Value of Intracranial Pressure Monitoring in TBI Questioned

A new trial published in, N Engl J Med. Published online December 12, 2012. Abstract Editorial, has questioned the Value of Intracranial Pressure Monitoring in TBI.
The trial found that care focused on maintaining monitored ICP at or below 20 mm Hg (as guidelines recommend) in order to avoid poor outcome was not superior to care based on serial computed tomography (CT) and neurologic clinical examination.

New Radiologic Prognostic marker in TBI

Fractional anisotropy (FA) on diffusion tensor imaging (DTI) is now identified as radiologic prognosticator for TBI (Traumatic brain injury). Low FA has been shown to be associated with worse outcomes after concussion, and higher the FA, the greater the likelihood of having fewer postconcussion symptoms and a better health-related quality of life a year after the injury,

Cranial dermoids with risk of intra cranial extension

Dermoids result from failure of dysjunction of the cutaneous and neuroectoderm and contain epithelium, hair follicles, sebaceous glands, and other cutaneous elements. 
Nasal and midline sub-occipital (inion) dermoid cysts are more likely to be associated with a small overlying pit or tract and have a higher risk of intracranial and intradural extension (generally between the leaves of the falx cerebri or falx cerebelli, respectively).
Cysts with intracranial extension present clinically either due to recurring meningitis or, rarely, with intracranial mass effect. 
The treatment in all cases is surgical extirpation. 

Thoracic and Lumbar pedicle screw insertion

Thorasic Spine: As a general rule the starting point for insertion of Pedicle screws is the point " where the superior border of the transverse process converges with the lamina along the lateral border of the articular facet. this point is typically in line with or just medial to the pars.

Lumbar Spine: The starting point is at the junction of the lateral facet and the transverse process (arrow)- taken from Spine Surgery (ed: Benzel; p 1056)
The other way is "Bisection of a vertical line through the facet joints and a horizontal line through the transverse process can also serve as a useful landmark for lumbar pedicle entry site".

Signs and Symptoms of Facet joint syndrome

The signs of Facet joint syndrome are

1. Local paraspinal tenderness;
2. Pain on hyperextension, rotation, and lateral bending;
3. Absence of neurologic deficit;
4. Absence of root tension sign; and hip, buttock, or back pain with straight leg raising .

Symptoms include

1. Hip and buttock pain,
2. Cramping leg pain involving the thigh but not radiating below the knee,
3. Low back stiffness, The back stiffness is typically most marked in the morning and
4. Absence of paresthesias.

Bruns Nystagmus

Bruns nystagmus is an unusual type of bilateral nystagmus most commonly occurring in patients with cerebellopontine angle tumours.
It is caused by the combination of slow, large amplitude nystagmus (gaze paretic nystagmus) when looking towards the side of the lesion, and rapid, small amplitude nystagmus (vestibular nystagmus) when looking away from the side of the lesion.
It occurs in 11% of patients with vestibular schwannoma, and occurs mainly in patients with larger tumours (67% of patients with tumours over 3.5cm diameter).
It may be caused by the compression of both flocculi, the vestibular part of the cerebellum, and improvement in both the nystagmus and balance problems occur commonly after removal of the tumour.
Bruns nystagmus is named for Ludwig Bruns

Stabilization of Dorsal Spine

I had a difficult case to manage independently in the very early post M.Ch period in the recent past.
A case of a 40 year male with a history of fall from a height of 20 feet and having total paraplegia and absent bowel and bladder sensation.
I thought of stabilizing the spine as I can mobilize the patient early and prevent the complications so forth. My experience with with Stabilization of dorsal spine with D2 to D5 screws and rods is very minimal as I had not done a similar case individually earlier.
With good home work I started the case and I could manage to do it reasonably good and safe. I had difficulty in identifying the starting point of the Pedicle screws and the land marks were not clearly visble. But with a little wider exposure I could make out the starting points and rest all went good under fluoro guidence. I had some more difficulty in decompressing the canal when I was trying to remove the anterior compression. But could manage adequate decompression at the end.

Post operatively patient didn't show good improvement and remained Grade 0 all through with no bowel and bladder sensations. POst OP period was uneventful and patient was discharged in a stable state.

Current management of Lumbar stenosis with Low grade Spondylolisthesis

Earlier view regarding the management of spinal canal stenosis with low grade Spondylolisthesis was by doing a laminectomy and wait and watch for the progression of listhesis and intervene accordingly.

But the current ideas regarding this is changing and is presented as a necessity for simultaneous stabilization and laminectomy. "Lumbar spinal fusion plus laminectomy appears to be a better option than laminectomy alone in terms of quality of life for patients with degenerative grade I spondylolisthesis with lumbar spinal stenosis"*.


* Zoher Ghogawala, MD, director of the Wallace Clinical Trials Center at Greenwich Hospital in Greenwich, Connecticut, presented these results from a prospective, 5-center, randomized, controlled trial here at the 80th Annual Scientific Meeting of the American Association of Neurological Surgeons.

Ref:  http://www.medscape.com/viewarticle/762967?src=mpnews&spon=26

Key Burr hole

The Key burr hole which is commonly performed in Pterional craniotomy is called the "Golf Club Head".

Ref: Photo Atlas of Skull Base Dissection: Techniques and Operative Approaches by Masahiko Wanibuchi.