Unusual Anterior Neck Swelling: Cervical Spinal Cord Schwannoma

Schwannomas are typically solitary, well-encapsulated, benign tumors running along or attached to a nerve. An intradural-extramedullary cervical spinal schwannoma, which first manifests as a swelling in the anterior neck, has not been reported to the best of our knowledge. We present the case of a 69-year-old patient complaining of a gradually worsening painful left cervical swelling for over 8 years. First, a posterior spinal midline approach was performed for the resection of the tumor and the tumor portion in the vertebral canal was totally removed. The second operation, the anterolateral approach, was planned to be executed in a second surgical session. The patient was discharged from the hospital without neurological deficits. Histopathological diagnosis was a schwannoma. The first aim of surgery is to treat neurological deficits in patients with cervical intraspinal schwannomas with/without extension into the extra-vertebral paravertebral neck regions. The surgical strategy combines the posterior midline and the anterolateral cervical approaches in the same session or at different times.

Cystic endometrial hyperplasia-pyometra complex in a mastectomized Boerboel bitch following tamoxifen administration

Tamoxifen is a non-steroidal, anti-estrogenic and selective estrogen receptor modulator commonly used as adjuvant chemotherapy in humans with breast cancer and occasionally in dogs following mastectomy. This report presents a case of cystic endometrial hyperplasia-pyometra in a dog following oral administration of the tamoxifen. A 4-year-old intact nulliparous Boerboel bitch presented at Veterinary Teaching Hospital, Federal University of Agriculture, Abeokuta. It was diagnosed with mammary carcinoma of the right cranial lumbar mammary gland. Mastectomy was performed followed by oral administration of Tamoxifen (10mg daily) for six weeks as adjunct chemotherapy. Eight weeks after, the owner reported that the bitch was lethargic, anorexic and had a purulent vaginal discharge. Abdominal ultrasound revealed cystic endometrial hyperplasia. Results of complete blood counts showed neutrophilic (absolute neutrophil count = 19.5×103/L) leukocytosis (total leukocyte count = 24.9X103/L), while bacterial culture yielded moderate growth of Staphylococcus aureus, which was sensitive to Ciprofloxacin, Ofloxacin, Sparfloxacin and Gentamycin. The bitch was treated with 400μg of Misoprostol and 500mg of Ciprofloxacin twice daily for two weeks. Ovariohysterectomy (OVH) was performed using a ventral midline approach when no significant improvement was observed from medical treatment. The dog improved significantly after ovariohysterectomy and was discharged one week after OVH. It was concluded that, although tamoxifen is routinely used as adjuvant chemotherapy following mastectomy, more research is required to evaluate its safety in intact bitches.

Comparative study of midline versus paramedian approach of spinal block in elderly.

Objective: To compare the efficacy of paramedian and midline approach for spinal block in elderly, in terms of success rate and number of attempts required by either approach. Study Design: Randomized Controlled Trial. Setting: Department of Anaesthesia, Madina Teaching Hospital Faisalabad. Period: January 2018 to December 2019. Material & Method: 120 elderly ASA I-III patients scheduled to undergo lower abdominal or limbs; general or orthopaedic surgery were randomly divided into two equal groups A and B of sixty patients. Patients were assigned into groups by lottery method. Group A patients were supposed to receive spinal block by midline approach while group B patients were planned to receive spinal block by paramedian approach. Results: It was observed that success rate was significantly high in group B, 98.3% as compared to group A, 80%, (p value 0.001). The number of attempts were significantly less in group B in comparison to group A (p-value 0.0001). Conclusion: The paramedian approach for spinal block in elderly patient’s offers ease of administration and a higher success rate as compared to midline approach.

Endoscopic Endonasal Supraoptic and Infraoptic Approaches for Complex “Parasuprasellar” Lesions: Surgical Anatomy, Technique Nuances, and Case Series

Surgical management of lesions involving the lateral area of the suprasellar region, including the lateral aspect of the planum sphenoidale and a tight junction region of the optic canal (OC), the anterior clinoid process (ACP), and the internal carotid artery (ICA) and its dural rings, is extremely challenging. Here, the authors introduce two novels endoscopic endonasal supraoptic (EESO) and endoscopic endonasal infraoptic (EEIO) approaches to access these regions, namely, “parasuprasellar” area. Surgical simulation of the EESO and EEIO approaches to the parasuprasellar area was conducted in 5 silicon-injected specimens. The same techniques were applied in 12 patients involving the parasuprasellar area.The EESO and EEIO approaches can be used independently or in combination, but are more often employed as a complement to the endoscopic endonasal midline approach and transcavernous approach. In clinical application, the EESO and EEIO approaches were successfully performed in 12 patients harboring tumors and multiple aneurysms involving the parasuprasellar area. Gross total and subtotal tumor resection were achieved in 9 patients and 1 patient, respectively. For two patients with multiple aneurysms, the lesions were clipped selectively according to location and size. Visual acuity improved in 7 patients, remained stable in 4, and deteriorated in only 1. No postoperative intracranial infection or ICA injury occurred in this series. The EESO and EEIO approaches can be combined with the current endoscopic endonasal midline approach and transcavernous approach to remove extensive pathologies involving the intrasellar, suprasellar, sphenoid, and cavernous sinuses and even bifurcation of the ICA.

Does Paramedian Approach Preferentially Secure Optimal Drug Delivery Onto Ventral Epidural Space and Subsequent Superior Clinical Efficacy Over a Dorsal Midline Approach During Cervical Interlaminar Epidural Injection?

BACKGROUND: There is paucity in the literature directly comparing the clinical results between the paramedian and the midline interlaminar cervical epidural injections. OBJECTIVE: To compare the proportion of ventral epidural spread of injectate and consequent clinical outcome between the paramedian and midline approach during interlaminar epidural injection in patients with axial neck and/or interscapular pain triggered from the underlying cervical spine pathologic condition. STUDY DESIGN: Retrospective study. SETTING: Primary pain clinic and spine hospital. METHODS: Two hundred and twenty-three patients with axial neck and/or interscapular pain due to cervical problem underwent interlaminar epidural injection through either a paramedian approach (PM group, n = 93) or a midline approach (ML group, n = 130). We compared the portion of ventral epidural filling, Numeric Rating Scale (NRS), and McNab criteria between both groups. The NRS and McNab criteria were also separately compared between the ventrally spread (VS) group and non-ventral spread (non-VS) group inside each PM and ML group, respectively, at 2 weeks and 10 weeks post-injection. RESULTS: The PM group showed a significantly higher proportion of ventral spread, successful NRS reduction, and satisfactory McNab criteria than the ML group at 10 weeks. In the PM group, the VS group showed the same results as above compared to the non-VS group. LIMITATIONS: A retrospective analysis based on the relatively short-term follow-up period clinical results. CONCLUSIONS: The paramedian approach showed the better direct injectate transfer over the ventral epidural space and subsequently superior clinical efficacy for the patients suffering from axial neck and/or interscapular pain secondary to cervical spine problems. KEY WORDS: Cervical disease, epidural injection, interlaminar, paramedian, midline, ventral epidural spread, Numeric Rating Scale, McNab criteria

COMPARATIVE STUDY OF PRE-PROCEDURE AND REAL TIME ULTRASOUNDGUIDED EPIDURALANAESTHESIA IN OBESE PATIENT.

Background And Aims: Epidural anaesthesia is widely performed using a landmark-guided midline approach. The indistinct or distorted landmark is associated with obesity, previous spinal surgeries, deformities, or degenerative changes due to ageing. In the present study, we compared the efcacy of real-time ultrasound (RUS)-guided paramedian approach, and pre-procedure ultrasound (PUS) landmark-guided paramedian approach in obese patients. Methods: Sixty patients with body mass index (BMI) >30 kg/m2 were included in the study. The participants were randomly assigned to two groups : PUS and RUS group . The primary end point was to attain a successful placement of epidural catheter. Variables like the number of attempts, the number of passes, the time taken for identifying epidural space(s), and time taken for successful epidural catheter placement(s) were secondary end points and were recorded in both the groups. Results: The median number of attempts were 4 (IQR 2-4) and 2 (IQR 1-2), respectively, in the PUS and RUS group (P-value < 0.001). The median number of passes, the median time for identifying space, and the time for successful epidural catheter placement was statistically signicantly less in the RUS group, than the PUS group. Conclusion:The time taken for the identication of the space, the number of attempts, number of passes, and the time taken for successful epidural catheter placement was more in the PUS group as compared to the RUS group.

Falx Cerebelli Meningioma: Case Report of a Rarely Occurring Tumor, Management Nuances, and Literature Review

The falx cerebelli is a small crescent fold of dura mater that is attached to the internal occipital crest and projects forward into the posterior cerebellar notch between the cerebellar hemispheres. We report a rare case of a 61-year-old female who presented with a 1-month history of headache and gait instability. Imaging findings were suggestive of a meningioma arising from the falx cerebelli. Complete surgical resection was achieved with a standard posterior fossa midline approach. Duraplasty was performed using animal allograft dura (Duraguard) and additional layers of oxidized cellulose preparation (Surgicel), fibrin sealant, and nonsuturable collagen matrix (Duragen) were utilized to reduce the risk of a cerebrospinal fluid leak. Pathology confirmed a World Health Organization (WHO) grade-I meningioma. Postoperatively, patient with asymptomatic thrombosis of the left transverse/sigmoid sinuses and later with a pseudomeningocele managed with a lumbar drain. To our knowledge, this is the second documented case in the literature. We discuss intraoperative nuances and unique aspects in the postoperative care and management of these patients.

Endoscopic Endonasal Supraoptic and Infraoptic Approaches for Complex “Parasuprasellar” Lesions: Surgical Anatomy, Technique Nuances, and Case Series

Purpose: Surgical management of lesions involving the lateral area of the suprasellar region, including the lateral aspect of the planum sphenoidale and a tight junction region of the optic canal (OC), the anterior clinoid process (ACP), and the internal carotid artery (ICA) and its dural rings, is extremely challenging. Here, the authors introduce two novel endoscopic endonasal supraoptic (EESO) and endoscopic endonasal infraoptic (EEIO) approaches to access these regions, namely, “parasuprasellar” area.Methods: Surgical simulation of the EESO and EEIO approaches to the parasuprasellar area was conducted in 5 silicon-injected specimens. The same techniques were applied in 12 patients involving the parasuprasellar area.Results: The EESO and EEIO approaches can be used independently or in combination, but are more often employed as a complement to the endoscopic endonasal midline approach and transcavernous approach. In clinical application, the EESO and EEIO approaches were successfully performed in 12 patients harboring tumors and multiple aneurysms involving the parasuprasellar area. Gross total and subtotal tumor resection was achieved in 9 patients and 1 patient, respectively. For two patients with multiple aneurysms, the lesions were clipped selectively according to location and size. Visual acuity improved in 7 patients, remained stable in 4, and deteriorated in only 1. No postoperative intracranial infection or ICA injury occurred in this series.Conclusion: The EESO and EEIO approaches can be combined with the current endoscopic endonasal midline approach and transcavernous approach to remove extensive pathologies involving the intrasellar, suprasellar, sphenoid, and cavernous sinuses and even bifurcation of the ICA.