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Aliasgar Vajihuddin Moiyadi, Bhagavatula Indira Devi and K. P. Sivaraman Nair

Object

Brachial plexus root avulsion injuries, which are devastating, usually result from high-speed accidents. Nerve transfer provides hope for successful treatment of this difficult set of injuries. Nevertheless, the controversies regarding indications, techniques, and outcome of the various available surgical procedures continue.

Methods

A retrospective analysis was performed in 51 patients (43 male and eight female patients) with brachial plexus injuries who underwent neurotization at the authors' institute between 1997 and 2003. Clinical, electrophysiological, and imaging data were used to identify the type and pattern of involvement of the various elements of the plexus. The mean duration of denervation was 6.4 months (range 2–24 months). Outcome was computed in terms of the overall improvement in power of the target muscle as well as the functional usefulness of such recovery.

Results

There were 50 supraclavicular injuries (25 preganglionic, eight postganglionic, and 17 mixed). One patient had an infraclavicular (posterior spinal cord) injury. Pan–brachial plexus injury with a flail upper limb was the most common pattern. Overall, 55 nerves were neurotized—33 musculocutaneous, 18 axillary, and two each for ulnar and radial nerves (47 single and four double neurotizations—by using intercostal nerve donors in the majority of cases. Adequate follow-up data were available in 36 patients (38 nerves) and these were used for the analysis of outcome. Overall, 58.3% of patients had improvement, and of these 62% achieved useful recovery. This accounted for 36% of overall useful recovery. Multiple logistic regression analysis revealed that regardless of age, sex, mode and pattern of injury, and recipient nerve, the duration of denervation showed a trend toward significance that correlated with overall (but not useful) improvement. The critical duration of denervation was 5.5 months.

Conclusions

Neurotization for brachial plexus root avulsion injuries is a viable option. Early detection and intervention (within 5.5 months) leads to a better overall recovery.

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Manjul Tripathi, Dhaval P. Shukla, Dhananjaya Ishwar Bhat, Indira Devi Bhagavatula and Tejesh Mishra

The issue of head injury in a noncontact sport like cricket is a matter of great debate and it carries more questions than answers. Recent incidents of fatal head injuries in individuals wearing a helmet have caused some to question the protective value of the helmet. The authors discuss the pattern, type of injury, incidents, and location of cranio-facio-ocular injuries in professional cricket to date. They evaluate the history of usage of the helmet in cricket, changes in design, and the protective value, and they compare the efficacy of various sports' helmets with injury profiles similar to those in cricket. The drop test and air cannon test are compared for impact energy attenuation performance of cricket helmets. A total of 36 cases of head injuries were identified, of which 5 (14%) were fatal and 9 (22%) were career-terminating events. Batsmen are the most vulnerable to injury, bearing 86% of the burden, followed by wicketkeepers (8%) and fielders (5.5%). In 53% of cases, the ball directly hit the head, while in 19.5% of cases the ball entered the gap between the peak and the faceguard. Ocular injuries to 3 wicketkeepers proved to be career-terminating injuries. The air cannon test is a better test for evaluating cricket helmets than the drop test. Craniofacial injuries are more common than popularly believed. There is an urgent need to improve the efficacy and compliance of protective restraints in cricket. A strict injury surveillance system with universal acceptance is needed to identify the burden of injuries and modes for their prevention.

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Venkatesh S. Madhugiri, Indira Devi Bhagavatula, Anita Mahadevan and Nagarathna Siddaiah

Phaeohyphomycosis is caused by pigmented fungi that are not normally pathogenic. Fonsecaea is a rare cause of cerebral infections, most of which are caused by F. monophora. Brain infections caused by F. pedrosoi are very rare, and there are only a few case reports describing this. Most infections take the form of abscesses (epidural or intracerebral). The authors report a rare case of a contained fungal granuloma caused by F. pedrosoi. The patient presented with epilepsy, which was treated as a case of extratemporal lesion–related epilepsy. The diagnosis was made after resection. The authors describe the clinical course of this patient.

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Umesh Srikantha, Indira Devi Bhagavatula, Satish Satyanarayana, Sampath Somanna and Bengaluru A. Chandramouli

✓Osteochondromas are the most common benign bone tumor. Although the metaphysial region of long bones is the usual site of these tumors, the vertebrae may be infrequently affected. The presentation may vary from typical compressive myelopathy to radiculopathy or radiculomyelopathy, depending on the site of involvement. The authors present 3 consecutive cases of cervical spine osteochondromas encountered over 3 years at their institution, each different in its site of involvement, presentation, and chosen treatment. The patient in Case 1 had the typical presentation and lesion site, and was treated with a conventional laminectomy. The patient in Case 2 presented with an extensive disease that required complex, staged surgery with spinal fusion and instrumentation. The patient in Case 3 presented with monoradiculopathy and had a facet joint osteochondroma that was successfully treated with a simple partial facetectomy, without laminectomy.

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Indira Devi Bhagavatula, Dhaval Shukla, Nishanth Sadashiva, Praveen Saligoudar, Chandrajit Prasad and Dhananjaya I. Bhat

OBJECTIVE

The physiological mechanisms underlying the recovery of motor function after cervical spondylotic myelopathy (CSM) surgery are poorly understood. Neuronal plasticity allows neurons to compensate for injury and disease and to adjust their activities in response to new situations or changes in their environment. Cortical reorganization as well as improvement in corticospinal conduction happens during motor recovery after stroke and spinal cord injury. In this study the authors aimed to understand the cortical changes that occur due to CSM and following CSM surgery and to correlate these changes with functional recovery by using blood oxygen level–dependent (BOLD) functional MRI (fMRI).

METHODS

Twenty-two patients having symptoms related to cervical cord compression due to spondylotic changes along with 12 age- and sex-matched healthy controls were included in this study. Patients underwent cervical spine MRI and BOLD fMRI at 1 month before surgery (baseline) and 6 months after surgery.

RESULTS

Five patients were excluded from analysis because of technical problems; thus, 17 patients made up the study cohort. The mean overall modified Japanese Orthopaedic Association score improved in patients following surgery. Mean upper-extremity, lower-extremity, and sensory scores improved significantly. In the preoperative patient group the volume of activation (VOA) was significantly higher than that in controls. The VOA after surgery was reduced as compared with that before surgery, although it remained higher than that in the control group. In the preoperative patient group, activations were noted only in the left precentral gyrus (PrCG). In the postoperative group, activations were seen in the left postcentral gyrus (PoCG), as well as the PrCG and premotor and supplementary motor cortices. In postoperative group, the VOA was higher in both the PrCG and PoCG as compared with those in the control group.

CONCLUSIONS

There is over-recruitment of sensorimotor cortices during nondexterous relative to dexterous movements before surgery. After surgery, there was recruitment of other cortical areas such as the PoCG and premotor and supplementary motor cortices, which correlated with improvement in dexterity, but activation in these areas was greater than that found in controls. The results show that improvement in dexterity and finer movements of the upper limbs is associated with recruitment areas other than the premotor cortex to compensate for the damage in the cervical spinal cord.

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Indira Devi Bhagavatula, Dhananjaya I. Bhat, Gopalakrishnan M. Sasidharan, Rakesh Kumar Mishra, Praful Suresh Maste, George C. Vilanilam and Talakkad N. Sathyaprabha

OBJECTIVE

Respiratory abnormalities are well documented in acute spinal cord injury; however, the literature available for respiratory dysfunction in chronic compressive myelopathy (CCM) is limited. Respiratory dysfunction in CCM is often subtle and subclinical. The authors studied the pattern of respiratory dysfunction in patients with chronic cord compression by using spirometry, and the clinical and surgical implications of this dysfunction. In this study they also attempted to address the postoperative respiratory function in these patients.

METHODS

A prospective study was done in 30 patients in whom cervical CCM due to either cervical spondylosis or ossification of the posterior longitudinal ligament (OPLL) was diagnosed. Thirty age-matched healthy volunteers were recruited as controls. None of the patients included in the study had any symptoms or signs of respiratory dysfunction. After clinical and radiological diagnosis, all patients underwent pulmonary function tests (PFTs) performed using a standardized Spirometry Kit Micro before and after surgery. The data were analyzed using Statistical Software SPSS version 13.0. Comparison between the 2 groups was done using the Student t-test. The Pearson correlation coefficient was used for PFT results and Nurick classification scores. A p value < 0.05 was considered significant.

RESULTS

Cervical spondylotic myelopathy (prolapsed intervertebral disc) was the predominant cause of compression (n = 21, 70%) followed by OPLL (n = 9, 30%). The average patient age was 45.06 years. Degenerative cervical spine disease has a relatively younger onset in the Indian population. The majority of the patients (n = 28, 93.3%) had compression at or above the C-5 level. Ten patients (33.3%) underwent an anterior approach and discectomy, 11 patients (36.7%) underwent decompressive laminectomy, and the remaining 9 underwent either corpectomy with fusion or laminoplasty.

The mean preoperative forced vital capacity (FVC) (65%) of the patients was significantly lower than that of the controls (88%) (p < 0.001). The mean postoperative FVC (73.7%) in the patients showed significant improvement compared with the preoperative values (p = 0.003). The mean postoperative FVC was still significantly lower than the control value (p = 0.002). The mean preoperative forced expiratory volume in 1 second (FEV1) (72%) of the patients was significantly lower than that of the controls (96%) (p < 0.001). The mean postoperative FEV1 (75.3%) in the cases showed no significant improvement compared with the preoperative values (p = 0.212). The mean postoperative FEV1 was still significantly lower than the control value (p < 0.001). The mean postoperative FEV1/FVC was not significantly different from the control value (p = 0.204). The mean postoperative peak expiratory flow rate was significantly lower than the control value (p = 0.01). The mean postoperative maximal voluntary ventilation was still significantly lower than the control value (p < 0.001). On correlating the FVC and Nurick scores using the Pearson correlation coefficient, a negative correlation was found.

CONCLUSIONS

There is subclinical respiratory dysfunction and significant impairment of various lung capacities in patients with CCM. The FVC showed significant improvement postoperatively. Respiratory function needs to be evaluated and monitored to avoid potential respiratory complications.

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Subhas Konar, Dhaval Gohil, Dhaval Shukla, Nishanth Sadashiva, Alok Uppar, Dhananjaya I. Bhat, Dwarkanath Srinivas, Arivazhagan Arimappamagan and Bhagavatula Indira Devi

OBJECTIVE

The aim of this study was to report the etiology, clinical features, microbiology, surgical outcome, and predictors of outcome of spontaneous subdural empyema (SDE).

METHODS

The authors conducted a retrospective study in a tertiary hospital. Children up to 18 years of age, with a diagnosis of SDE with infective etiology, were included in the present cohort. Patients with posttraumatic, postsurgery, and tubercular origin of SDE were excluded from the study. The Glasgow Outcome Scale was used for outcome assessment at the end of 3 months. For analysis purposes, the demographic data, clinical features, radiological data, microbiology, type of surgery, and complication data were categorized, and univariate and multivariable logistic regression analyses were performed to identify the factors associated with outcome.

RESULTS

Ninety-eight children were included in the study and the mean age was 10.9 years. Otogenic origin (34.7%) was the most common source of infection, followed by meningitis (14.3%). The mean duration of symptoms was 12 days. Seventy-six children presented with Glasgow Coma Scale (GCS) score > 8 and the supratentorial location was the most common location. Almost 75% of the children underwent craniotomy or craniectomy and the rest had burr-hole evacuation. Beta-hemolytic Streptococcus (10%) was the most common organism isolated. Cerebral venous thrombosis (CVT; 10.2%) was the most frequent complication in this cohort. The other complications were infarction (6.1%), new-onset seizure (4.1%), and bone flap osteomyelitis (4.1%). Thirteen cases had a recurrence of pus collection, which was more common in the craniotomy group than in the burr-hole group. Age (p = 0.02), GCS score ≤ 8 (OR 8.15, p = 0.001), CVT (OR 15.17, p = 0.001), and presence of infarction (OR 7, p = 0.05) were strongly associated with unfavorable outcome. In multivariable logistic regression analysis, only GCS score ≤ 8 (p = 0.01), CVT (p = 0.02), and presence of infarction (p = 0.04) had a significant impact on unfavorable outcome.

CONCLUSIONS

Prompt diagnosis and immediate intervention is the goal of management of SDE, especially in children as a delay in diagnosis can result in unconsciousness and secondary complications such as CVT and infarction, which adversely affect outcome.

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Ajit Mishra, Andiperumal Raj Prabhuraj, Dhaval P. Shukla, Bevinahalli N. Nandeesh, Nagarathna Chandrashekar, Arvinda Ramalingaiah, Arimappamagan Arivazhagan, Dhananjaya Ishwar Bhat, Sampath Somanna and Bhagavatula Indira Devi

OBJECTIVE

Intracranial fungal granuloma (IFG) remains an uncommon entity. The authors report a single-institute study of 90 cases of IFG, which is the largest study until now.

METHODS

In this retrospective study, all cases of IFG surgically treated in the years 2001–2018 were included. Data were obtained from the medical records and the pathology, microbiology, and radiology departments. All relevant clinical data, imaging characteristics, surgical procedure performed, perioperative findings, and follow-up data were recorded from the case files. Telephonic follow-up was also performed for a few patients to find out their current status.

RESULTS

A total of 90 cases consisting of 64 males (71.1%) and 26 (28.9%) females were evaluated. The mean patient age was 40.2 years (range 1–79 years). Headache (54 patients) was the most common presenting complaint, followed by visual symptoms (35 patients), fever (21 patients), and others such as limb weakness (13 patients) or seizure (9 patients). Cranial nerve involvement was the most common sign (47 patients), followed by motor deficit (22 patients) and papilledema (7 patients). The mean duration of symptoms before presentation was 6.4 months (range 0.06–48 months). Thirty patients (33.3%) had predisposing factors like diabetes mellitus, tuberculosis, or other immunocompromised status. A pure intracranial location of the IFG was seen in 49 cases (54.4%), whereas rhinocerebral or paranasal sinus involvement was seen in 41 cases (45.6%). Open surgery, that is, craniotomy and decompression, was performed in 55 cases, endoscopic biopsy was done in 30 cases, and stereotactic biopsy was performed in 5 cases. Aspergilloma (43 patients) was the most common fungal mass, followed by zygomycosis (13 patients), chromomycosis (9 patients), cryptococcoma (7 patients), mucormycosis (5 patients), and candida infection (1 patient). In 12 cases, the exact fungal phenotype could not be identified. Follow-up was available for 69/90 patients (76.7%). The mean duration of the follow-up was 37.97 months (range 3–144 months). The mortality rate was 52.2% (36/69 patients) among the patients with available follow-up.

CONCLUSIONS

A high index of suspicion for IFG should exist for patients with an immunocompromised status and diabetic patients with rhinocerebral mass lesions. Early diagnosis, aggressive surgical decompression, and a course of promptly initiated antifungal therapy are associated with a better prognosis.