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Background: A number of complications following surgery aimed at atlantoaxial fixation have been reported. However, there is no report in the literature describing visual loss following vertebral artery injury. Objective: Vision loss as a complication of vertebral artery injury during surgery for atlantoaxial fixation is reported. Material and Methods: This is a report of two patients who were operated for atlantoaxial instability by the Goel technique of atlantoaxial fixation. During surgery, there was an injury to the vertebral artery and the artery had to be sacrificed. Results: Both patients suffered severe visual loss following surgery. One patient had a partial visual recovery that started within few days of surgery while the other patient remained completely blind. Conclusions: Although rare, visual loss can be a complication of vertebral artery sacrifice during surgery for atlantoaxial stabilization.

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OBJECTIVE: To report an outcome analysis following surgical treatment of 45 patients with cavernous hemangiomas involving cavernous sinus. METHODS: From 1992 to 2020, 45 cases of cavernous hemangiomas involving the cavernous sinus were surgically treated. These patients were retrospectively analyzed. RESULTS: Patients included 12 males and 33 females; the average age was 34 years (age range, 15-61 years). Two patients had only headache as presenting symptom, and 43 patients had headache and diplopia as presenting symptoms. Investigations showed characteristic radiological imaging and encasement of internal carotid artery (35 cases), extension toward the sella, and displacement of cranial nerves III-V. An entirely extradural surgical approach was adopted in 39 cases. Cranial nerves III-V had a discrete dural covering and were always displaced over the dome of the tumor. The sixth cranial nerve was displaced on the dome of the tumor adjacent to the floor of the cavernous sinus. Three patients died in the early postoperative period, all related to excessive bleeding. In 36 patients, ocular movement dysfunction did not recover or worsened. During an average follow-up period of 110 months (range, 6 months to 27 years), 3 patients had tumor recurrence after postoperative imaging had shown complete tumor resection. CONCLUSIONS: Surgery on cavernous hemangiomas of cavernous sinus can be a challenge owing to the vascular profile and complex anatomical location. An extradural approach provides satisfactory exposure for radical tumor resection.

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This is a retrospective analysis of cases with hangman's fracture. The subject of 'hangman's fracture' has been elaborately evaluated in the literature. The authors propose an alternative format of surgical treatment that is based on modification of existing classification schemes. During the period 2015 to March 2020, 15 patients having hangman's fracture were identified and were surgically treated. The clinical condition was classified on the basis of American Spinal Injury Association scale (ASIA scale) and VAS parameters. The patients were classified into 4 groups depending on the presence (or absence) of atlantoaxial and/or C2-3 instability. Surgical decisions were guided by the proposed classification. Clinical evaluation and dynamic CT scan were done at follow-up visits. During the average follow-up of 26 months, all patients are essentially asymptomatic. There was marginal restriction of extent of neck movements in all cases. There was solid bone fusion in all cases. The proposed novel classification scheme based on the presence of atlantoaxial and C2-3 instability assisted in directing the treatment strategy of hangman's fracture.

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OBJECTIVE: The clinical outcome following multilevel stabilization in patients who suffered cervical spinal injury and developed severe neurological deficits and then gradually partially recovered is evaluated. The basis of the surgical concept was that cervical spinal degeneration is a result of single or multilevel spinal instability and that spinal trauma exaggerates the instability. MATERIALS AND METHODS: During the period 2015-2020, 14 patients who suffered severe cervical spinal injury and could be included in the classification of spinal cord injury without computed tomography evidence of trauma were surgically treated. There were 11 males and 3 females. The ages ranged from 45 to 67 years, average being 53 years. Cervical canal stenoses related to degenerative spinal changes were observed in all patients. All patients suffered severe neurological deficits and within few days or weeks had shown significant but incomplete neurological recovery. The identification of the levels of unstable spinal segments was done on the basis of radiological and clinical parameters and direct observation of spinal instability in adjoining spinal segments. Transarticular fixation was done by Camille's transarticular fixation technique. Using ASIA score, modified JOA score, and Goel Clinical Grading Scale, the clinical course of the patients was monitored. RESULTS: All patients showed recovery in the neurological status. Recovery started in the immediate postoperative period and the improvement progressed during the period of follow-up. CONCLUSIONS: Surgery for spinal stabilization can be indicated even in cases that improve in the neurological function.

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Coronavirus disease-2019 (COVID-19) pandemic has severely affected and disrupted medical practice all over the world since December 2019 till date. This has affected the pediatric surgical practice in general and neurosurgical practice in particular. An analysis of 26 neonatal patients with open neural tube defects who underwent surgery in the neurosurgery department at the King Edward VII Memorial Hospital (KEM), Mumbai during the period of March 2020 till December 2020 is presented. The cumulative experience and challenges encountered in the comprehensive management of these cohort of patients in the difficult period of the pandemic is discussed in accordance with relevant literature on the subject.

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We present a report of two patients having the association of omovertebra, Sprengel's deformity of the shoulder and Klippel-Feil abnormality with craniovertebral junctional instability. Our literature survey did not locate any report of such association. Significance of bone alterations is analyzed. Two young patients presented with neck pain, torticollis, webbed neck, and spastic quadriparesis. In both patients, the investigations revealed basilar invagination, Klippel-Feil abnormality and Sprengel's deformity of the shoulder. Apart from these relatively common associations, both the patients had omovertebral bone that extended from the transverse process of C5 vertebra to scapula. Following atlantoaxial stabilization surgery, the patients rapidly recovered from all symptoms. Musculoskeletal abnormalities at the craniovertebral junction that include Klippel-Feil abnormality, Sprengel's shoulder, and omovertebra are secondary alterations to primary atlantoaxial instability.

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OBJECTIVE: The potential significance of relationship of atlantoaxial instability with retro-odontoid pseudotumor, pannus, and/or cyst (RPC) is analyzed. METHODS: We searched the database of patients with craniovertebral junction-related instability treated by atlantoaxial fixation from January 2000 to March 2020. We identified 63 patients in whom there was an RPC in the region posterior to the odontoid process or posterior to the posterior aspect of the C2 body. RESULTS: The RPC was solid in 10 patients, predominantly cystic in 39 patients, and had both solid and cystic components in 14 patients. The vertical dimension of the RPC varied from 4.5 to 10.5 mm (average, 7.9 mm) and the transverse dimension ranged from 2 to 5.2 mm (average, 3.4 mm). In 51 patients, the RPC was in the midline and in 9 patients, it was eccentric in location. In 38 patients, there was erosion of the C2 body adjoining the RPC. Analysis of investigations showed that in 100% of patients, the dome of the RPC was in line with the most susceptible point of potential bone compression of neural structures. The RPC was eccentric in location in 9 patients presenting with torticollis. RPC indicated the presence of atlantoaxial instability even when there were no other positive and validated radiologic indicators. After atlantoaxial stabilization, the RPC spontaneously regressed or disappeared. Direct resection of the RPC was neither performed nor was necessary in any case. CONCLUSIONS: RPCs are secondary consequences of atlantoaxial instability and need not be primarily addressed by surgical resection. Their location suggests that they might have a neural protective function.

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BACKGROUND: Gliomas are "confined" tumors arising from a named white fiber tract and displacing adjoining "normal" white fibers. The surgical strategy of "en masse" resection of gliomas based on this concept is evaluated. OBJECTIVE: We evaluate the feasibility of the surgical strategy of "en masse" tumor resection for low-grade gliomas arising from the short arcuate fibers. METHODS: We retrospectively evaluated our series of 74 patients with low-grade gliomas involving the short arcuate fibers who were operated on between the years January 2016 and June 2019. The tumor resection was done on the premise that gliomas arise from and grew along a specific white fiber tract and the expanding tumor displaced but did not transgress the border formed by adjoining tracts. Although modified as per the situation, an en masse tumor resection strategy was the basis of surgical resection. Intraoperative motor cortical and subcortical mapping was performed in 14 cases. Awake surgery was performed on 11 patients. RESULTS: There were 46 males and 28 females. Total/supratotal tumor resection was achieved in 62 (83.8%) patients. Forty-seven patients had an essentially en masse tumor resection. Seventy-one patients improved in their preoperative complaints. The follow-up ranged from 11 to 56 months. Sixty-two patients who underwent a total or supratotal resection were not given any adjuvant treatment. Twelve patients with subtotal resection were subjected to adjuvant radiotherapy with or without additional chemotherapy. CONCLUSIONS: En masse tumor resection of low-grade gliomas is possible and "safe" based on understanding that gliomas are "confined" tumors and have a well-defined plane of surgical dissection.

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BACKGROUND AND IMPORTANCE: The article identifies the feasibility of transarticular screw fixation after mobilizing the vertebral artery in cases where it is in a "high-riding" location. CLINICAL PRESENTATION: A 42-yr-old male patient had a 4-yr history of progressive quadriparesis. Investigations revealed severe basilar invagination. There was assimilation of atlas and C2-3 fusion. The vertebral artery was "high-riding" into the pedicle-facet of C2 vertebra on both sides. Vertebral artery loop was exposed and mobilized inferiorly on both sides after careful drilling of pedicular bone on the posterior aspect of the dome of the artery. C2 facetal bone on the anterior face of the vertebral artery dome was now available for screw insertion. The C1-2 facets and the articulation were directly in line, making transarticular screw fixation relatively straightforward. The wide bone space available permitted insertion of 2 screws in a transarticular fashion on both sides. The patient had satisfactory clinical improvement. Imaging after 22 mo showed bone fusion across the facets. CONCLUSION: Mobilization of the high-riding vertebral artery loop can help salvage the surgical procedure of lateral mass stabilization.

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BACKGROUND: Musculoskeletal and neural alterations secondary to chronic atlantoaxial instability are evaluated. CASE DESCRIPTION: An 11-year-old girl presented with major symptoms of progressively worsening dorsal kyphoscoliosis (spinal kyphoscoliosis [SKS]). In addition to dorsal SKS, investigations revealed multiple craniovertebral and cervical spinal musculoskeletal abnormalities, Chiari formation, and syringomyelia. Dynamic imaging revealed atlantoaxial instability. Atlantoaxial stabilization resulted in rapid improvement in SKS, regression of tonsillar herniation, and resolution of syrinx. CONCLUSIONS: The experience with the case showcases wide ranged spinal consequences as a result of chronic atlantoaxial instability.

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OBJECTIVE: We describe the dural relationships and its surgical implications for large lower cranial nerve (CN) neurinomas. The study is based on surgical experience with 14 cases. METHODS: During the period January 2014 to December 2019, 14 consecutive cases with large lower CN neurinomas were surgically treated with the aim of radical tumor resection. RESULTS: There were 9 males and 5 females, ranging in age from 17 to 65 years. All patients were operated in a single stage. The principal surgical observation was that the entire extent of tumor, which included intracranial, jugular fossa, and extracranial components, was within the "dural" confines and the tumor adjoining critical neural and vascular structures was displaced around the dome of the tumor. Radical surgical resection was achieved in all cases. During the follow-up period that ranged from 3 to 71 months (average 32 months), no symptomatic recurrence was observed and no patient needed reoperation. At the time of last clinical follow-up, the lower CN function in all patients was better than at the time of presentation. CONCLUSIONS: The "dural" cover of the lower CN neurinomas forms a strong and reliable plane of compartmentalization and allows safe tumor resection.

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BACKGROUND: The conventional retrosigmoid and lateral supracerebellar approach was used for surgery in 5 select cases of large chordomas. METHODS: Patients were treated during 2011 and 2019. Location of the tumor in the depth from surface, wide tumor extensions, and intimate relationships with critical neural and vascular lesions made the approach selection a formidable challenge. RESULTS: The discussed approach provided a satisfactory and wide exposure that permitted circumferential dissection of the tumor. Maneuvering the angulation of microscope provided access to the part of tumor that extended in the region of cavernous sinus. CONCLUSIONS: Radical resection of all the tumors was achieved.

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