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Narendra Nathoo

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Narendra Nathoo, Marc R. Mayberg, and Gene H. Barnett

✓ W. James Gardner, a skillful neurosurgeon and inventor, is best remembered for his cervical tongs and hydrodynamic theory of syringomyelia.

A pioneer of modern neurosurgery, Gardner trained under Charles Frazier in Philadelphia, and in 1929 he moved to Ohio where he became chief of neurosurgery at the Cleveland Clinic, a position he was to hold for the next 33 years. A large surgical practice made it imperative for Gardner to develop surgical methods that were quick, effective, and advantageous for patient and surgeon. He was an early proponent of the sitting position for patients undergoing cranial surgery, which led to the development of a neurosurgical chair with a head fixation device. To reduce the risks of hypotension and air embolism when the patient is in the sitting position, Gardner invented the clinical G suit. He was the first to advocate and use induced arterial hypotension for intracranial surgery and the first neurosurgeon in the US to publish his experiences performing lumbar discography. He converted an operating table so that he could induce hypothermia during aneurysm surgery and then applied pneumatic cuffs to occlude the major arterial supply to the brain. His pioneering work has been documented in many other areas such as hemifacial spasm and trigeminal neuralgia, for which he performed the first vascular decompression, in cervical sympathectomy for treatment of various ailments, and in the use of intrathecally delivered steroid drugs for sciatica. During his career, he authored 256 publications and one book on the dysraphic states. Many of his contributions to the discipline of neurosurgery are now taken for granted.

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Narendra Nathoo

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Narendra Nathoo, Frederick K. Lautzenheiser, and Gene H. Barnett

✓ Much has been written about Harvey Cushing, his contributions to neurosurgery, and his relationship with many of his contemporaries. Nevertheless, there is no independent report documenting his relationship with Ohio's first neurosurgeon, George W. Crile. Crile's role as a neurosurgeon is limited to the late nineteenth and early twentieth centuries, and he is best remembered for other accomplishments. Father of physiological surgery, pioneering surgeon, innovator, inventor, soldier, and the principal founder of the Cleveland Clinic Foundation, Crile lived during the golden era of surgery, when the discipline was evolving from a crude and chancy art to an applied science. Crile achieved distinction by performing and describing the first successful radical neck dissection for head and neck cancers and the first successful direct human-to-human blood transfusion. He helped introduce the measurement of blood pressure during surgery, first used cocaine for regional anesthesia in the US, proposed “anoci-anesthesia” to prevent shock during surgery, helped establish one of the first nurse anesthetist schools, and invented the Crile forceps and the pneumatic suit, which was the forerunner to the aviator's antigravity suit. He was a founding member of the American College of Surgeons, its second president (1916–1917), and chairman of the Board of Regents (1913–1939). Crile was a teacher, lecturer, and author who published more than 400 papers and 24 books.

In this report the authors trace the relationship between Crile and Cushing from their initial competition for a staff surgeon's position to their common interest in blood pressure, and their roles in the American Ambulance in France and later in World War I.

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Narendra Nathoo, Atom Sarkar, Gandhi Varma, and Ehud Mendel

Although nail-gun injuries are a common form of penetrating low-velocity injury, impalement with barbed nails has been underreported to date. Barbed nails are designed to resist dislodgment once embedded, and any attempt at removal may splay open the barbs along the path of entry, with the potential for significant soft-tissue and neurovascular injury. A 25-year-old man sustained a nail impalement of the cervical spine from accidental discharge of a nail gun. The patient was noted to be fully conscious with no neurological deficits. Cervical Zone 2 impalement was noted, with only the head of the nail visible. Angiography revealed the nail lying just anterior to the right vertebral artery (VA), with compression of the vessel. Preoperatively, analysis of a similar nail revealed that orientation of the head determined position of the barbs. A deep neck dissection was then performed to the lateral aspect of the C-3 body, using the nail as a guide. Prior to removal, the nail was turned 180° to change the position of the barbs, to prevent injury to the VA. Nail removal was uneventful. The authors present a simple technique for treatment of a nail-gun injury with a barbed nail. Prior to removal, radiographic analysis of the impaled nail must be performed to determine the presence of barbs. If possible, the surgeon should request a similar nail for analysis prior to surgery. Last, the treating surgeon must have knowledge of the barbs' position at all times during nail removal, to prevent damage to critical structures.

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Trigeminal nerve schwannoma with ancient change

Case report and review of the literature

Kene Ugokwe, Narendra Nathoo, Richard Prayson, and Gene H. Barnett

✓ Ancient change in a schwannoma is a histological variant typically found in longstanding tumors. Histologically, the tumor has biphasic features typical of a schwannoma with evidence of degenerative changes that may complicate diagnosis. The authors report on a 23-year-old man with no features of neurofibromatosis who presented with headaches, blurred vision, and ataxic gait. Magnetic resonance imaging demonstrated a rim-enhancing lesion in the cerebellopontine angle with displacement of brainstem structures and no supratentorial hydrocephalus. Using a lateral suboccipital approach together with image guidance and intraoperative neurophysiological monitoring, a gross-total macroscopic excision was performed. At surgery, the tumor was found to arise from the inferior division of the trigeminal nerve. The final histological diagnosis was schwannoma with ancient change. Note that ancient change in schwannomas is a histological variant thought to result from degenerative changes in longstanding tumors. To the authors' knowledge, this is the first independent report of this histological variant in an intracranial schwannoma.

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Cranial fasciitis

Case illustration

Preneshlin V. Govender, Rondhir Jithoo, Vivian Chrystal, Tracy Däuth, and Narendra Nathoo

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Pradeep K. Narotam, Fan Qiao, and Narendra Nathoo


Complete dural closure is not always possible following posterior fossa surgery, often requiring a graft to secure complete closure. The authors report their experience of using a collagen matrix as an onlay dural graft for repair of a posterior fossa dural defect.


A retrospective analysis was performed in 52 adult patients who had undergone collagen matrix duraplasty for the posterior fossa. Complications directly related to the dural graft, the presence or absence of hydrocephalus, and the role of closed suction wound drainage in relation to postsurgical pseudomeningoceles were analyzed.


The indication for posterior fossa surgery was tumors in 32 patients, vascular abnormalities in 9 patients, and spontaneous cerebellar hemorrhage in 11 patients. Closed suction wound drainage was used in 23 patients (44.2%). Forty-eight (92.3%) of 52 patients had a dural defect > 2 cm. Nine (81.8%) of 11 patients with hydrocephalus required ventriculoperitoneal shunts. Complications of the surgery included pseudomeningoceles in 2 patients (3.8%; no closed suction wound drainage); superficial wound infections in 1 patient (1.9%; with closed suction wound drainage); and unexplained eosinophilia in 1 patient.


Duraplasty using a collagen matrix is safe and effective in the posterior fossa, and is easy to use and time efficient. Meticulous layered wound closure, the detection and effective control of hydrocephalus, and the use of closed suction wound drainage reduces complications related to collagen matrix duraplasty for the posterior fossa.