Routine placement of subdural drain after burr hole evacuation of chronic and subacute subdural hematoma: a contrarian evidence based approach

The objective of this paper was to evaluate whether available evidence supporting placement of subdural drain placement after evacuation of chronic subdural haematoma (CSDH) is applicable to a cohort of patients managed by us. In this observational cohort study, clinical follow-up was obtained in 166 patients who underwent burr hole evacuation of CSDH without placement of subdural drain followed by 3 days of bed rest. The primary outcome studied was recurrence requiring reoperation. Factors predicting recurrence were also analysed. We compared the patient characteristics and management protocols in our cohort with that in reports supporting drain placement to determine whether such evidence is relevant to our patient group. The mean age of our patients was 58 ± 17 years (range, 1 to 89 years). Sixteen of the 166 (9.6%) patients presented with symptomatic recurrence. The median time to reoperation for recurrence (15 of 16 patients) after the primary procedure was 17 days (range, 2 to 68 days). Antiplatelet and anticoagulant therapy was the only factor that was significantly associated with recurrence (p = 0.01). There were no infective or non-infective complications in our patient cohort. Our patient cohort and outcomes differed from those reporting drain placements in the following parameters: they were a decade younger, all patients received bed rest for 3 days after surgery and the recurrence rate was similar to that reported in the drained groups but significantly less than that reported in the non-drained groups. Routine placement of drain following burr hole evacuation of CSDH should only be done after careful comparison of the patient cohort under consideration and those reporting superior outcomes with drains. Evidence-based medicine supports such an approach.     

Correlation between change in graft height and change in segmental angle following central corpectomy for cervical spondylotic myelopathy

OBJECT: This study was undertaken to examine the correlation between change in graft height and change in angulation across grafted segments (segmental angle) in patients undergoing central corpectomy (CC) with autologous bone reconstruction for cervical spondylotic myelopathy (CSM). METHODS: The authors performed a retrospective analysis of 70 cases in which patients with CSM underwent uninstrumented single- or multilevel CC and had evidence of osseous fusion of their grafts at follow-up. The segmental angles and heights of the grafted segments on preoperative, postoperative, and follow-up radiographs were compared. RESULTS: The mean change in graft height (+/- standard deviation) was -7.3 +/- 3.8 mm (mean duration of follow-up 19.7 +/- 5.4 months, range 13-53 months). There was a mean kyphotic change in segmental angle of -7.3 +/- 3.8 degrees (p < 0.001). In patients who had a straight or kyphotic cervical spine (28 patients) or a straight or kyphotic segment (32 patients) preoperatively, there was a significant linear correlation between changes in graft height and changes in segmental angle (Pearson correlation, r = 0.40, p = 0.03; r = 0.40, p = 0.02, respectively). Such a correlation was not seen in the patients who had a lordotic cervical spine (42 patients) or a lordotic segment (38 patients) preoperatively (Pearson correlation, r = -0.04, p = 0.81; r = 0.08, p = 0.62, respectively). The change in segmental angle did not influence improvement in Nurick grade (p = 0.8). The degree of agreement between the 2 observers was almost perfect for measurement of graft height (postoperative intraclass correlation coefficient [ICC] = 0.94, follow-up ICC = 0.90) but was significantly lower for measurement of segmental angles (postoperative ICC = 0.71, follow-up ICC = 0.67). CONCLUSIONS: Among patients undergoing uninstrumented CC for CSM, there is a significant correlation between postoperative settling and kyphotic change across fused segments in those who had straight or kyphotic cervical spines or segments preoperatively but not in those who had lordotic cervical spines or segments preoperatively. A more vigorous surgical correction of the segmental kyphosis than achieved in this study might have caused the kyphotic segments to behave like the lordotic segments. Paraspinal muscles and ligaments may play a role in determining the segmental angle as graft settling in patients with lordotic spines or segments is not linearly correlated with angular change.     

Buccal Fat Pad in Intraoral Defect Reconstruction

The use of buccal fat pad as a graft for intraoral defects is an uncommonly reported procedure but, it has been frequently used for closure of oro-antral and oro-nasal communications. Buccal fat pad was used to reconstruct 3 medium sized defects due to tumoral resection and oro-antral communication. It was used as an unlined pedicled graft. Three cases are discussed along with anatomical aspect of the buccal fat pad. The findings support the view that the buccal fat pad is versatile, logical, convenient, and reliable method for the reconstruction of oral defects up to 4–5 cm in diameter and it healed within 4–5 weeks.     

Oxidative stress–associated hypertension in surgically induced brain injury patients: Effects of β-blocker and angiotensin-converting enzyme inhibitor

BackgroundPostoperative hypertension is a common problem in patients undergoing surgical procedures, and the modification of this response could result in improved surgical outcome. Although it is recognized that the incidence of postoperative hypertension is higher in neurosurgical procedures, mechanisms behind this are not well understood. Oxidative stress is an important component of brain injury, and free radicals can influence blood pressure by a number of mechanisms. This study examined the effect of pretreatment with antihypertensive agents on postoperative hypertension in patients undergoing neurosurgery for supratentorial brain tumors and the role of oxidative stress in the process.MethodsForty-nine consecutive patients who underwent surgery for supratentorial brain tumors were divided in to three groups (control, Tab. Glucose; atenolol; and lisinopril groups). Blood was drawn at three time points (1 d before the surgery, at the time of dura opening, and at the time of extubation). Hemodynamic parameters in all three groups and levels of malondialdehyde, protein carbonyl content, nitrate, and α-tocopherol in serum at various time points were analyzed.ResultsThe results showed that perioperative hemodynamic changes were highly associated with oxidative stress parameters in all the three groups. It was seen that atenolol and lisinopril significantly decreased levels of malondialdehyde, protein carbonyl content, and nitrate in the intraoperative period (P < 0.05), an effect which continued postoperatively.ConclusionsThe results demonstrate that pretreatment with β-receptor blocker (atenolol) or angiotensin-converting enzyme inhibitor (lisinopril) reduces postoperative hypertension in patients undergoing neurosurgery, and inhibition of oxidative stress may be a potential mechanism for this effect.     

Liquid nitrogen cryotherapy in the management of oral lesions: a retrospective clinical study

Background & objectives  The purpose of this study was to evaluate effectiveness and convenience of cryosurgical procedure, to assess the events during postoperative healing and to find out the incidence of recurrence Materials and methods  This study was conducted in the Department of Oral and Maxillofacial Surgery, KLESVK Institute of Dental Sciences, Belgaum. The 40 patients selected for the study were divided into 2 groups of 20 patients each irrespective of age and sex. Group I 20 patients with Pre-Malignant Lesions Group II 20 patients with Oral Mucous Cyst Results  It was observed that all the 20 patients of mucocele were cured without any complication and recurrence, but in 20 patients of leukoplakia 5 patients had recurrence which was directly attributed to their persisting habits. Conclusion  We state that this modality of treatment is promising with good results and has certain advantage over other modalities of treatment.     

IL12Rβ1ΔTM Is a Secreted Product of il12rb1 That Promotes Control of Extrapulmonary Tuberculosis

IL12RB1 is a human gene that is important for resistance to Mycobacterium tuberculosis infection. IL12RB1 is expressed by multiple leukocyte lineages, and encodes a type I transmembrane protein (IL12Rβ1) that associates with IL12p40 and promotes the development of host-protective T_H1cells. Recently, we observed that il12rb1—the mouse homolog of IL12RB1—is alternatively spliced by leukocytes to produce a second isoform (IL12Rβ1ΔTM) that has biological properties distinct from IL12Rβ1. Although the expression of IL12Rβ1ΔTM is elicited by M. tuberculosis in vivo, and its overexpression enhances IL12p40 responsiveness in vitro, the contribution of IL12Rβ1ΔTM to controlling M. tuberculosis infection has not been tested. Here, we demonstrate that IL12Rβ1ΔTM represents a secreted product of il12rb1 that, when absent from mice, compromises their ability to control M. tuberculosis infection in extrapulmonary organs. Furthermore, elevated M. tuberculosis burdens in IL12Rβ1ΔTM-deficient animals are associated with decreased lymph node cellularity and a decline in T_H1 development. Collectively, these data support a model wherein IL12Rβ1ΔTM is a secreted product of il12rb1 that promotes resistance to M. tuberculosis infection by potentiating T_H cells response to IL-12.