III This study evaluated the effect of duraplasty based on cerebellar tonsillar descent (CTD) grade in 82 patients who underwent surgical correction of Chiari malformation type I (CM-I) from 1998-2009. Patients were divided into two groups: those who underwent posterior fossa decompression (PFD) with duraplasty (Group 1, n=58), and those who underwent PFD without duraplasty (Group 2, n=24). The study found no significant differences in outcomes between the groups for CTD grades 1 and 2. However, for grade 3, the decrease in syrinx size and clinical improvement based on Japanese Orthopaedic Association scores were significantly better
More harm than benefit of perioperative dexamethasone on recovery following ...Dibya Falgoon Sarkar
1. A prospective double-blind randomized trial found that perioperative dexamethasone provided minor pain relief but significantly increased insulin requirements and risk of infections in patients undergoing reconstructive head and neck cancer surgery.
2. Dexamethasone did not accelerate recovery or shorten hospital stay and its use in head and neck cancer reconstruction provided no clear clinical benefits while increasing complications.
3. A randomized controlled trial of corticosteroids after transoral robotic surgery found extended perioperative dexamethasone was safe and may allow for earlier improvement in diet consistency and decreased hospital stay, though it minimally affected postoperative pain.
Genioglossus muscle advancement and simultaneous sliding genioplasty in the m...Dibya Falgoon Sarkar
This study describes a technique that combines genioglossus muscle advancement and sliding genioplasty to treat obstructive sleep apnea. The technique was performed on 14 patients with OSA and retrognathia. It resulted in advancement of the genioglossus muscle to help keep the airway open during sleep. Only 3 patients underwent follow-up sleep studies, which showed improvement in 2 patients. While this technique provides both functional and aesthetic benefits, larger studies are still needed to fully evaluate its effectiveness in treating OSA.
This case report describes a rare occurrence of an aneurysmal bone cyst arising from an iliopubic chondromyxoid fibroma in a 20-year-old male patient. Imaging showed an osteolytic tumor in the left iliopubic ramus. The tumor was excised surgically and microscopic examination confirmed the diagnosis of chondromyxoid fibroma with areas consistent with an aneurysmal bone cyst. This case represents an unusual location for a chondromyxoid fibroma and confirms the rare association between aneurysmal bone cysts and chondromyxoid fibromas. The patient recovered well after surgery with no recurrence after one year of follow up.
Corseting: A new technique for the management of diffuse venous malformations...Dibya Falgoon Sarkar
1) The study introduces the "corset suturing" technique for treating large diffuse venous malformations in the head and neck region. Corset suturing involves continuous suturing that incorporates the lesion and strangulates the vessels to induce occlusion.
2) The technique was performed on 90 patients with non-cutaneous venous malformations. Most lesions resolved within 4-8 weeks with minimal complications and good cosmetic outcomes.
3) While corset suturing provides an effective and low-cost alternative treatment, the study had limitations as a retrospective study without controls to fully evaluate the technique.
Surgical approaches for condylar fractures related to facial nerve injury: de...Dibya Falgoon Sarkar
This study compared different percutaneous surgical approaches for treating condylar fractures to determine their relationship to facial nerve injury (FNI). The study found that approaches involving deep dissection beneath the marginal mandibular nerve branch (submandibular and retroparotid approaches) and the presence of a dislocated fracture were significantly associated with higher risks of FNI. In contrast, approaches involving more superficial dissection above the marginal mandibular nerve branch (transparotid, transmasseteric anteroparotid, high cervical transmasseteric anteroparotid approaches) had lower risks of FNI. The study concluded that superficial group approaches should be recommended to minimize the risk of F
Study of current pattern of Cervical Spondylotic Myelopathy and to evaluate t...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Kyphosis as a sequel of myelomeningocele is a malformation that may result in many problems including ulcers, limited use of the arms for support purposes, and reduced pulmonary function. Treatment is complex and demanding. In 1998 the authors started treating 15 patients using the Alfredo Cardoso Monterrubio (ACM) plate for an average of 2.9 years. On average, the ACM plate provided 67.4 degrees of correction initially, with some loss of correction over time. Complications included infections and plate loosening, but patients reported improved posture and functionality.
1) A study compared the clinical results of using hollow screws versus plates for treating spiral fractures of the lower third of the tibia combined with posterior malleolar fractures.
2) 61 patients were treated with tibia plate fixation and either hollow screw fixation (34 patients) or plate fixation (27 patients) of the posterior malleolar fracture.
3) At 6-36 months follow up, all fractures healed well with no differences in healing time or infection rates between the two groups. Functional outcomes assessed using the Baird-Jackson scoring system also did not significantly differ between groups.
More harm than benefit of perioperative dexamethasone on recovery following ...Dibya Falgoon Sarkar
1. A prospective double-blind randomized trial found that perioperative dexamethasone provided minor pain relief but significantly increased insulin requirements and risk of infections in patients undergoing reconstructive head and neck cancer surgery.
2. Dexamethasone did not accelerate recovery or shorten hospital stay and its use in head and neck cancer reconstruction provided no clear clinical benefits while increasing complications.
3. A randomized controlled trial of corticosteroids after transoral robotic surgery found extended perioperative dexamethasone was safe and may allow for earlier improvement in diet consistency and decreased hospital stay, though it minimally affected postoperative pain.
Genioglossus muscle advancement and simultaneous sliding genioplasty in the m...Dibya Falgoon Sarkar
This study describes a technique that combines genioglossus muscle advancement and sliding genioplasty to treat obstructive sleep apnea. The technique was performed on 14 patients with OSA and retrognathia. It resulted in advancement of the genioglossus muscle to help keep the airway open during sleep. Only 3 patients underwent follow-up sleep studies, which showed improvement in 2 patients. While this technique provides both functional and aesthetic benefits, larger studies are still needed to fully evaluate its effectiveness in treating OSA.
This case report describes a rare occurrence of an aneurysmal bone cyst arising from an iliopubic chondromyxoid fibroma in a 20-year-old male patient. Imaging showed an osteolytic tumor in the left iliopubic ramus. The tumor was excised surgically and microscopic examination confirmed the diagnosis of chondromyxoid fibroma with areas consistent with an aneurysmal bone cyst. This case represents an unusual location for a chondromyxoid fibroma and confirms the rare association between aneurysmal bone cysts and chondromyxoid fibromas. The patient recovered well after surgery with no recurrence after one year of follow up.
Corseting: A new technique for the management of diffuse venous malformations...Dibya Falgoon Sarkar
1) The study introduces the "corset suturing" technique for treating large diffuse venous malformations in the head and neck region. Corset suturing involves continuous suturing that incorporates the lesion and strangulates the vessels to induce occlusion.
2) The technique was performed on 90 patients with non-cutaneous venous malformations. Most lesions resolved within 4-8 weeks with minimal complications and good cosmetic outcomes.
3) While corset suturing provides an effective and low-cost alternative treatment, the study had limitations as a retrospective study without controls to fully evaluate the technique.
Surgical approaches for condylar fractures related to facial nerve injury: de...Dibya Falgoon Sarkar
This study compared different percutaneous surgical approaches for treating condylar fractures to determine their relationship to facial nerve injury (FNI). The study found that approaches involving deep dissection beneath the marginal mandibular nerve branch (submandibular and retroparotid approaches) and the presence of a dislocated fracture were significantly associated with higher risks of FNI. In contrast, approaches involving more superficial dissection above the marginal mandibular nerve branch (transparotid, transmasseteric anteroparotid, high cervical transmasseteric anteroparotid approaches) had lower risks of FNI. The study concluded that superficial group approaches should be recommended to minimize the risk of F
Study of current pattern of Cervical Spondylotic Myelopathy and to evaluate t...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Kyphosis as a sequel of myelomeningocele is a malformation that may result in many problems including ulcers, limited use of the arms for support purposes, and reduced pulmonary function. Treatment is complex and demanding. In 1998 the authors started treating 15 patients using the Alfredo Cardoso Monterrubio (ACM) plate for an average of 2.9 years. On average, the ACM plate provided 67.4 degrees of correction initially, with some loss of correction over time. Complications included infections and plate loosening, but patients reported improved posture and functionality.
1) A study compared the clinical results of using hollow screws versus plates for treating spiral fractures of the lower third of the tibia combined with posterior malleolar fractures.
2) 61 patients were treated with tibia plate fixation and either hollow screw fixation (34 patients) or plate fixation (27 patients) of the posterior malleolar fracture.
3) At 6-36 months follow up, all fractures healed well with no differences in healing time or infection rates between the two groups. Functional outcomes assessed using the Baird-Jackson scoring system also did not significantly differ between groups.
This document discusses various surgical approaches to the craniovertebral junction (CVJ), including classic transoral microsurgery, endoscopic endonasal, transoral, and transcervical approaches. The transoral approach has traditionally been used but is limited by technical difficulties with visualization. Endoscopic techniques aim to overcome these issues and provide alternatives. Each approach has advantages and disadvantages regarding exposure, visualization, postoperative recovery, and types of pathologies that can be addressed. The nasopalatine line is discussed as an anatomical landmark to predict the extent of endonasal surgery.
Validity of sentinel node biopsy in early oral and oropharyngeal carcinomaDibya Falgoon Sarkar
This study evaluated the validity of sentinel node biopsy in early oral and oropharyngeal carcinoma to determine if it can help avoid unnecessary elective neck dissections. The study found that sentinel node biopsy identified occult metastases in 12 of 36 patients (33.3%), suggesting that neck dissection may be overtreatment for many patients. Sentinel nodes correctly identified metastases in 14 of 15 cases. While the study was limited by its small size and retrospective design, the results suggest sentinel node biopsy could help reduce overtreatment through more precise staging of early-stage cancers. Larger prospective studies are still needed to establish sentinel node biopsy as a reliable alternative to elective neck dissection.
The document summarizes research on gait analysis of patients with spina bifida. It describes the three main types of spina bifida and their associated neurological impairments and functional classifications. Instrumental gait analysis is discussed as a tool to objectively measure biomechanical variables during walking. Results from gait analysis can inform treatment through assessing quality of ambulation, effects of orthotics, muscle function, and postoperative changes.
This study evaluated the surgical management of 18 patients with posterior cruciate ligament (PCL) avulsions from the tibia using cannulated screw fixation. The average age was 29 years and most injuries were from road traffic accidents. Patients underwent open reduction and fixation of the avulsed PCL fragment with a cannulated screw. At an average follow up of 31 months, all patients had full range of motion and good knee stability. The average postoperative Lysholm score was 91, indicating excellent outcomes. The authors concluded that open reduction and fixation with a cannulated screw is an effective technique for tibial avulsion injuries of the PCL.
Percutaneous Hydrodiscectomy - A Procedure for Treating Herniated DiscDr. Brian Klagges
Dr. Brian Klagges earned his MD from the SUNY at Buffalo School of Medicine before launching his career as an anesthesiologist and pain interventionist. He currently serves as chief of anesthesia at The Minimally Invasive Surgery Center of New England and as the director of the Interventional Spine Center at Elliot Hospital in Bedford and Manchester, New Hampshire, respectively. Dr. Brian Klagges treats patients using a variety of procedures and was the first in the state to perform percutaneous hydrodiscectomy.
A relatively new surgical technique, percutaneous hydrodiscectomy uses a high-intensity stream of water to treat pain caused by herniated spinal discs. HydroCision, Inc., developed this treatment solution, and it has been shown to be an effective and less-invasive alternative to traditional microdiscectomy.
During the hydrodiscectomy procedure, a physician uses fluoroscopic guidance to insert a needle into the nucleus of the affected vertebral disc. Then, using the needle as a guide, the physician inserts a dilator, which is followed by a cannula that is used to shield the nerve root while a water-delivery device is introduced and advanced into the disc space. Once the device is in place, the physician delivers a high-intensity stream of water to ablate the herniated disc, releasing the pressure on nerves and thus providing pain relief.
In clinical studies, percutaneous hydrodiscectomy has been shown to be highly effective at reducing both leg and back pain caused by herniated discs. It also carries fewer complication risks than open discectomy procedures. Finally, because hydrodiscectomy requires an incision no larger than 4 millimeters, there is minimal scarring and patients typically recover within one week following the procedure.
This research article studied parameters of the lower lumbar intervertebral foramen related to the superior articular process using X-ray imaging. X-rays of the lumbar spine from 104 adults were analyzed. Measurements were taken of the height, width, and other dimensions of the lower lumbar intervertebral foramen. The results found no significant gender differences in foramen parameters. Parameters related to the superior articular process, such as height and distance from bony landmarks, showed significant age-related differences between those aged 40-60 and over 60. This data supplements the intervertebral foramen database and provides a reference for individualized minimally invasive spine surgeries, especially in elderly patients over 60 years old.
Endoscopic Endonasal Transclival Approach to the Ventral BrainstemDr. Shahnawaz Alam
Endoscopic Endonasal Transclival Approach to the Ventral Brainstem: Anatomic Study of the Safe Entry Zones Combining Fiber Dissection Technique with 7 Tesla Magnetic Resonance Guided Neuronavigation
This document describes a study evaluating the efficacy of using a dynamic hip screw (DHS) drill under image intensifier guidance to ablate osteoid osteoma of the lower extremities in children and adolescents. Eighteen patients between ages 4-16 were treated with this minimally invasive technique, with 16 achieving initial success from one drilling. Complications included one tibial fracture and two skin abrasions. At follow-up, all patients were classified as having a good clinical response. The combination of intraoperative localization using image intensifier guidance and ablation with a DHS drill provided an efficient, safe, and curative procedure with minimal bone loss for treating osteoid osteoma.
Minimally invasive spine surgeries (MISS) since its inception around 15 years ago has undergone rigorous changes with ever evolving technologies. Minimally invasive spine surgeries with “percutaneous” and “tubular” approaches is based on novel concept of minimizing collateral soft tissue damage, while achieving surgical goal in various spinal pathologies. MISS has been applied to simple spinal procedures of discectomy, decompression and fusion to even complex surgeries like deformity correction. MISS vis a vis “conventional open techniques” has benefits in terms of postoperative pain, concurrent tissue damage, disruption of spinal stabilizing structures, estimated blood loss, need of blood transfusion, length of hospital stay, surgical site infections, time to ambulation and functional recovery.
This document reports a case study of a 29-year-old schizophrenic patient who attempted genital auto-mutilation for the second time. The first attempt resulted in shallow wounds, but the second attempt was more severe, resulting in complete amputation of the penis. The patient was brought to the emergency department in hemorrhagic shock and required resuscitation. Surgeons were able to control bleeding and perform a urethrostomy. Given the severity of injury and time delay, reattachment was not possible. The patient received postoperative care and will be followed by psychiatrists to monitor for risk of recurrence. Genital auto-mutilation is a psychiatric emergency that requires multidisciplinary treatment from surgeons,
Arthroscopic Management of Anterior, Posterior, and Multidirectional Shoulder...Peter Millett MD
Arthroscopic treatment of the unstable shoulder has evolved rapidly and significantly in recent years. Better understanding of the pathoanatomy, advancements in technology, and improved surgical techniques have led to dramatic improvements in outcome. An arthroscopic approach includes significant advantages. Arthroscopy provides better identification of concomitant pathology, lower morbidity, less soft tissue dissection, maximal preservation of motion, shorter surgical time, and improved cosmesis. There is less pain, and many patients have an easier functional recovery, with greater returns in motion compared with traditional open techniques. Finally, some of the inherent risks of open procedures, such as postoperative subscapularis rupture, are virtually eliminated. Surgeons can now routinely expect results that are at least comparable, if not better than, those achieved with open techniques. For more shoulder surgery and instability studies, visit Dr. Millett, Orthopedic Surgeon, Vail Colorado http://drmillett.com/shoulder-studies
The document discusses surgical meshes and methods of fixation for hernia repair. It covers biologic and synthetic meshes and factors that influence hernia occurrence. Direct closure of hernias has a high recurrence rate of around 50%, which is reduced to around 5-18% when meshes are used. Long stitch lengths during closure are associated with higher rates of surgical site infection and hernia recurrence compared to short stitch lengths. Polypropylene meshes allow for tissue ingrowth but can cause complications like chronic infection, fistulas and erosion over time. Other synthetic mesh options discussed include ePTFE meshes.
This study evaluated the results of 42 patients who underwent arthroscopic repair of full-thickness rotator cuff tears using a side-to-side suturing technique without fixation to bone. At a mean follow-up of 73 months, 98% of patients reported good to excellent results on the UCLA shoulder scale. The mean UCLA score was 33, and 41 of 42 patients were satisfied with the repair. The study concludes that side-to-side arthroscopic repair without anchoring can effectively treat full-thickness rotator cuff tears.
The document reviews three studies on the use of interbody spinal cages for treating compromised spinal columns due to trauma or disease. Specifically, it examines the use of expandable titanium cages and stackable cages, as well as the posterior surgical approach. The studies found that interbody cages can successfully correct kyphotic deformities and maintain spinal stability in patients with spinal trauma or tumors. Complication rates were low. The document concludes that interbody cages and the posterior surgical approach may provide good outcomes for treating certain spinal conditions.
The document summarizes the evolution of trauma surgery training and practice in the United States. It discusses how trauma surgery originated in large city hospitals but has since expanded to regional trauma centers. It also notes changes in surgical training away from generalist models towards increased specialization. Trauma surgery is increasingly encompassing broader emergency general surgery duties due to workforce shortages, while training programs emphasize specialized rather than broad skills.
clavical fractures are most controversial in case of treatment modalities in orthopaedics. it is one of the common fracture of all ages. so we are explaining our point what to do or not?
This study compared outcomes of fasciocutaneous flaps versus biplanar (muscle and fasciocutaneous) flaps for reconstructing pressure ulcers in 90 immobile patients with spinal cord injuries. The biplanar flap group had a significantly lower wound recurrence rate of 25% compared to 53% for the fasciocutaneous flap group. Both groups had similar follow-up times and times to recurrence. While postoperative complications like infection were similar, the addition of muscle flaps in biplanar reconstruction significantly reduced recurrence of pressure ulcers in this high-risk patient population.
Role of magnetic resonance Imaging in acute spinal trauma hazem youssef
1. Magnetic resonance imaging (MRI) plays an important role in evaluating acute spinal trauma by detecting injuries that may be missed on other imaging studies like CT scans or x-rays.
2. MRI is better than other imaging modalities at identifying ligamentous injuries, disc herniations, epidural hematomas, and spinal cord injuries which are important to evaluate spinal stability and guide management.
3. The typical MRI protocol for acute spinal trauma includes sagittal and axial T1-weighted, T2-weighted, STIR, and T2* gradient echo sequences to fully characterize bone fractures, disc abnormalities, cord injuries, ligamentous injuries, and hemorrhage.
This study evaluated the intermediate and long-term results of femoral neck lengthening (Morscher osteotomy) in 18 patients (20 hips) with a median follow-up of 7 years. Postoperatively, the Trendelenburg test was negative in most patients and the median Harris Hip Score improved significantly. Radiographic examination found progression of osteoarthritis in 3 patients, while one operation failed and required total hip replacement after 4 years and two others required it at 10 years. The procedure successfully reduced leg length discrepancy in most patients. The study concluded that Morscher osteotomy can effectively treat patients with short femoral neck and overgrown greater trochanter with a positive Trendelenburg test and mild leg length
1. The study examines the reduction in size of keratocystic odontogenic tumors (KCOTs) in the mandible via marsupialization and 3D CT scans over time.
2. Fifteen patients with KCOTs underwent marsupialization surgery, and their 42 serial CT scans were analyzed to measure tumor diameter and volume changes.
3. The results show that KCOTs reduced equally towards the marsupialization window and that volume reduction per day followed the formula Vr = -0.0029 × V, indicating volume is reduced by half over 239 days of marsupialization. This allows prediction of tumor size changes over time.
This document discusses various surgical approaches to the craniovertebral junction (CVJ), including classic transoral microsurgery, endoscopic endonasal, transoral, and transcervical approaches. The transoral approach has traditionally been used but is limited by technical difficulties with visualization. Endoscopic techniques aim to overcome these issues and provide alternatives. Each approach has advantages and disadvantages regarding exposure, visualization, postoperative recovery, and types of pathologies that can be addressed. The nasopalatine line is discussed as an anatomical landmark to predict the extent of endonasal surgery.
Validity of sentinel node biopsy in early oral and oropharyngeal carcinomaDibya Falgoon Sarkar
This study evaluated the validity of sentinel node biopsy in early oral and oropharyngeal carcinoma to determine if it can help avoid unnecessary elective neck dissections. The study found that sentinel node biopsy identified occult metastases in 12 of 36 patients (33.3%), suggesting that neck dissection may be overtreatment for many patients. Sentinel nodes correctly identified metastases in 14 of 15 cases. While the study was limited by its small size and retrospective design, the results suggest sentinel node biopsy could help reduce overtreatment through more precise staging of early-stage cancers. Larger prospective studies are still needed to establish sentinel node biopsy as a reliable alternative to elective neck dissection.
The document summarizes research on gait analysis of patients with spina bifida. It describes the three main types of spina bifida and their associated neurological impairments and functional classifications. Instrumental gait analysis is discussed as a tool to objectively measure biomechanical variables during walking. Results from gait analysis can inform treatment through assessing quality of ambulation, effects of orthotics, muscle function, and postoperative changes.
This study evaluated the surgical management of 18 patients with posterior cruciate ligament (PCL) avulsions from the tibia using cannulated screw fixation. The average age was 29 years and most injuries were from road traffic accidents. Patients underwent open reduction and fixation of the avulsed PCL fragment with a cannulated screw. At an average follow up of 31 months, all patients had full range of motion and good knee stability. The average postoperative Lysholm score was 91, indicating excellent outcomes. The authors concluded that open reduction and fixation with a cannulated screw is an effective technique for tibial avulsion injuries of the PCL.
Percutaneous Hydrodiscectomy - A Procedure for Treating Herniated DiscDr. Brian Klagges
Dr. Brian Klagges earned his MD from the SUNY at Buffalo School of Medicine before launching his career as an anesthesiologist and pain interventionist. He currently serves as chief of anesthesia at The Minimally Invasive Surgery Center of New England and as the director of the Interventional Spine Center at Elliot Hospital in Bedford and Manchester, New Hampshire, respectively. Dr. Brian Klagges treats patients using a variety of procedures and was the first in the state to perform percutaneous hydrodiscectomy.
A relatively new surgical technique, percutaneous hydrodiscectomy uses a high-intensity stream of water to treat pain caused by herniated spinal discs. HydroCision, Inc., developed this treatment solution, and it has been shown to be an effective and less-invasive alternative to traditional microdiscectomy.
During the hydrodiscectomy procedure, a physician uses fluoroscopic guidance to insert a needle into the nucleus of the affected vertebral disc. Then, using the needle as a guide, the physician inserts a dilator, which is followed by a cannula that is used to shield the nerve root while a water-delivery device is introduced and advanced into the disc space. Once the device is in place, the physician delivers a high-intensity stream of water to ablate the herniated disc, releasing the pressure on nerves and thus providing pain relief.
In clinical studies, percutaneous hydrodiscectomy has been shown to be highly effective at reducing both leg and back pain caused by herniated discs. It also carries fewer complication risks than open discectomy procedures. Finally, because hydrodiscectomy requires an incision no larger than 4 millimeters, there is minimal scarring and patients typically recover within one week following the procedure.
This research article studied parameters of the lower lumbar intervertebral foramen related to the superior articular process using X-ray imaging. X-rays of the lumbar spine from 104 adults were analyzed. Measurements were taken of the height, width, and other dimensions of the lower lumbar intervertebral foramen. The results found no significant gender differences in foramen parameters. Parameters related to the superior articular process, such as height and distance from bony landmarks, showed significant age-related differences between those aged 40-60 and over 60. This data supplements the intervertebral foramen database and provides a reference for individualized minimally invasive spine surgeries, especially in elderly patients over 60 years old.
Endoscopic Endonasal Transclival Approach to the Ventral BrainstemDr. Shahnawaz Alam
Endoscopic Endonasal Transclival Approach to the Ventral Brainstem: Anatomic Study of the Safe Entry Zones Combining Fiber Dissection Technique with 7 Tesla Magnetic Resonance Guided Neuronavigation
This document describes a study evaluating the efficacy of using a dynamic hip screw (DHS) drill under image intensifier guidance to ablate osteoid osteoma of the lower extremities in children and adolescents. Eighteen patients between ages 4-16 were treated with this minimally invasive technique, with 16 achieving initial success from one drilling. Complications included one tibial fracture and two skin abrasions. At follow-up, all patients were classified as having a good clinical response. The combination of intraoperative localization using image intensifier guidance and ablation with a DHS drill provided an efficient, safe, and curative procedure with minimal bone loss for treating osteoid osteoma.
Minimally invasive spine surgeries (MISS) since its inception around 15 years ago has undergone rigorous changes with ever evolving technologies. Minimally invasive spine surgeries with “percutaneous” and “tubular” approaches is based on novel concept of minimizing collateral soft tissue damage, while achieving surgical goal in various spinal pathologies. MISS has been applied to simple spinal procedures of discectomy, decompression and fusion to even complex surgeries like deformity correction. MISS vis a vis “conventional open techniques” has benefits in terms of postoperative pain, concurrent tissue damage, disruption of spinal stabilizing structures, estimated blood loss, need of blood transfusion, length of hospital stay, surgical site infections, time to ambulation and functional recovery.
This document reports a case study of a 29-year-old schizophrenic patient who attempted genital auto-mutilation for the second time. The first attempt resulted in shallow wounds, but the second attempt was more severe, resulting in complete amputation of the penis. The patient was brought to the emergency department in hemorrhagic shock and required resuscitation. Surgeons were able to control bleeding and perform a urethrostomy. Given the severity of injury and time delay, reattachment was not possible. The patient received postoperative care and will be followed by psychiatrists to monitor for risk of recurrence. Genital auto-mutilation is a psychiatric emergency that requires multidisciplinary treatment from surgeons,
Arthroscopic Management of Anterior, Posterior, and Multidirectional Shoulder...Peter Millett MD
Arthroscopic treatment of the unstable shoulder has evolved rapidly and significantly in recent years. Better understanding of the pathoanatomy, advancements in technology, and improved surgical techniques have led to dramatic improvements in outcome. An arthroscopic approach includes significant advantages. Arthroscopy provides better identification of concomitant pathology, lower morbidity, less soft tissue dissection, maximal preservation of motion, shorter surgical time, and improved cosmesis. There is less pain, and many patients have an easier functional recovery, with greater returns in motion compared with traditional open techniques. Finally, some of the inherent risks of open procedures, such as postoperative subscapularis rupture, are virtually eliminated. Surgeons can now routinely expect results that are at least comparable, if not better than, those achieved with open techniques. For more shoulder surgery and instability studies, visit Dr. Millett, Orthopedic Surgeon, Vail Colorado http://drmillett.com/shoulder-studies
The document discusses surgical meshes and methods of fixation for hernia repair. It covers biologic and synthetic meshes and factors that influence hernia occurrence. Direct closure of hernias has a high recurrence rate of around 50%, which is reduced to around 5-18% when meshes are used. Long stitch lengths during closure are associated with higher rates of surgical site infection and hernia recurrence compared to short stitch lengths. Polypropylene meshes allow for tissue ingrowth but can cause complications like chronic infection, fistulas and erosion over time. Other synthetic mesh options discussed include ePTFE meshes.
This study evaluated the results of 42 patients who underwent arthroscopic repair of full-thickness rotator cuff tears using a side-to-side suturing technique without fixation to bone. At a mean follow-up of 73 months, 98% of patients reported good to excellent results on the UCLA shoulder scale. The mean UCLA score was 33, and 41 of 42 patients were satisfied with the repair. The study concludes that side-to-side arthroscopic repair without anchoring can effectively treat full-thickness rotator cuff tears.
The document reviews three studies on the use of interbody spinal cages for treating compromised spinal columns due to trauma or disease. Specifically, it examines the use of expandable titanium cages and stackable cages, as well as the posterior surgical approach. The studies found that interbody cages can successfully correct kyphotic deformities and maintain spinal stability in patients with spinal trauma or tumors. Complication rates were low. The document concludes that interbody cages and the posterior surgical approach may provide good outcomes for treating certain spinal conditions.
The document summarizes the evolution of trauma surgery training and practice in the United States. It discusses how trauma surgery originated in large city hospitals but has since expanded to regional trauma centers. It also notes changes in surgical training away from generalist models towards increased specialization. Trauma surgery is increasingly encompassing broader emergency general surgery duties due to workforce shortages, while training programs emphasize specialized rather than broad skills.
clavical fractures are most controversial in case of treatment modalities in orthopaedics. it is one of the common fracture of all ages. so we are explaining our point what to do or not?
This study compared outcomes of fasciocutaneous flaps versus biplanar (muscle and fasciocutaneous) flaps for reconstructing pressure ulcers in 90 immobile patients with spinal cord injuries. The biplanar flap group had a significantly lower wound recurrence rate of 25% compared to 53% for the fasciocutaneous flap group. Both groups had similar follow-up times and times to recurrence. While postoperative complications like infection were similar, the addition of muscle flaps in biplanar reconstruction significantly reduced recurrence of pressure ulcers in this high-risk patient population.
Role of magnetic resonance Imaging in acute spinal trauma hazem youssef
1. Magnetic resonance imaging (MRI) plays an important role in evaluating acute spinal trauma by detecting injuries that may be missed on other imaging studies like CT scans or x-rays.
2. MRI is better than other imaging modalities at identifying ligamentous injuries, disc herniations, epidural hematomas, and spinal cord injuries which are important to evaluate spinal stability and guide management.
3. The typical MRI protocol for acute spinal trauma includes sagittal and axial T1-weighted, T2-weighted, STIR, and T2* gradient echo sequences to fully characterize bone fractures, disc abnormalities, cord injuries, ligamentous injuries, and hemorrhage.
This study evaluated the intermediate and long-term results of femoral neck lengthening (Morscher osteotomy) in 18 patients (20 hips) with a median follow-up of 7 years. Postoperatively, the Trendelenburg test was negative in most patients and the median Harris Hip Score improved significantly. Radiographic examination found progression of osteoarthritis in 3 patients, while one operation failed and required total hip replacement after 4 years and two others required it at 10 years. The procedure successfully reduced leg length discrepancy in most patients. The study concluded that Morscher osteotomy can effectively treat patients with short femoral neck and overgrown greater trochanter with a positive Trendelenburg test and mild leg length
1. The study examines the reduction in size of keratocystic odontogenic tumors (KCOTs) in the mandible via marsupialization and 3D CT scans over time.
2. Fifteen patients with KCOTs underwent marsupialization surgery, and their 42 serial CT scans were analyzed to measure tumor diameter and volume changes.
3. The results show that KCOTs reduced equally towards the marsupialization window and that volume reduction per day followed the formula Vr = -0.0029 × V, indicating volume is reduced by half over 239 days of marsupialization. This allows prediction of tumor size changes over time.
The study compared cervical laminoplasty using piezosurgery osteotomy versus high-speed drilling in 60 patients. Piezosurgery osteotomy resulted in less intraoperative blood loss and postoperative drainage. Both groups showed improved JOA scores after surgery with no significant differences in outcomes. Piezosurgery osteotomy may be superior for operation time, blood loss, and drainage while providing similar safety and efficacy as high-speed drilling for cervical laminoplasty.
Deep infiltrating endometriosis is defined as endometrial tissue infiltrating the peritoneum by more than 5 mm. A definitive diagnosis requires laparoscopy to visually inspect the pelvis. Treatment options include laparoscopically assisted surgery and abdominal incisions depending on the location of lesions. Pain associated with deep infiltrating endometriosis results from peripheral nerve stimulation and sensitization due to endometriosis-associated inflammation.
This document discusses a study on the management of intra-articular fractures of the calcaneus (heel bone) using a combined percutaneous and minimal internal fixation technique. 22 patients with this fracture were treated with minimal incision and fixation using a single cancellous screw and 2 K-wires. At follow-up of 26 months on average, all fractures had healed without complications. Patients were evaluated using the Modified Rowe Score and outcomes were rated as excellent for 10 patients, good for 10 patients, and satisfactory for 2 patients, with an average score of 80. The technique aims to minimize complications by using minimal soft tissue dissection and implants.
This document summarizes a study that evaluated the efficacy of ultrasonography and computed tomography in diagnosing palpable neck masses. 40 patients with neck masses were examined clinically and underwent ultrasound and CT scans. The results found that ultrasound was useful for characterizing masses as solid or cystic and identifying features like margins, calcifications and necrosis. CT provided additional information on tissue attenuation, extent of lesions, and involvement of surrounding structures or distant spread. The study concluded that ultrasound combined with CT provides valuable information to accurately diagnose neck masses and guide their management.
This document describes a case study of a 48-year-old woman who presented with a large perianal tumor arising from long-standing perianal endometriosis in an episiotomy scar. She underwent wide excision surgery to remove the tumor, which was diagnosed as endometrioid adenocarcinoma. This resulted in a large perineal and perianal defect. The defect was reconstructed immediately using an inferior gluteal artery perforator (IGAP) flap. The IGAP flap provided good functional and aesthetic results for perianal reconstruction after tumor excision. The patient recovered well post-operatively with no complications or tumor recurrence after one year.
A case report of open reduction, internal fixation and platting of clavicle f...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
This document discusses foramen magnum meningiomas, a type of brain tumor. It defines the foramen magnum region and describes the structures that pass through it. Foramen magnum meningiomas present with variable neurological symptoms and are challenging to treat due to their proximity to critical structures. Imaging plays an important role in diagnosis and surgical planning. The surgical approach depends on factors such as tumor location and relationship to the vertebral artery. Complications can include lower cranial nerve deficits, cerebrospinal fluid leakage, and vascular injury. Complete resection remains the goal but must be balanced against risk of morbidity.
Sino Nasal malignancy & Anterior skull base surgery, Endoscopy is the best ???Ajay Manickam
1) The document compares endoscopic versus open surgery for sinonasal and anterior skull base tumors. It finds that endoscopic surgery provides comparable oncologic outcomes to open surgery, with lower morbidity, faster recovery, and shorter hospital stays.
2) A review of studies found no difference in margins or survival between the two approaches. Endoscopic surgery was associated with significantly shorter hospital stays.
3) Complications were also lower with endoscopic surgery. While open surgery remains necessary in some complex cases, endoscopic surgery is presented as a valid alternative for most sinonasal and anterior skull base malignancies.
This document discusses olfactory groove meningiomas. It describes their location in the anterior cranial fossa near the olfactory nerves. It outlines their typical presentation with long-standing headaches and anosmia. Imaging shows well-defined enhancing masses. Preoperative embolization is described as a safe option to reduce blood loss during surgery. Complete resection is the goal but recurrence can occur due to direct invasion or incomplete resection. Complications include CSF leakage, vascular injury, and seizures.
The value of dynamic MRI in cervical spondylotic myelopathy: About 24 cases.T...Michel Triffaux
Dynamic magnetic resonance imaging (MRI) of the cervical spine is extremely useful in assessing
pathological changes at the spinal cord, vertebrae, discs, ligaments and facet joints. we attempted to
document the radiological changes that the cervical spine undergoes during dynamic maneuvers and the
effects of Dynamic MRI in management of cervical myelopathy, emphasizing on the changes in treatment
protocol effected by the new findings discovered. Our work is based on 24 consecutive patients with
cervical spondylotic myelopathy had cervical MR imaging in neutral position, in flexion and extension of
the cervical spine between January 2021 and December 2021. The result found the mean age was 57.9
years (range 26-85 years). Among these 24 patients, there were 11 males and 13 females. Total number of
levels of compression were 47 and the additional levels of involvement were 17. Additional levels of
compression were noted in 12 patients, among these 17 new levels, 7 were in the posterior and 10 in the
anterior. The most affected level was C5C6 with 16 cases. All additional levels of compression were noted
in extension; Reduction of the cervical canal was observed in 20 patients only in extension. In the bending
sequences we have noticed an increase of the canal diameter in 3 patients. The location of the
compression is in 15 cases anterior, 2 cases posterior and 5 cases are mixed anterior and posterior
Surgery was considered in 17 patients. Anterior procedures were 11 (ACDF/ corpectomy and fusion) and
Posterior surgeries were 6 (laminoplasty/laminectomy), and. The rest of the patients did not require
surgery and was conservatively treated. A change of the signal was found in 3 patients during the
acquisition in extension position a. Most studies have shown a reduction of the root canal with an increase
of the compression level, which was the case in our study. MRI is a useful tool for diagnosis of CM, it does
not give an exact idea as to which is the offending level in a multilevel compression that requires surgery.
Even the approach and procedure cannot be decided on a static examination and hence are subject to
significant interpractitioner the role of extension MRI in determining cervical compression levels. Thus,
dynamic cervical spine MRI should be an important investigation before we decide to write off surgical
treatment in patients with cervical myelopathy and cord signal changes without definitive compression on
static MRI. Flexion and extension MRI is an important tool for decision making and planning appropriate
management in cervical compressive myelopathy.
Background: Cerebellopontine Angle (CPA) meningiomas comprise 10% of all intracranial meningiomas and due to their location, are producing different surgical challenges. This study is evaluating surgical management and clinical outcome of CPA meningiomas operated during 15 years.
This document summarizes a presentation on a novel technique called temporomandibular joint hematoma nerve block (TMJHNB) for the management of mandibular condylar fractures. The technique involves blocking the auriculotemporal and masseteric nerves to evacuate the hematoma and relax muscles, facilitating reduction of fractured segments. A study of 11 patients found the technique was less painful, with a mean pain score of 1.18 during reduction, and yielded accurate anatomic results. However, the study had limitations as a small single-center trial without randomization or long-term follow-up.
Closure of Myelomeningocele Defect Using a Keystone Design Perforator Island ...CrimsonPublishersTNN
Introduction: Early surgical repair of myelomeningocele (MMC) is recommended to reduce infection rates, but severe and large defects can
preclude primary closure. Many techniques of repair have been proposed to treat large defects and we report two cases of patients who underwent
keystone design perforator island flap (KDPIF) for closure MMC.
Methods: Retrospective analysis of two patients who underwent KDPIF for MMC repair at birth was performed. Skin and neural tube defects were
large and precluded primary closure. Surgical repair of MMC consisted of reconstruction of neural placode with dissection of meningeal sac without
neural damage. The opposing sliding flaps were prepared, based on randomly located vascular perforator. Skin incisions were made on the outline
of the flap and continued through the subcutaneous tissues down to lumbar fascia and muscles. Closure was performed in layers and then the V-Y
advancement of each end of the flap in the longitudinal axis is completed. Wound healing was satisfactory and no complications were noted.
Conclusion: Early surgical repair of the defect is recommended and the neurosurgeon who deal with pediatric neurosurgery must be prepared to
treat large and complex spina bifida defects. We have effectively demonstrated the use of KDPIF closure as an alternative for more complex MMC cases.
1. The document discusses the approach to chest wall tumors and reconstruction following resection. It covers anatomy, diagnosis, classification, surgical planning and considerations, resection techniques, and reconstruction options for both bone and soft tissue.
2. Resection aims to remove the tumor with adequate margins while reconstruction seeks to replace the chest wall rigidity and restore respiratory mechanics.
3. Reconstruction methods include mesh, plates, and flaps to repair bone and muscle flaps, skin grafts, or free flaps to replace soft tissue. The goal is to protect underlying structures and allow for pulmonary function.
Posttreatment imaging in head and neck cancer can help evaluate tumor response and recurrence but is complicated by changes from surgery, radiation, and reconstruction techniques. The summary describes:
1) Tumor recurrence typically appears as an infiltrative enhancing mass within 2 years, most commonly at surgical margins. Differentiating recurrence from fibrosis can be difficult.
2) Common surgery complications include fluid collections, fistulas, and flap necrosis appearing as fluid collections or thromboses. Late radiation effects involve surrounding tissues like skin thickening, bone necrosis, and vascular damage.
3) Imaging findings of recurrence, complications, and treatment effects can overlap, requiring correlation with clinical history and prior imaging for accurate interpretation.
Is Medial Ridge Sign a Reliable Indicator Glenoid Bone Loss-Dr. Dhanasekarapr...TheRightDoctors
The document discusses the "medial ridge sign" seen on CT scans of patients with recurrent shoulder dislocations as an indicator of glenoid bone loss. The study aimed to evaluate if the medial ridge sign reliably indicates significant bone loss. It found the sign had high sensitivity but low specificity for significant loss. While the sign suggested some bone loss, glenoid bone loss measurements were still needed to determine if augmentation was required rather than just Bankart repair. So the medial ridge sign is not reliable in deciding between the two surgical procedures.
A Visual Guide to 1 Samuel | A Tale of Two HeartsSteve Thomason
These slides walk through the story of 1 Samuel. Samuel is the last judge of Israel. The people reject God and want a king. Saul is anointed as the first king, but he is not a good king. David, the shepherd boy is anointed and Saul is envious of him. David shows honor while Saul continues to self destruct.
Andreas Schleicher presents PISA 2022 Volume III - Creative Thinking - 18 Jun...EduSkills OECD
Andreas Schleicher, Director of Education and Skills at the OECD presents at the launch of PISA 2022 Volume III - Creative Minds, Creative Schools on 18 June 2024.
CapTechTalks Webinar Slides June 2024 Donovan Wright.pptxCapitolTechU
Slides from a Capitol Technology University webinar held June 20, 2024. The webinar featured Dr. Donovan Wright, presenting on the Department of Defense Digital Transformation.
Level 3 NCEA - NZ: A Nation In the Making 1872 - 1900 SML.pptHenry Hollis
The History of NZ 1870-1900.
Making of a Nation.
From the NZ Wars to Liberals,
Richard Seddon, George Grey,
Social Laboratory, New Zealand,
Confiscations, Kotahitanga, Kingitanga, Parliament, Suffrage, Repudiation, Economic Change, Agriculture, Gold Mining, Timber, Flax, Sheep, Dairying,
🔥🔥🔥🔥🔥🔥🔥🔥🔥
إضغ بين إيديكم من أقوى الملازم التي صممتها
ملزمة تشريح الجهاز الهيكلي (نظري 3)
💀💀💀💀💀💀💀💀💀💀
تتميز هذهِ الملزمة بعِدة مُميزات :
1- مُترجمة ترجمة تُناسب جميع المستويات
2- تحتوي على 78 رسم توضيحي لكل كلمة موجودة بالملزمة (لكل كلمة !!!!)
#فهم_ماكو_درخ
3- دقة الكتابة والصور عالية جداً جداً جداً
4- هُنالك بعض المعلومات تم توضيحها بشكل تفصيلي جداً (تُعتبر لدى الطالب أو الطالبة بإنها معلومات مُبهمة ومع ذلك تم توضيح هذهِ المعلومات المُبهمة بشكل تفصيلي جداً
5- الملزمة تشرح نفسها ب نفسها بس تكلك تعال اقراني
6- تحتوي الملزمة في اول سلايد على خارطة تتضمن جميع تفرُعات معلومات الجهاز الهيكلي المذكورة في هذهِ الملزمة
واخيراً هذهِ الملزمة حلالٌ عليكم وإتمنى منكم إن تدعولي بالخير والصحة والعافية فقط
كل التوفيق زملائي وزميلاتي ، زميلكم محمد الذهبي 💊💊
🔥🔥🔥🔥🔥🔥🔥🔥🔥
2. comparisons among these categories, JOA
scores, recovery rate, decrease in syrinx
size, complications, and reoperation rate
were assessed for each grade (Table 1).
Surgicalindicationswereusuallyheadache
or tussive headache; drop attacks; neck, arm,
orbackpain;swallowingdifficulties;orupper
extremity numbness or tingling. The pres-
ence of a syrinx was also an indication for
surgery when it occurred in the presence of
the aforementioned symptoms.
Surgical Procedure
Allpatientsunderwentosseousdecompres-
sion including PFD and C1 laminectomy
and were grouped according to tonsillar de-
scending grading scale. The degree of ton-
sillar descent was graded in relation to the
superior and inferior borders of the C1 lam-
ina. The specific surgical procedure (non-
duraplasty or duraplasty) was chosen based
on the surgeon’s experience and prefer-
ence.Aftergeneralanesthesiawasadminis-
tered, all surgeries were performed with the
patientinthepronepositionwithrigidhead
fixation. A midline incision extending from
the inion to the upper cervical spine was
used to perform a standard subperiosteal
dissection of muscle from the occipital and
cervical region. Muscle attachments were
preserved at the superior nuchal line and
usually at the C2 lamina. Osseous decom-
pression was achieved with a high-speed air
drill, encompassing the inferior aspect of
the occipital bone with modest superior ex-
tension (approximately 1.5–2.0 cm) and lat-
eral extension to the lateralmost aspect of
the foramen magnum and cervical spinal
canal, and C1 laminectomy (and C2 if nec-
essary) was performed. In the duraplasty
group, after the dura was opened, dural
grafting was performed with cadaveric
dura, bovine pericardium, fascia lata, or au-
tologous pericranium. No sealant was used
to reinforce the dural suture line, and no
forced inspiratory pressure was routinely
used to test the integrity of the dural clo-
sure.Inthenonduraplastygroup,onlybone
removal was performed. Finally, the wound
was meticulously closed with interrupted
sutures, each layer at a time: muscles, fas-
cia, subcutaneous tissue, and skin.
Follow-up
Postoperative clinical improvement was as-
sessed from clinic notes and generally re-
flected subjective reports of improvement
in symptoms evaluated using the JOA scale
and recovery rate. Recovery rate according
to the JOA scale (15), which indicates the
degree of normalization after surgery, was
calculated using the following formula:
Postoperative score Ϫ Preoperative score
Recovery rate ͑%͒ ϭ __________ ϫ 100
18 Ϫ Preoperative score
All patients underwent MRI 3–5 days after
surgery and at least one subsequent MRI ses-
sion at the follow-up consultation, usually
6–12 months later. The presence or absence
ofsyringomyeliaanditslocationandextentin
thecervicalorthethoraciccord(orboth)were
assessed preoperatively and at least 6 months
postoperatively and as needed thereafter. Syr-
inx improvement was defined as any demon-
strable decrease in maximal syrinx diameter,
as seen on MRI at least 6 months postopera-
tively. In practical terms, syrinxes that were
smaller postoperatively showed minimal re-
sidual, indistinguishable from mild dilation
ofthecentralcanal.Inpatientswithpostoper-
ative MRI (Figure 2), the change in the size of
the syrinx cavity was classified as improved
(decreased maximal diameter), unchanged,
or increased.
Outcome Measures
The long-term (average 9 months postopera-
tively) surgery-related result was considered
excellent if symptoms resolved. The result
was considered good if the patient experi-
encedsignificantimprovementbutalsoresid-
ual symptoms. A poor result indicated no
change in symptoms or deterioration. Specif-
ically noted symptoms were assessed at the
time of follow-up examination.
Statistical Evaluation
Statisticalanalysiswasperformedwiththeassis-
tance of computer statistics programs (SPSS
10.0.7;SPSS,Inc.,Chicago,Illinois,USA)byone
oftheauthors(Y.T.).Statisticalanalysiswasper-
formedusingStudentttest,analysisofvariance
test, and univariate and multivariate regression
analysis.AprobabilityvalueϽ0.05wasconsid-
eredstatisticallysignificant.
RESULTS
Meanageofpatientsineachgroupwassim-
ilar at the time of surgery (duraplasty group
38.9 years and nonduraplasty group 31
years). There were 58 patients in group 1,
who underwent combined PFD, C1 (and C2
if necessary) laminectomy, and duraplasty;
the 24 patients in group 2 underwent PFD
without duraplasty. There were 36 men and
46 women.
Group 1 (Duraplasty Group)
Of the 58 patients in group 1, 25 (43.1%)
were in CTD grade 1, 21 (36.2%) were in
CTD grade 2, and 12 (20.7%) were in CTD
grade3.ThemeansoftheJOAscoresbefore
surgeryandatthefinalfollow-upevaluation
Figure 1. (A) Grade 1 tonsillar descent. Tonsil descended to above C1 arch. (B) Grade 2 tonsillar
descent. Tonsil descended to C1 arch level. (C) Grade 3 tonsillar descent. Tonsil descended below
C1 arch.
PEER-REVIEW REPORTS
ADEM YILMAZ ET AL. DURAPLASTY IN SURGICAL TREATMENT OF CHIARI MALFORMATION TYPE I
308 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2010.09.005
3. were 14.2 points (range 10–17 points) and
16.01 points (range 8–18 points), and the
mean recovery rate was 56.3%. An improve-
ment in symptoms occurred in 52 (89.6%)
of these patients. Based on CTD grading
scale in group 1, all 25 patients in grade 1,
18 (85.7%) of 21 patients in grade 2, and
9 (75%) of 12 patients in grade 3 showed
clinical improvement. Of these patients, 45
(77.5%) had syringomyelia. Of the patients
who underwent follow-up MRI, 41 (91.1%)
had a decrease in the size of syringomyelia,
and 37 (90.2%) had clinical improvement.
In addition, 10 (83.3%) of 13 patients with-
out syringomyelia experienced clinical re-
covery. The size of the syringomyelia cavity
was decreased in 17 (89.4%) patients in
grade 1, 16 (94.12 %) patients in grade 2,
and 8 (88.8%) patients in grade 3.
Group 2 (Nonduraplasty Group)
Group 2 comprised 24 patients who under-
went PFD and C1 laminectomy without du-
raplasty. There were 11 (45.8%) patients in
CTD grade 1, 8 (33.3%) patients in CTD
grade 2, and 5 (20.9%) patients in CTD
grade3.ThemeansoftheJOAscoresbefore
surgery and at final follow-up evaluation
were 14.8 points (range 9–18 points) and
16.5 points (range 12–18 points), and the
mean recovery rate was 51.9%. An improve-
ment in symptoms occurred in 19 (79.1%)
of these patients. Based on CTD grading
scale, 10 (90.9%) of 11 patients in grade 1, 6
(75%) of 8 patients in grade 2, and 3 (60%)
of 5 patients in grade 3 experienced an im-
provement of symptoms. Of these patients,
19 (79.1%) had syringomyelia. Of the pa-
tients who underwent follow-up MRI, 16
(84.2%) had a decrease in the size of syrin-
gomyelia, and 16 (84.2%) had clinical im-
provement. Three (60%) of five patients
without syringomyelia experienced clinical
recovery.
Procedure-Related Complications
Complicationsoccurredinsevenpatientsin
the duraplasty group (group 1): CSF leak in
three cases, additional focal neurologic def-
icit in two cases, superficial infection in one
case, and meningitis in one case. Two pa-
tients(3.6%)ingroup1underwentreopera-
tion because of open CSF fistulas. In the
nonduraplasty group (group 2), surgical
complicationsincludedasuperficialwound
infection and temporary neurologic deficit
in one patient. Two patients (9.5%) in
group 2 underwent reoperation because of
inadequate decompression (Table 2).
The cavity size of syringomyelia preoper-
atively and postoperatively, JOA scores, re-
covery rate, and complication rate were de-
termined. Two samples Student t test were
performed. There were no statistically sig-
nificant differences between preoperative
andpostoperativecavitysizesofsyringomy-
elia and JOA scores in duraplasty and non-
duraplasty groups in CTD grades 1 and 2; in
CTD grade 3, the decrease in syrinx cavity
and clinical improvement were statistically
better in group 1 compared with group 2 (P
Ͻ 0.05). Complications in group 1 were sta-
tistically significantly increased compared
with group 2 (P Ͻ 0.05).
DISCUSSION
Surgery for CM-I with or without syringo-
myelia aims at (1) restoration of normal CSF
Table 1. Japanese Orthopaedic Association Cervical Spine Myelopathy Functional
Assessment Scale
Score Definition
Motor Dysfunction Score
of Upper Extremities
0 Inability to move hands
1 Inability to eat with a spoon but able to move hands
2 Inability to button shirt but able to eat with a spoon
3 Able to button shirt with great difficulty
4 Able to button shirt with slight difficulty
5 No dysfunction
Motor Dysfunction Score
of Lower Extremities
0 Complete loss of motor and sensory function
1 Sensory preservation without ability to move legs
2 Able to move legs but unable to walk
3 Able to walk on flat floor with a walking aid (ie, cane or crutch)
4 Able to walk up and down stairs with handrail
5 Moderate to significant lack of stability but able to walk up and down
stairs without handrail
6 Mild lack of stability but able to walk with smooth reciprocation unaided
7 No dysfunction
Sensory Dysfunction Score
of Upper Extremities
0 Complete loss of hand sensation
1 Severe sensory loss or pain
2 Mild sensory loss
3 No sensory loss
Sphincter Dysfunction Score
0 Inability to micturate voluntarily
1 Marked difficulty with micturation
2 Mild to moderate difficulty with micturation
3 Normal micturation
Modified from Benzel EC, Lancon J, Kesterson L, Hadden T: Cervical laminectomy and dentate ligament section for cervical
spondylotic myelopathy. J Spinal Disord 4:286-95, 1991.
PEER-REVIEW REPORTS
ADEM YILMAZ ET AL. DURAPLASTY IN SURGICAL TREATMENT OF CHIARI MALFORMATION TYPE I
WORLD NEUROSURGERY 75 [2]: 307-313, FEBRUARY 2011 www.WORLDNEUROSURGERY.org 309
4. circulation at the foramen magnum, (2) re-
duction of the syrinx if there is one, and (3)
relief of the compression exerted by the cer-
ebellar tonsils on the brainstem (Figure 3).
The correct way to treat Chiari malforma-
tions is one of the most disputed issues in
neurosurgery (1, 12, 23, 26).
Surgical Procedure
Considerable debate exists about which
surgical options are best for the manage-
ment of CM-I. Patients with herniation
should be deemed candidates for decom-
pression with or without duraplasty. The
aim of this study was to compare the surgi-
cal outcomes of patients with CM-I after
PFD with or without duraplasty based on
CTD grading scale. The outcome of decom-
pression surgery usually is evaluated by
comparing symptoms before and after sur-
gery. In an effort to define the current sur-
gical strategies, members of the American
Association of Neurological Surgeons were
surveyed as to the surgical approach they
used in pediatric patients with CM-I (10).
Only 9% recommended performing decom-
pressive surgery in asymptomatic patients.
For the treatment of symptomatic patients,
various approaches were used: Approxi-
mately 20% recommended osseous decom-
pression only; 30% recommended osseous
decompression with dural grafting; 25% rec-
ommended osseous decompression with
dural grafting and intradural dissection of
adhesions; and 30% recommended osse-
ous decompression with dural grafting, in-
tradural dissection, and tonsillar manipula-
tion and resection (10). Authors of recent
reports in the literature have suggested that
good clinical outcomes can be attained
without more complex and invasive neuro-
surgical procedures (9, 16).
Duraplasty versus Nonduraplasty
Some authors have advocated that craniec-
tomy alone for CM-I may be sufficient (7,
21, 30), whereas others have argued that the
dura must be opened (11, 17, 22). In a review
of patients who underwent PFD with and
without duraplasty, Matsumoto and Symon
(17) noted no difference in the reduction of
hydromyelia; however, regarding the im-
provement in symptoms, patients who did
not undergo duraplasty had a significantly
worse outcome compared with patients
who underwent duraplasty. Some data sug-
gest a more reliable outcome in size reduc-
tion and even disappearance of an existing
syrinx are achieved when duraplasty is per-
formed (12, 21, 26). Munshi et al. (21) de-
scribed 33 patients who presented with
Chiari malformations during a 10-year pe-
riod. Eleven patients underwent PFD with-
out duraplasty (73% had improvement),
and 23 underwent PFD with duraplasty
(87% had improvement). The rate of minor
complications was higher in the latter
group. There seems to be a subset of pa-
tients, however, whose symptoms resolve
and whose hydromyelic cavity decreases
with the removal of bone only (21). In an-
other study performed in pediatric patients,
it was found that PFD with duraplasty is
associated with a lower risk of reoperation
than PFD but a greater risk of CSF-related
complications. There was no significant
difference between the two operative tech-
niqueswithrespecttoclinicalimprovement
or decrease in syringomyelia (7).
McGirt et al. (18) reviewed the records of
256 children who underwent first-time PFD
for CM-I. All patients underwent suboccipital
craniectomy and laminectomy of the atlas.
The hindbrain was examined intraoperatively
on transdural ultrasonography. If the sub-
arachnoid spaces dorsal to the cerebellar ton-
sils and ventral to the medulla were effaced,
and if the tonsils exhibited the characteristic
rostrocaudal,pistonlikepulsation,duraplasty
was performed. Otherwise, the dura mater
was left undisturbed, and the procedure was
concluded. In children with displacement of
the tonsils below the inferior border of the
arch of the atlas, ultrasonography-indicated
osseousdecompressionalonewasassociated
with twice the risk of symptom recurrence as
decompression with duraplasty. In children
with lesser degrees of tonsillar displacement,
duraplastyindicatedbyultrasonographyfind-
ings yielded the same results as achieved with
osseous decompression alone. McGirt et al.
(18) concluded that intraoperative ultra-
sonography can be used to identify cases that
do not require duraplasty among patients
with lesser degrees of tonsillar displacement,
but it cannot be used for this purpose in pa-
tients with more severe involvement.
Durham and Fjeld-Olenec (7) searched
Medline-Ovid, The Cochrane Library, and
the conference proceedings of the Ameri-
can Association of Neurological Surgeons
and the Congress of Neurological Surgeons
(2000–2007) for surgical techniques of
Figure 2. Syrinx regression after decompressive surgery. (A) Preoperative craniocervical MRI. (B)
Postoperative craniocervical MRI.
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ADEM YILMAZ ET AL. DURAPLASTY IN SURGICAL TREATMENT OF CHIARI MALFORMATION TYPE I
310 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2010.09.005
5. PFD and PFD with duraplasty in CM-I. In
theirmeta-analysis,theseauthorsevaluated
five retrospective and two prospective co-
hort studies involving 582 patients. Of the
582 patients, 316 were treated with PFD
with duraplasty, and 266 were treated with
PFD alone. Patients undergoing PFD with
duraplasty had a significantly lower reop-
eration rate and a higher rate of CSF-related
complications. There were no significant
differences in clinical improvement or sy-
ringomyelia decrease between PFD with
and without duraplasty (7). Existing evi-
dence supports the rationale of enlarging
the craniocervical CSF spaces, however (2,
20, 22). In the present study, as Durham
and Fjeld-Olenec (7) reported, there were
no statistically significant differences be-
tween preoperative and postoperative cavity
size of syringomyelia and JOA scores of du-
raplasty and nonduraplasty groups in CTD
grade 1 and 2 (P Ͼ 0.05), whereas in CTD
grade 3, decrease in syrinx cavity and clini-
cal improvement were statistically signifi-
cantly better in the duraplasty group com-
pared with nonduraplasty group (P Ͻ 0.05).
Inthisstudy,manipulationofthesubarach-
noid space and tonsil resection were not
performed because of complications. The
complication rate was significantly higher
in the duraplasty group than nonduraplasty
group, however. We recommend using pre-
operative CTD grading from MRI findings,
and duraplasty should be performed in all
CTD grade 3 patients.
Is Duraplasty Associated with Frequent
Cerebrospinal Fluid–Related Morbidity?
In light of the effort to move toward a less
invasiveandpurportedlylessmorbidproce-
dure, there is a current argument for the use
Figure 3. Artist’s drawing of preoperative and postoperative grade 3 Chiari type I. Posterior fossa
decompression with duraplasty led to decreased syrinx cavity.
Table 2. Summary of Clinical Outcomes After Chiari Surgery According to Cerebellar Tonsillar Descent
No.
Patients
No.
Syrinx
No. Patients with
Symptom Improvement
No. Patients with
Hydromyelia Decrease
No. Patients with
ComplicationsYes No Yes No
Posterior Fossa Decompression
C1 Laminectomy, Duraplasty
(Group 1)
58 (70.8%) 45 (77.5%) 52 (89.6%) 6 (10.4%) 41 (91.1%) 4 (8.9%) 7 (12.0%)
Tonsillar descent
Grade 1 25 (43.1%) 19 (42.2%) 25 (100%) 0 17 (89.4%) 2 (10.6%) 1 (neurologic deficit),
1 (superficial infection)
Grade 2 21 (36.2%) 17 (37.7%) 18 (85.7%) 3 (14.3%) 16 (94.1%) 1 (5.9%) 2 (CSF leak),
1 (neurologic deficit),
1 (meningitis)
Grade 3 12 (20.7%) 9 (20.1%) 9 (75%) 3 (25%) 8 (88.9%) 1 (11.1%) 1 (CSF leak)
Posterior Fossa Decompression,
C1 Laminectomy (Group 2)
24 (29.2%) 19 (79.1%) 19 (79.1%) 5 (20.9%) 16 (87.5%) 3 (12.5%) 2 (8.3%)
Tonsillar descent
Grade 1 11 (45.8%) 8 (42.1%) 10 (90.9%) 1 (9.1%) 7 (87.5%) 1 (12.5%) 1 (superficial infection)
Grade 2 8 (33.3%) 7 (36.8%) 6 (85.7%) 1 (14.3%) 7 (100%) 0
Grade 3 5 (20.9%) 4 (21.1%) 3 (60%) 2 (40%) 2 (50%) 2 (50%) 1 (neurologic deficit)
CSF, cerebrospinal fluid.
PEER-REVIEW REPORTS
ADEM YILMAZ ET AL. DURAPLASTY IN SURGICAL TREATMENT OF CHIARI MALFORMATION TYPE I
WORLD NEUROSURGERY 75 [2]: 307-313, FEBRUARY 2011 www.WORLDNEUROSURGERY.org 311
6. of dural-sparing surgery based on the as-
sumption that dural opening is associated
with frequent CSF-related morbidity (5, 6,
17). The common opinion for osseous de-
compression without duraplasty is sup-
ported by the purportedly lower morbidity
of this approach. In this study, according to
our practice protocol, we performed in pa-
tients with CM-I with or without syringo-
myelia a standard PFD, including a small
suboccipitalandforamenmagnumcraniec-
tomy, removal of the C-1 arch, and dura-
plasty, or without duraplasty, and water-
tight closure. In both groups, 2 patients
underwent reoperation. The cause was CSF
fistula in group 1 and insufficient decom-
pression in group 2.
Occurrence of Syringomyelia
Syringomyelia occurs in 50%–76% of pa-
tients. Altered CSF circulation at the fora-
men magnum prevents instantaneous pres-
sure equilibration between the intracranial
and spinal subarachnoid space. Presum-
ably, an intermittent vector of force devel-
ops with each Valsalva maneuver, which
can lead to the progressive downward
movement of developing tissue through the
foramen magnum. If the impediment to
CSF equilibration occurs after the tonsils
have formed, the pressure gradient favors
tonsillar herniation and may be responsible
for the initiation of syringomyelia forma-
tion (26, 28, 29). In the present study, 45
(77.5%) of 58 patients in the duraplasty
group and 19 (79.1%) of 24 patients in the
nonduraplasty group had syringomyelia.
The size of the syringomyelia cavity was
decreased in 41 (91.1%) patients in the dura-
plasty group and 16 (87.5%) patients in
nonduraplasty group.
Value of the Present Study
This consecutive series of 82 patients
treated for CM-I constitutes one of the
larger series reported (3, 8, 11, 13, 14, 19, 24,
25, 27). In this study, in CTD grade 3 pa-
tients, PFD and duraplasty seem to be the
essential surgical treatment of this condi-
tion. Overall, the significant and sustained
postoperative improvement shown in these
82 patients suggests a favorable therapeutic
result in itself and when compared with
other results obtained in previously re-
ported studies. Although the data of the
present study reflect our current practice
regimen, there have been no prospective
studies in which one treatment form is di-
rectly compared with another. In addition,
in light of the many theories of pathophys-
iology, broad clinical presentations, and
multitude of surgical interventions with
variable outcomes, it is not surprising that a
single surgical approach does not exist, and
the results of treatment are difficult to as-
sess given the absence of uniform outcome
measures and a randomized controlled trial
in which the different treatments are com-
pared. In most articles in which outcome is
discussed, the authors have reported an
80%–90% rate of good outcome, with ei-
ther resolution of the symptoms or cessa-
tion of progression.
CONCLUSIONS
PFD with duraplasty in CM-I is associated
with a greater risk for CSF-related compli-
cations. As a result, in this study, complica-
tions from surgical intervention were mini-
mal and results were good, although more
complications were observed in the dura-
plasty group (Table 2). In our experience,
PFD with or without duraplasty in symp-
tomatic adult patients with CM-I is success-
ful in most cases with minimal complica-
tions. We believe that the risk of CSF leak
has to be accepted as a downside of the
essential procedure, which is opening the
dura and widening the cisternal space with
a graft.
We recommend tailoring the surgical ap-
proach to treat the dominant clinical prob-
lem. There is little controversy today that the
commondenominatorofalltreatmentstrate-
gies is posterior craniovertebral decompres-
sion with or without duraplasty. Proper
patientselectioniscrucialtopreventunneces-
sary procedures and to maximize outcome,
and we recommend using CTD grading scale
before planning duraplasty, which should be
reserved for patients who are CTD grade 3.
Furtherstudiesareneededtocharacterizebet-
ter the effect of patients’ tonsillar descending
grade on clinical outcome.
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312 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, DOI:10.1016/j.wneu.2010.09.005