60 yr female presented with quadriparesis following fall . U/l power proximal 3/5 . L/L 0/5. Pt put on teaction and steroids operated after 2 weeks after deficit became stable .
Saturday, 25 August 2018
Severe cervical spine injury sucessfully
Wednesday, 22 August 2018
Friday, 17 August 2018
Wednesday, 11 June 2014
SKULL BASE SURGERY/ TRANS SPHENOIDAL SURGERY FOR PITUTARY TUMOURS
A 60 year old man presented in our OPD with chief complaints of vision loss and headache . MRI done revealed large sellar and suprasellar mass compressing chiasma . Patient was operated via trans sphenoidal route . He made rapid recovery and he was discharged the next day.
MRI IMAGES SHOEING LARGE SELLAR MASS WITH SUPRASELLAR EXTENSION
MRI IMAGES SHOEING LARGE SELLAR MASS WITH SUPRASELLAR EXTENSION
INTRAOPERATIVE FLUROSCOPIC IMAGES SHOWING SUPRASELLAR TUMOUR BEING REMOVED
Sunday, 20 April 2014
RARE SKULL BASE TUMOUR OPERATED AT IVY HOSPITAL VIA OSTEOPLASTIC MAXILLOTOMY APPROACH
RARE SKULL BASE TUMOUR OPERATED AT IVY HOSPITAL VIA OSTEOPLASTIC MAXILLOTOMY APPROACH
Neuro surgical procedures are one of the most technically demanding and complex surgical procedures . For most of the patients undergoing a neurosurgical procedure is equivalent of having a second life . However with latest advancement in surgical field mortality and morbidity following neurosurgical procedure have declined significantly. As neurosurgical procedures are rapidly getting refined tumours and areas of brain previously thought inaccessible or in operable are being rapidly approached with excellent results. Skull base tumours have been always approached with caution because of technical difficulty in approaching such tumours and their proximity to vital structures of brain.
A rare skull base tumour was recently operated at IVY hospital by Senior Neurosurgeon Dr Vineet Saggar . Complete tumour removal was achieved and patient was sucessfuly discharged within few days . He was ably supported by excellent plastic surgery team headed by Dr Rahul Goyal which played huge role in minimizing scarring to facial region as approach to tumor of skull base required a facial incision.
A 28 year old male presented to Dr Vineet Saggar with complaints of lossof vision in right eye and swelling around right eye. His MRI was already done and it revealed large skull base tumour behind face and nose extending to other side . A nasal endoscopic bipopsy was taken at some other hospital had revealed a benign ( non cancerous) tumour of nerves (schwannoma). He had shown to many private and government hospitals but was reffered to AIIMS as they told him it was difficult to approach this tumour and it may not be possible to remove it completely. However this tumour was completely removed at IVY Hospital by Dr Vineet Saggar via OSTEOPLASTIC MAXILLOTOMY a rare and technically demanding Skull base approach . Patient was discharged 6 days after surgery.
PRE OPERATIVE CT SCAN SHOWING LARGE TUMOUR BEHIND FACE AND NOSE UPTO SKULL BASE
POST OPERATIVE SCAN OF PATIENT SHOWING COMPLETE TUMOUR REMOVAL
INTRAOPERATIVE PICTURE OF THE PATIENT
POST OERATIVE PICTURE OF THE SAME PATIENT BEFORE DISCHARGE
Dr Vineet Saggar is senior consultant Nuro and spinal surgery at IVY HOSPITAL. He is specially trained in skull base and Aneurysm surgeries and complex spinal surgeries
Dr. Vineet Saggar (MCh)
Neuro Surgeon / Spinal Surgeon
Chandigarh, Mohali -
Ivy Hospital Sector 71
+91-9855990990
Neuro Surgeon / Spinal Surgeon
Chandigarh, Mohali -
Ivy Hospital Sector 71
+91-9855990990
Monday, 25 November 2013
FOOT BALL MENINGIOMA OPERATED AT IVY HOSPITAL BY DR VINEET SAGGAR
Meningiomas account for 15% of intracranial tumors and 90 percent of meningiomas are intracranial. They commonly occur in the fourth through sixth decades of life. They are more common in females and are rare in children. Meningiomas are brain tumors which do not arise from the cells of the brain (as against glioms which arise from glial cells and other tumors which arise from neural cells). As they do not arise from “brain” cells, they actually are extra-axial in location. By that I mean, they are located outside the brain but inside the skull. So meningiomas do not actually “invade” the brain, on the other hand as they grow in size they press on the brain from outside inwards. Meningiomas are slow growing tumors and as I stated earlier they usually do not invade the brain (though they may be locally invasive at times and these tumors are called atypical or malignant meningiomas).
Since these tumours are slow growing they can achieve enormous sizes before causing symptoms . there are areas in brain which are non eloquent ( areas which are non vital to daily functioning of brain ) such as frontal sub frontal areas , these tumours can achive huge sizes before causing any deficits . Such tumours are akin to large FOOTBALLS in brain . Removal of these tumours require patience and and long duration surgeries and some times tumour is removed sub totally in first attempt and to avoid complications of prolonged surgery in one go rest of tumour is removed next 1-2 days
SIGNS AND SYMPTOMS OF MENINGIOMAS DEPEND UPON THEIR LOCATION
Vision Changes
Meningioma that grows on the bгain mаy cauѕe vision problems, such аs blυrred οr double vision or vision loss.
Hearing Lοss
Hearing loss is а sүmptom οf meningioma near tһe аuditory nerνes oг the bones of the eаr
Headaches
Aсcording to the Mаyo Clіnic, meningioma cаn cause pressure аnd inflammation inside of the ѕkull and result іn headachөs.
Seizures
Mөningioma οf thө Ьrain maү cause sөizures іn people whο һave neνer beforө had а seizure oг seizure disorder.
Mental Dysfunction
Meningiomas at the base of the sĸull can cause mental dysfunction, such аs cοnfusion and memory loss, that may wοrsen over time as the tumor grows.
Weakness
Weakness of thө muscles in the аrms and legs may be а symрtom of meningioma of tһe spinаl cord, aсcording to thө Mayo Clinic.
CASE REPORT
A 22 year male presented in our emergency with complaints of Headache , Vomiting and Altered sensorium of two days duration. Patient s GCS on Examination was E2V2 M6 and had lower cranial nerve palsies. MRI of brain was done which reveled large extraaxial mass in right parieto-occipital region likely a meningioma measuring approx12-13 cms in size . Due to large size of tumour and deteriorating GCS of the patient he was operated in emergency by Dr Vineet Saggar and after 12 hours of marathon surgery complete tumour removal was achieved . Though patient remained on tracheostomy for few days due to lower cranial palsies which finally recovered and tracheostomy was removed , there was no other neurological deficit. Patient was discharged within 15 days of such a major surgery
Discussion
Surgery is indicated in patients with worsening neurological symptoms and in most patients under 70 who present with a seizure or with any neurological symptoms. If patients are over 70 and present with a seizure or have mild symptoms, they can be followed with scans and undergo surgery if there is evidence of definite growth. However, if there is significant edema or a history of worsening symptoms, age is not a contraindication to surgery. A number of patients are now seen in whom the tumor is found incidently and there is no edema. These patients can be followed with periodic scans, including those with large tumors.Since these tumours are slow growing and exra axial they may attain large sizes if they are located near non eloquent areas as brain continues to compensate due to slow groth rate of tumours . How ever these large sized tumours pose many technical challenges both intra operatively and post operatively.
Apart from increasing surgical and anaesthesia timing large tumours especially near skull base require some degree of brain retraction there by increasing risk of brain edema post operatively. Such tumours some times require extended skull base maneuvers such as extended frontal craniotomies, cranioorbitozygomatic approaches to increase exposure and decrease brain retraction.
M ost of the blood supply of the meningioms is from dura via external carotid system, however venous driange is generally towards venous sinuses and as they grow larger in size they start draining supply of surrounding brain via surrounding piamater .Due to prolonged com pression Autoregulation is also impaired in surrounding brain . So when these tumours are removed it suddeny increased blood supply to surrounding brain there by increasing brain edema or hyper perfusion syndrome.
Our patient had persistent tachycardia inspite of normal hydration and haematocrit following surgery and irritability which settled only few days after the surgery
CONCLUSION
In the end I would like to conclude that meningiomas are slow growing tumours of brain which are amenable to complete surgical removal however sometimes location and size of tumour precludes complete tumour removal,
Very large sized tumours measuring 10-15 cms in size or apprx 1/3 – ¼ volume of brain are rare and pose special challenges to surgeons both intra and post operatively. Such tumours appear like large FOOTBALLS in MR IMAGING require special setup and experienced medical team to counter challenges posed by altered haemodynamics in brain circulation and autoregulation.
Dr. Vineet Saggar (MCh)
Neuro Surgeon / Spinal Surgeon
Chandigarh, Mohali -
Ivy Hospital Sector 71
+91-9855990990
Neuro Surgeon / Spinal Surgeon
Chandigarh, Mohali -
Ivy Hospital Sector 71
+91-9855990990
Monday, 12 August 2013
Minimally invasive treatment of vertebral compression fractures at Ivy Hospital by per-cutaneous vertebroplasty by Dr Vineet Saggar (Neuro-Spinal Surgeon)
Minimally
invasive treatment of vertebral compression fractures at Ivy Hospital
by per-cutaneous vertebroplasty by Dr Vineet Saggar
A 54 years old female presented in our OPD with severe pain in back for past three months. Her X-Ray showed wedge collapse of L1 vertebrae without canal compromise. She had been on bed rest for three months but her pain had failed to subside even after full conservative therapy. She was treated with percutaneous vertebroplasty and her pain was relieved and she was discharged in fully ambulatory state the next day.
Fig Showing fluoroscopic placement of needle in fractured vertebrae
Fig showing
vertebroplasty cement in fractured vertebrae
Post Operative Ct scan
showing vertebroplasty cement in L1 Vertebrae
Patient just before discharge
Post op pic showing dressing and small incisions
WHAT IS VERTEBROPLASTY AND KYPHOPLASTY?
This
is a technique of injecting bone cement at the site of painful vertebral
compression fractures under fluroscopyand. Painful vertebral osteoporotic
compression fractures lead to significant morbidity and mortality. A painful osteoporotic vertebral fracture can
be a significant burden for patients (and their families), impairing physical
function and quality of life. Independent of pain, there is morbidity
associated with the spinal deformity. In the thoracic spine this is due to
decreased lung capacity (FVC and FEV1). In the lumbar spine compression
fractures also affect lung capacity, probably due to restrictive airway disease
caused by loss of height, and lead to a reduction in abdominal space associated
with loss of appetite and secondary sequel related to poor nutrition. Additionally,
vertebral body compression fractures (VCFs) cause chronic pain, sleep loss,
decreased mobility, depression, and a loss of independence.
The
medications taken for symptomatic relief can lead to further mood or mental
alterations that compound the medical condition. A large prospective study
noted a 23% increase in mortality in women older than 65 years with VCFs
compared with age-matched controls. The mortality rate increases with the
number of vertebrae fractured. Most painful VCFs are treated palliatively, with
bed rest, narcotic analgesics, orthotics, and time. However, bed rest accelerates
bone loss and leads to muscle de conditioning, resulting in increased pain from
both of these mechanisms. The other
treatments for osteoporosis (e.g., hormone replacement, bisphosphonates,
calcitonin) are important for the long term treatment of this disease but often
do not provide short-term pain relief.
INDICATIONS OF VETEBROPLASTY AND
KYPHOPLASTY
PER CUTANEOUS VERTEBROPLASTY has been used in anterior and posterior
stabilization of the spine for metastatic disease, giant cell tumors of,
treatment of vertebral hemangiomas and . vertebral
compression fractures via the transpedicular or paravertebral approach under CT
and/or fluoroscopic guidance has been described.
TECHNIQUE OF VERTEBROPLASTY AND
KYPHOPLASTY
Upon
completing the informed consent process, the patient is placed in the prone
position on the angiography table. Monitoring of blood pressure, heart rate,
and pulse oximetry is done continuously throughout the procedure. Oxygen
supplied via a nasal cannula is used when necessary. Neuroleptic analgesics in
the form of fentanyl (Sublimaze, Abbott Labs, North Chicago,
Ill) and midazolam (Versed, Roche Pharma,
Manati, Puerto Rico) are administered by the
angiography nurse under the direction of the operating physician. The procedure
is performed under strict sterile conditions. All personnel wear surgical masks
and caps in addition to gowns and gloves for the operators, to minimize the
risk of infection. The vertebral body to be treated is localized under
fluoroscopic control and the skin overlying this area is prepped and draped.
Biplane fluoroscopy
is
recommended, as it allows near simultaneous imaging of the stylet tip position
in two planes, thus decreasing the overall procedure time. The anteroposterior
tube is angled in such a way as to maximize the oval appearance of the pedicle
(“looking down the barrel”) (Fig 1). The skin over the center of the pedicle
oval is anesthetized with bupivacaine hydrochloride (0.25%) followed by
deep injection of bupivacaine to and including the periosteum. A small skin
incision is made with a #11 scalpel blade. A disposable 11-gauge Jamshidi
needle is positioned with Fig 1. The pedicle to be punctured is isolated
and marked with the tip of a surgical clamp. The skin, subcutaneous tissues,
and periosteum are anesthetized with 0.25% bupivacaine. Fig 2. After a small
skin incision is made, the Jamshidi needle is advanced nto the pedicle. Notice
that the shaft of the needle (arrow) maintains a bulls-eye appearance in
relation to the pedicular edges (arrowheads) in the anteroposterior plane. Fig
3. In the lateral plane, the shaft of the needle runs parallel to the
superior and inferior cortices of the pedicle (arrows). After the stylet has
been withdrawn, the needle tip is positioned in the middle of the vertebral
body.
Figure 1 Figure 2 Figure 3
its tip in the center of the oval and
advanced until the stylet tip abuts the bone. Lateral fluoroscopy shows the tip
at the level of the upper to midpoint of the pedicle such that advancement of
the needle is within the midportion of theof the pedicle oval to indicate that the needle is proceeding parallel to the X-ray beam (Fig 2). The lateral view shows the needle moving roughly parallel to the superior and inferior edges of the pedicle (Fig 3) or in a slightly descending course through the pedicle. Minor adjustments in either plane may be required during needle advancement. Once the needle tip has traversed the cortex and the pedicle. A slight twisting
motion is used to advance the tip through the cortex, and frequent checking of
needle placement in both planes is required. The anteroposterior view shows the
needle shaft end-on as a circle within the center
pedicle and is located within soft bone marrow, less pressure may be required
to advance the needle into the vertebral body. Care must be taken not to
abrogate the anterior vertebral wall or the endplates. The stylet tip is placed
at or near the junction of the anterior and middle third of the vertebral body
line. Because the stylet tip projects beyond the end of the needle shaft,
removal of the stylet will position the needle end in the middle or
anterior half of the vertebral body (Fig 3). Before injecting the PMMA,
venography is done to exclude needle placement directly within the
basivertebral venous complex and to ensure continuity of the posterior
vertebral wall as evidenced by containment of the contrast material within the
bony trabeculae (Fig 4). We use a hand injection of 5 mL of iohexol (Omnipaque
300, Nycomed,Princeton, NJ) and film in both planes at a rate of two
frames per second. Rapid flow of contrast material into the vena cava and/or
perivertebral veins without visibility of intervening bone marrow indicates
direct communication of the needle tip with a major venous outlet and requires
needle advancement. Once correct placement of the needle is confirmed,
treatment is begun. If a bone biopsy is warranted, a variety of standard,
commercially available biopsy needles can be passed through the Jamshidi shaft
to obtain tissue samples before vertebroplasty One operator injects the
material as the second loads the syringes. The stylet is removed and,
unless blood fills the dead space in a retrograde manner, the dead space is
injected with PMMA using a long 18-gauge spinal needle. The 1-mL syringe is
attached tightly to the shaft port of the Jamshidi needle and injection begins.
The injection pressure required to push the material will increase over time
as the vertebral body fills and the PMMA polymerizes. Injection is performed
under lateral or anteroposterior oblique fluoroscopy ( and particular attention
must be paid to the region of the vena cava and the epidural space as seen on
the venogram. If passage of material into the venous system is when
appropriate.noted, the injection is slowed or halted while the material attains
a thicker consistency. Injection is continued until hemivertebral or
holovertebral filling is achieved, no more material can be pushed into the
body, or extravasation into veins or the disk space is noted. Repositioning of
the needle is not recommended, as the location of the tip will be unknown, and
unwanted vascular embolization may occur. Upon completing the injection,
the needle is removed and hemostasis at the puncture site is achieved by gentle
pressure. The contralateral hemivertebra is then treated in the same fashion.
More than one vertebra can be treated at the same time, depending on the
patient’s tolerance After the procedure, the patient is placed supine and
asked to remain flat for 3 hours to allow complete curing of the PMMA prior to
axial loading. Although patients usually remain overnight, those from our local
area are allowed to return home the same day.
Dr. Vineet Saggar (MCh)
Neuro Surgeon / Spinal Surgeon
Chandigarh, Mohali -
Ivy Hospital Sector 71
+91-9855990990
Neuro Surgeon / Spinal Surgeon
Chandigarh, Mohali -
Ivy Hospital Sector 71
+91-9855990990
http://www.neurosurgeoninchandigarh.com
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