arnold-Chiari malformation type 1 (ACM-1) with or without syrinx. Endoscope-assisted decompression of the posterior fossa has been found to be safe and effective. We report our initial experience of endoscopic management of ACM-I. Material and Methods This was a prospective study of 15 symptomatic patients. Pre- and postoperative clinical status and computed tomography and magnetic resonance imaging findings were recorded. Suboccipital bone of ∼ 3 cm distance from the foramen of magnum and posterior arch of atlas was removed. Partial splitting of the dura mater with preservation of the inner portion and the arachnoid membrane was performed. Any change in axial and sagittal length of the syrinx, tonsillar ascension, shape of the tonsil tip, appearance of cerebrospinal fluid posterior to the tonsil, and formation of the cisterna magna were recorded. Patients with atlantoaxia...

Introduction Endoscopic techniques are being used in lumbar disk disease and lumbar canal stenosis to decompress the spinal canal. The present study analyzed pre- and postoperative magnetic resonance imaging (MRI) measurements of the lumbar canal. Material and Methods This was a prospective study of 30 lumbar levels. Patients < 18 years of age with unilateral compression, previous surgery at the same level, and spinal instability were excluded. Endoscopic posterior decompression was used. Pre- and postoperative MRIs of all the patients were performed. Anteroposterior (AP), transverse, interfacet diameter, canal surface area, and height and angle of the lateral recess were measured. Results Mean ages of male and female patients were 42.1 ± 10.3 and 45.0 ± 9.9 years, respectively. Pathologies were at L4-L5, L5-S1, and L2-L3 levels in 16, 13, and 1 patient, respectively. There was significant improvement in AP diameter (4.75 ± 1.75 mm to 10.33 ± 2.11 mm), interfacet distance (12.70 ...

Background Retraction of the overlying brain can be difficult without causing significant trauma when using traditional brain retractors with blades. These retractors may produce focal pressure and may result in brain contusion or infarction. Tubular retractors offer the advantage of low retracting pressure that is less likely to be traumatic. Low retraction pressure in the tubular retractor is due to the distribution of retraction force in all directions in a larger area. Material and Methods We conducted a retrospective study of 100 patients with deep-seated tumors operated on from January 2010 to December 2014. Tumor removal was accomplished with the help of a microscope and/or endoscope. Tubular brain retractors sizes 23, 18, and 15 mm were used. Folding of the tubular retractor after making a longitudinal cut allowed a small corticectomy. Larger retractor sizes were used in the earlier part of the study and in larger tumors. All the patients were evaluated postoperatively by computed tomography scan on the first postoperative day, and subsequent scans were done as and when needed. Any brain contusion or infarctions and the amount of tumor removal were recorded. Results A total of 74 patients had astrocytomas; 12, meningiomas; 4, colloid cyst of the third ventricle; 4, metastases; 4, primitive neuroectodermal tumor; 1, neurocytoma; and 1, ependymoma. Pure endoscopic excision without using a microscope was performed in 12 patients. Lesions were in the frontal (n = 34), parietal (n = 22), intraventricular (n = 16), basal ganglion or thalamic (n = 14), occipital (n = 10), and cerebellar (n = 4) areas. Total, near-total, and partial excision was achieved in 49, 29, and 22 patients, respectively. Use of a conventional retractor for excision of peripheral and superficial parts of a large tumor, small brain contusions, and technical failure were observed in 7, 4, and 1 patient, respectively. The low incidence of contusion may be partly due to the nonavailability of magnetic resonance imaging in the early postoperative period because of financial constraints. Conclusion Removal of deep-seated tumors was safe and effective using our simple tubular retractor. It also helped minimize bleeding during surgery. A tubular brain retractor and conventional retractor can be used to complement each other if required.

Craniopharyngiomas treatment has been challenging because of their anatomical location. The endoscopic endonasal (EE) transsphenoidal approach is indicated in sellar, supra sellar, selected intra ventricular, petroclival, nasopharyngeal, and recurrent craniopharyngiomas in adults and children. High definition wide angle improved visualization without brain retraction, good infrachiasmatic exposure, minimally invasive nature, greater tumor resection rate, improved visual outcome, less severe adverse events and lack of external scars are some of the benefits. Large tumors with significant parasellar extension, lack of stereoscopic visualization, steep learning curve, narrow surgical corridor, vascular encasement, difficulty in control of hemorrhage, dural and bony defect closure, and cerebrospinal fluid (CSF) leak are some of the limitations. Multilayer dural closure and vascular flap has reduced CSF leak rate significantly. Preoperative pituitary dysfunctions usually do not show any ...

ABSTRACTPneumocephalus is a rare complication of chronic otitis media. Despite its rarity intra-cranial air carries a potential risk of increased intra-cranial pressure or meningitis, which requires immediate therapy. A 10-year-old child presented to us with complaints of fever, headache, vomiting, and decreased hearing from left ear. He had history of left ear discharge since 2 years. Clinical examination revealed neck rigidity and left chronic otitis media. Contrast enhanced computed axial tomography scan of head [Figure 1] and [Figure 2] showed pneumocephalus in left cerebellopontine angle, opacification of left middle ear and nonpneumatisation of left mastoid. Child was immediately put on empirical intravenous antibiotics and decongestants. He showed clinical improvement in 3 days. Pneumocephalus secondary to chronic otitis media is extremely rare; we are reporting one such case in a child with review of literature.

Microneurosurgical operations differ from other surgery. Longer operative time, narrow and deep-seated operative corridors, hand-eye coordination, fine manipulation, and physiologic tremor present special problems. Proper understanding of visual feedback, control of physiologic tremor, better instrument design, and development of surgical skills with better precision is important for optimal surgical results. Using the pen-type precision grip with well-supported arm, wrist, hand, and fingers avoids fatigue and improves precision. Proper instrument design, patient positioning, hemostasis techniques, tilting operative table, good operative microscope, an adjustable chair, careful use of suction tube, bipolar forceps, and brain retraction play important roles in microneurosurgery. Sufficient clinical case volume or opportunity during routine operative hours may not be available in the beginning for young neurosurgeons; microsurgical training using various models can enable them to gain experience. Training models using deep-seated and narrow operative corridors, drilling, knot-tying technique, and anastomosis using fine sutures under high magnification can be practiced for skill improvement. Training laboratory and simulation modules can be useful for resident training and skill acquisition. Indigenously made inexpensive models and comparatively less expensive microscopes can be used in resource-constrained situations. The maintenance of microsurgical ability should be preserved by staying active in operative practice. The knowledge of ergonomics, proper training, observing hand movements of skillful surgeons, and the use of operative videos can improve skill. Endoscopic assistance, computer-assisted robot hand technique, and microtechnology can provide access to the smallest areas of the body.

Lumbar canal stenosis (LCS) is quite common. Surgery is indicated when patient fails to improve after conservative treatment. Endoscopic technique can be used in LCS and lateral recess stenosis. It can be performed in degenerative canal stenosis or with disc bulges. Bilateral severe bony canal stenosis and unstable spine are the contraindications. This procedure should be avoided in patients with a history of trauma. Detailed history and thorough physical examination should be performed to find out exact level of pathology responsible for symptoms. Patient’s symptoms must correlate with radiological findings. Magnetic resonance imaging is the investigation of choice because of its superior visualization of soft-tissue. Computed tomography scan does give a more accurate and detailed picture of the bony anatomy. Although the operative time and the complication rate could be more in the initial learning curve, the results of endoscopic decompression are comparable with conventional ope...

ABSTRACTEndoscopic endonasal trans-sphenoid surgery (EETS) is increasingly used for pituitary lesions. Pre-operative CT and MRI scans and peroperative endoscopic visualization can provide useful anatomical information. EETS is indicated in sellar, suprasellar, intraventricular, retro-infundibular, and invasive tumors. Recurrent and residual lesions, pituitary apoplexy and empty sella syndrome can be managed by EETS. Modern neuronavigation techniques, ultrasonic aspirators, ultrasonic bone curette can add to the safety. The binostril approach provides a wider working area. High definition camera is much superior to three-chip camera. Most of the recent reports favor EETS in terms of safety, quality of life and tumor resection, hospital stay, better endocrinological, and visual outcome as compared to the microscopic technique. Nasal symptoms, blood loss, operating time are less in EETS. Various naso-septal flaps and other techniques of CSF leak repair could help reduce complications. ...