Objective: Conventional methods for anterior upper dorsal spine are not devoid of intra-operative complications due to anatomical constraints, a major blood vessel and vital organs. We analyzed the details of Trans- axillary approach without muscle cutting in tuberculosis, tumor, and traumatic lesions of T2 to T6 and upper limb causalgia.Materials and Methods: A prospective quasi-experimental study was conducted for 3 years included 30 patients presented with dorsal myelopathy due to D2 to D6 vertebral body involvement. Right and left sided approaches were utilized. Medical Research Council grading was used to assess neurological status.Results: Mean age was 32 ± 15 years, which included male 18.60% and female 12.40%. T4 vertebrae were commonly involved. Others were T5, T3 and T6 respectively. The majority of lesions were tuberculosis of the spine (n = 14), tumor (n = 8), trauma (n = 5) and causalgia of upper limb (n = 3). No intra-operative complications occurred, estimated blood was 80-100 ml and operative time was 120-160 minutes. Postoperative complications included pneumonia (n = 1), superficial wound infection (n = 3), death (n = 1). Serial follow up was for 2 years, Patients were discharged with improved neurological status and causalgia patients got immediate post-operative relief.Conclusions: Transaxillary approach is a unique anatomical corridor which is safe, feasible with promising results. It provides optimal decompression, reconstruction with better fixation and alignment in various pathologies of upper dorsal spine.

This study explored the hemodynamic characteristics of a subcranial-intracranial bypass from the internal maxillary artery by measuring blood flow on intraoperative duplex sonography. The hemodynamic parameters of the internal maxillary artery (n = 20), radial artery (n = 20), internal maxillary artery-middle cerebral artery bypass (n = 42), and internal maxillary artery-posterior cerebral artery bypass (n = 9) were measured by intraoperative duplex sonography. There was no significant difference in the internal diameters of the internal maxillary and radial arteries (mean ± SD, 2.51 ± 0.34 versus 2.56 ± 0.22 mm; P = .648). The mean radial artery graft length for subcranial-intracranial bypasses was 88.5 ± 12.78 mm (95% confidence interval [CI], 80.8-90.2 mm). Internal maxillary artery-middle cerebral artery bypasses required a shorter radial artery graft than internal maxillary artery-posterior cerebral artery bypasses (77.8 ± 2.47 versus 104.8 ± 4.77 mm; P = .001). The mean flow volumes were 85.3 ± 18.5 mL/min (95% CI, 76.6-93.9 mL/min) for the internal maxillary artery, 72.6 ± 26.4 mL/min (95% CI, 64.3-80.9 mL/min) for internal maxillary artery-middle cerebral artery bypasses, and 45.4 ± 6.7 mL/min (95% CI, 40.7-50.0 mL/min) for internal maxillary artery-posterior cerebral artery bypasses. All grafts were opened after the success of the salvage procedures had been established, and the early patency rates (1 month after the operation) were 95% for internal maxillary artery-middle cerebral artery bypasses and 100% the internal maxillary artery-posterior cerebral artery bypasses. Measurement of blood flow by intraoperative sonography can be helpful in decision making and predicting graft patency and success after neurosurgical bypass procedures.

Sir,Aneurysmal bone cysts (ABCs) are multi-cystic, osteolytic growths. The classic or standard form (95%) has blood filled spaces among bony trabeculae. Osteoid tissue and osteoclastic giant cells are found in the stromal tissue. The solid form (5%) shows fibroblastic proliferation, osteoid production and degenerated calcifying fibromyxoid elements. 1 ABCs are usually seen in younger patients. Around 80% of the patients are less than 20 years of age, more frequently in females. ABCs occurring de novo are called as primary ABCs. Secondary ABCs have accompanying tumors like chondroblastoma and giant cell tumor in 30% of patients. Other associated tumors or non-tumorous conditions include ossifying fibroma, osteosarcoma, chondrosarcoma, non-ossifying fibroma, chondromyxoid fibroma, unicameral or solitary bone cyst or trauma. 2 ABCs are commonly found in long bones, membranous bones of the thorax, pelvis and vertebra. In long tubular bones, these tend to be eccentrically located in the metaphysis. However, these can occur in any location, including the diaphysis and epiphysis, rarely, involving multiple bones simultaneously. 3 Skull is rarely affected. 4,5 The treatment modalities include selective arterial embolization, irradiation, intralesional curettage, intraoperative adjuvants, bone grafting, marginal resection or wide excision. Tumor has to be excised and all cystic lining curetted. Cryotherapy, phenol or cauterizations (intraoperative adjuvants) are used to remove microscopic tumor cells. Resulting bony defects may be replaced with homologous bone or cadaveric bone. We, herein, present a 50-year patient who was admitted with the complaints of headache, and rapidly enlarging swelling in the right temporal and mastoid area elevating the auricle. There was serosanguinous ear discharge and loss of hearing from right ear. There was no history of trauma. Swelling was non-tender, firm to hard and pulsatile. Cough impulse was negative and no bruit was audible. Right seventh nerve was paralysed with lower motor neuron features. No other body part was involved. CT scan brain with contrast and CT-angio brain revealed a vascular mass with bony outgrowth and cystic spaces involving right temporal petrous and mastoid area with midline brain shift (Figure 1). Patient underwent operation and lesion was excised and surrounding bony area was cauterised. Attached dura was coagulated with bipolar diathermy. Histopathology report confirmed the diagnosis of chondroblastoma with secondary ABC. Patient remained well for one year, however, he had recurrence of same growth after one year. Second operation was performed in the same way. He was then referred for radiotherapy. This case is unique as it presented at advanced age and in an unusual location. As mentioned above, skull is very rarely the primary site for this lesion. Both the primary tumour and the associated secondary ABC are rare at this age. Moreover, this case recurred after one year. Recurrence is not rare in ABCs. Most commonly, it results from incomplete removal of the...

Objectives:  To analyze the management and outcome of ruptured anterior cerebral circulation aneurysm by a variety of procedures including microsurgical clipping. Material and Methods:  A quasi-experimental study, carried out in The Department of Neurosurgery, Peoples’ Medical University Hospital Nawabshah from November 2010 to December 2020.We enrolled 38 patients and 40 aneurysms who presented with ruptured aneurysms. Hunt and Hess grading was used to evaluate the neurological status and ruptured aneurysms were managed by microsurgical clipping, excision, and suture ligation. Results:  Out of 38 patients Male were (23) 61% and females were (15) 39%, with a mean age of 50±25 years with aneurysmal subarachnoid hemorrhage and graded according to Hunt and Hess grade and fissure grading. Middle cerebral artery aneurysm was 45%, Anterior communicating artery 30%, Anterior Cerebral Artery 10%, carotid bifurcation 2.5%. Multiple aneurysms at internal carotid plus anterior communicating artery (n = 2) and internal carotid plus middle cerebral artery aneurysms n = 2. Distal anterior cerebral (n = 1). In 33 patients, the aneurysm was clipped, in 3 patients with fissure grading 4 and huge intracerebral bleed with signs of brain herniation, decompression plus aneurysm clipping was done, suture ligation (n = 1) and excision of a giant aneurysm (n = 3). Conclusions:  Microsurgical clipping is considered an ideal modality to secure a ruptured intracerebral aneurysm. Rarely it can be amendable by suture ligation, or excision. Presenting Hunt and Hess, fissure grading, age, and volume of intracerebral bleed have a direct impact on prognosis.

Objectives: The aim of study to know the pattern of injury in terms of severity & outcome in patients with head injuries admitted in trauma unit of a tertiary care Centre. Study Design: Descriptive Study. Setting: Trauma Centre, Peoples medical university hospital Nawabshah. Period: From June, 2018 to May, 2019. Material & Methods: This included 385 patients admitted in trauma unit of Neurosurgery Department of Peoples medical university hospital Nawabshah, through emergency Department with head injury sustained due to road traffic accident, fall, sports related injuries or Assault etc as evident on CT scan brain (plain) with bone window. Patients with poly trauma, bleeding disorders, previously operated and those who failed to turn up in OPD for follow up were excluded.  Glasgow Coma Scale (GCS) was used for categorizing the subjects with head injury into mild (GCS 14-15), moderate (GCS 9-13) and severe injury (GCS 3-8). CT scan brain with bone window was done in all patients. These were then managed accordingly according to the severity of the injuries. Follow up Glasgow Coma Outcome scale was used to assess the outcome in these patients. Results: Regarding nature of traumatic injuries in these patients commonest were contusion (21.8%), extradural hematoma (27.5%), subdural hematoma (22.3%), diffuse axonal injury (13.2%), and subarachnoid hemorrhage (4.2%). This was followed by skull fracture (7.3%) and intracerebral hemorrhage (3.6%). Majority of the patients were with severe head injury. Glasgow Outcome Scale of Patients at Follow- up reveled complete recovery in 106 (27.5 %), Mild disability in 81(21.0%), Moderate Disability in 64 (16.6%), Severe Disability in 72 (18.7%), Persistent Vegetative state in 36 (9.4%), and death in 26 (6.8 %). Conclusion: Good outcome is observed in patients who are properly treated by continuous monitoring & timely surgical intervention in a tertiary care hospital.