Awake Craniotomy

FAQs on Pituitary Tumors

What are pituitary tumors, and how common are they?

Can pituitary tumors be hereditary, and are there any genetic factors that increase the risk of developing these tumors?

• Most people who develop pituitary tumors do not have a family history of the disease. Many people with pituitary tumors have no known risk factors.
• However, rarely, pituitary tumors can run in families. When this happens, they are often found as part of a genetic syndrome that may involve other types of tumors as well. Like multiple endocrine neoplasias (MEN syndrome).

What are the typical symptoms of a pituitary tumor?

• Symptoms may result from pressure on the brain or nearby structures.
• Common symptoms include headaches, vision changes, hormonal imbalances, and fatigue.

How do pituitary tumors affect hormone levels in the body, and what are the long-term effects of hormonal imbalances caused by these tumors?

• Functioning tumors: They secrete excess levels of hormones. Symptoms depend on which hormone is in excess. Tumors which secrete excess growth hormone can cause changes in facial features such as enlargement of the nose, thickening of lips, enlarged hands and feet. Tumors which lead to excess cortisol production (also called Cushing’s syndrome) can lead to obesity, Diabetes, Hypertension, and decreased immunity. Tumors producing excess prolactin can cause menstrual irregularities, and failure to conceive and have children in women. 
• Nonfunctioning tumors: They reduce the levels of hormones like thyroid hormones, cortisol, and growth hormone by pressing on the normal pituitary gland.  causing problems like fatigue, weight problems, and menstrual irregularities.

State of the Art Technology to Combat Brain Tumours

Brain tumours are the most terrifying diagnosis one can get upon visiting the neurosurgeon for a headache, vomiting, loss of vision, weakness of the limbs, speech and memory problems or imbalance. As for most tumours, they may be benign or malignant. 

In India 5-10 people per lakh are diagnosed with a brain tumour of which approximately 2% are malignant. A benign tumour is a lump which is typically slow-growing over many months or years which becomes evident only when the patient develops symptoms due to its size or a critical location affecting functions like strength in the limbs, speech, memory or balance. A cancerous/malignant tumour on the other hand is commonly a fast-growing entity which can produce symptoms due to rapidly increasing pressure on the normal brain as well as destruction of the brain tissue and resultant swelling around the tumour. However, ‘brain tumour’ need not be a fatal diagnosis in many cases in this technologically advanced day and age. At Sakra World Hospital we are breaking barriers at the forefront of science using state of the art technology to improve diagnosis and accuracy of surgical treatment, so more patients recover faster and an excellent quality of life after surgery.

As we have stepped into the 21st century there have been groundbreaking technological advances which make it easier for the surgeon to achieve complete resection of tumours while preserving vital parts of the brain which have been unaffected. These include surgical microscopes, ultrasonic suction aspirators (CUSA), navigation systems, novel intra operative imaging, electrophysiological monitoring, functional mapping, minimally invasive surgery and robotic surgery to name a few. 

A surgical microscope can help magnify up to 40 times so that the surgeon can visualize the smallest structures in the brain both in 2D and 3D.They are also equipped with special lighting used with fluorescence producing dyes like fluorescein or 5-Aminilevulanic acid (5-ALA) to better distinguish the tumour from normal brain visually during microscopic surgery.

Patients with tumours in critical speech or motor areas are at risk of losing these functions and use of “awake brain surgery” to assess the speech or strength in the limbs while the surgeon is resecting the tumour is undertaken instead of keeping the patient completely unconscious. 

CUSA (cavitron ultrasonic suction aspirator) is a device which used ultrasonic cutting with suction simultaneously to accurately cut through firm lesions without affecting the surrounding blood vessels and normal brain tissue faster reducing the duration of surgery.

Minimally invasive techniques like keyhole surgery, endoscopy, as well as robotic surgeries, use small openings in the skull to access even deeper areas so that there is minimal damage to the normal brain. It improves the precision, improves the surgical outcomes, reduces blood loss and reduces hospital stay. 

Modern intraoperative imaging techniques like ultrasound, CT and MRI help to locate the lesion as well as confirm the adequate removal after the procedure. It helps the surgeon to resect as much of the tumour safely as possible. Navigation systems are like GPS for brain used to locate the lesion accurately before surgery to guide the neurosurgeon and reduce the size of the incision and duration of surgery.  It provides a real time information about the 3D spatial location of the lesion and surrounding important structures of the brain.  It is typically used in conjunction with MRI or CT scan images of the brain. It may be augmented by use of functional imaging of the brain to determine the areas of the brain responsible for movements of the limbs or speech etc, so that these areas may be avoided during the procedure.

Newer electrophysiological monitoring and mapping techniques are available to get an electrical imprint of the various essential parts of the brain responsible for motor functions or sensations to be preserved. This is especially useful for tumours in the motor or sensory areas of the brain.

We at the Department of Neurosurgery at Sakra evolve constantly and adapt to new technological innovations and are committed to delivering the best for our patients.

“Art of surgery aided by technology for the love of humanity….”

Smart Ways of Identifying Stroke and Treating It at the Earliest

Stroke is the leading cause of disability and in many cases, they don’t have to be deadly. Early diagnosis and treatment of the stroke can limit the brain damage and improve the outcomes of treating it. 

When does a stroke occur?

A stroke occurs when the blood supply to an area of the brain cuts off.

What are the symptoms of the stroke?

Symptoms of the stroke depend on how much of the brain tissue is deprived of blood supply. Symptoms of a stroke include:

• Trouble speaking and understanding what others are saying

• Numbness of the face, arm or leg

• Problem seeing in one or both eyes

• Headache

• Trouble walking

What are the causes of Stroke?

There are two main causes of stroke:

Ischemic Stroke: It is caused by a blocked artery or leaking or bursting of a blood vessel and is the most common type of stroke. Blocked arteries are caused by fatty deposits that build up in the blood vessels or by blood clots that travel through the bloodstream.
Some research shows that COVID-19 infection may be a possible cause of ischemic stroke, but as of now, more study is required.

Hemorrhagic Stroke: It occurs when a blood vessel in the brain leaks or ruptures. Factors related to hemorrhagic stroke include:

• Uncontrolled high blood pressure

• Overtreatment with blood thinners

• Trauma

• Protein deposits in the blood vessel that lead to weakness

• Ischemic stroke leading to haemorrhage

Transient Ischemic Attack (TIA): It is also known as a ministroke in which you have a temporary period of symptoms similar to those you had in a stroke. They are caused due to the temporary decrease in blood supply to the part of the brain which lasts for five minutes.

Consult the doctor immediately if you think you or your loved ones are having a stroke.

Stroke can happen to anyone at any time. The best ways to minimise the risk and damage of stroke are awareness and prevention. The FAST test can be very helpful for the most common symptoms of a stroke:

F: Face Drooping

A: Arm Weakening

S: Speech Difficulties

T: Time

These signs can be easily noticed. If you notice a side of the face drooling while smiling then a person may be having a stroke. If someone experiences a slurred or strange speech, it may be a hint of an upcoming stroke attack. If you are facing any of the symptoms then immediately get in touch with a doctor.

Risk Factors of Stroke

There are various risk factors of stroke such as:

• Blood pressure

• Diabetes

• Heart and blood vessels diseases

• High LDL cholesterol levels

• Rheumatoid Arthritis

• Smoking

• Age

Babies who are less than a year are more at risk of having a stroke and at the younger age men are more prone to get a stroke. Women may suffer from a stroke during pregnancy or immediately after giving birth.

Preventing Stroke  (Prevention is better!!)

Lifestyle modification plays an important role in stroke prevention. Some of the ways by which stroke can be prevented includes:

• Eating a healthy diet

• Stress management

• Regular exercise

• Giving up smoking

• Avoiding excessive alcohol consumption 

Case Study: 64-yr-old Mr Khan (name changed) from Oman presented at Sakra World Hospital with complaints of having multiple episodes of Transient Ischemic Attack (a warning sign of stroke) and left-sided weakness for the past one month. He was brought on a wheelchair and incontinent. Upon investigation, he was diagnosed with Right Internal Carotid Artery Severe Stenosis or narrowing of the large artery on the side of the neck that carries blood to the head, face and brain due to atherosclerosis (a condition where plaque build-up within the arteries). Mr Khan suddenly developed weakness on one side of his body which caused him to lose balance and fall most of the time. He also had multiple episodes of giddiness as warning signs previously. He consulted doctors and sought medical help at his native but his condition could not be improved. 

At Sakra World Hospital, he consulted Dr Swaroop Gopal, Director - Neuro Sciences, who upon examination and evaluation found severe calcified blockages in the neck artery and after counselling the family conducted Right Carotid Micro Endarterectomy (surgery used to treat carotid stenosis. Following the surgery, Mr Khan’s condition improved considerably. He became ambulant and content and in a few days has flown back to his home country to continue medical management and rehabilitation. 

Understanding EVLT and Its Role in Treating Varicose Veins

What is a varicose vein

Varicose veins are twisted, enlarged veins. Any superficial vein may become varicose, but the veins most commonly affected are those in your legs.  It happens because of defective valves in the vein that causes reflux and pooling of blood towards the direction of gravity.  

For many people, varicose veins and spider veins — a common, mild variation of varicose veins — are simply a cosmetic concern. For other people, varicose veins can cause aching pain and discomfort. Sometimes varicose veins lead to more serious problems.

Symptoms

When painful signs and symptoms occur, they may include:

1. An achy or heavy feeling in your legs, burning, throbbing, muscle cramping and swelling in your lower legs

2. Worsened pain after sitting or standing for a long time

3. Itching around one or more of your veins

4. Skin discolouration (blackening), thickening, dryness and loss of hair.

5. Leg ulcers and bleeding

Spider veins are similar to varicose veins, but they're smaller. Spider veins are found closer to the skin's surface and are often red or blue. They vary in size and often look like a spider's web.

When to visit a doctor

Self-care such as exercise, leg elevation or compression stockings — can help you from getting worse. But if you're concerned about the cosmesis or self-care measures are not sufficient from getting worse, see your doctor.

Causes

Weak or damaged valves can lead to varicose veins. Arteries carry blood from your heart to the rest of your tissues, and veins return blood from the rest of your body to your heart, so the blood can be recirculated. To return blood to your heart, the veins in your legs must work against gravity.

Muscle contractions in your lower legs act as pumps, and elastic vein walls help blood return to your heart. Tiny valves in your veins open as blood flow toward your heart then close to stop blood from flowing backwards. If these valves are weak or damaged, blood can flow backwards and pool in the vein, causing the veins to stretch or twist.

Risk factors

1. Age. Due to loss of vein elasticity, some blood flows back into your veins where it collects instead of flowing up to your heart.

2. Sex. Women are more likely to develop because of hormonal changes during pregnancy, pre-menstruation or menopause tend to relax vein walls thereby the development of varicose veins. Also, birth control pills may increase your risk of varicose veins.

3. Family history. If other family members had varicose veins, there's a greater chance you will too.

4. Obesity. It puts additional pressure on your veins.

5. Standing or sitting for long periods of time. Jobs involving prolonged standing and sedentary lifestyle. 

Complications

1. Ulcers. Painful ulcers, particularly near the ankles. A discoloured spot on the skin usually begins before ulcer forms. Needs urgent consultation.

2. Blood clots (DVT). Any persistent leg pain or swelling warrants medical attention because it may indicate a blood clot within deep veins (DVT).

3. Bleeding. This happens because of increased pressure.

Prevention

1. No way to completely prevent but improving your circulation and muscle tone may reduce the risk of developing varicose veins or getting additional ones. 

2. Exercising with weight control

3. Eating a high-fibre, low-salt diet

4. Avoiding high heels and tight hosiery

5. Elevating your legs

6. Changing your sitting or standing position regularly

What is EVLT

Endovenous laser ablation therapy (EVLT) is a minimally invasive procedure that makes use of catheters, lasers, and ultrasound to treat varicose veins. The EVLT procedure begins with an Interventional Radiologist inserting a catheter into the varicose vein. Using ultrasound to see inside the patient, the doctor guides the catheter through the vein. A laser at the end of the catheter heats the walls of the vein, which closes it. This causes blood to stop flowing through the vein.

As the body recovers after the procedure, circulation becomes more efficient since blood is not flowing through a faulty vein and the problem vein shrinks and fades. Blood then flows through other nearby veins instead.

WHY EVLT

1. Outpatient procedure(walk-in - walk out). Can resume normal activities immediately

2. Quick and easy to perform

3. Minimally invasive and less traumatic

4. No scarring

5. Excellent clinical result

6. Better result than open surgery

7. Reduced procedure cost

What happens after endovenous laser varicose vein surgery?

You will be encouraged to walk right after the procedure, for about 30 to 60 minutes.
Your leg may have some bruising. The bruises should go away in about 2 weeks.
You’ll need to have someone drive you home after the procedure.

Follow up to the procedure

Follow up with within one weeks’ time followed by next follow up after 1 month.
You will be advised to use stockings for 2 months.

A Journey Of Strength: Stand Tall This World Spine Day

What if you had a spine deformity so severe that you couldn’t walk? Does it seem like a hopeless situation? It doesn’t have to be. Sakra World Hospital is a pioneer in spinal care and surgery and we pride ourselves on our high success rates and the positive change we bring to the lives of our patients.

Here is an inspiring story from one of our patients who came to us with a severely deformed spine that left him immobile, in pain, and depressed. Thanks to our expert doctors, he walked away taller and stronger than ever.

Case History:

The patient presented with a history of hereditary motor neuropathy with resulting rigid kyphoscoliosis. He complained of breathlessness, difficulty walking, and feelings of depression due to his condition. His back was visibly crooked with a hunchback. The spine displayed gross deformity with a kyphotic degree of 75 and scoliotic degree of 70.

The patient was advised to undergo kyphoscoliotic correction surgery to reverse the deformity and improve overall functionality and quality of life. The surgery was undertaken by a team of spine surgeons which included Dr Satish Rudrappa, Dr Ramachandran, and Dr Ramakrishna. 

Dr Satish Rudrappa was the head surgeon. The surgery was conducted in 8 hours and was a complete success.

Post-surgery, the patient had a rapid recovery. He began walking the day after surgery and his height had increased by 7 cms. He underwent rehabilitative treatment and was discharged in 5 days with full mobility.

Hereditary Motor Neuropathy and Kyphosis

Hereditary motor neuropathies, also called distal motor neuropathies, are a group of motor neuron diseases. As the name suggests, these neuropathies are genetic in nature. Distal motor neuropathy is primarily characterized by the loss of motor neurons in the anterior horn of the spinal cord resulting in motor impairment and muscular atrophy or degeneration.

The onset of hereditary motor neuropathy is usually during childhood or adolescence with rapidly progressive weakness and wasting of the large muscles of the legs. As the disorder progresses, the muscles of the arms and hands can also be affected. In some subtypes of hereditary motor neuropathies, the symptoms start in the feet instead of the legs.

Spinal deformities are reported in some patients with hereditary motor neuropathy such as scoliosis, kyphosis, or kyphoscoliosis. The normal spine has a natural curvature and three segments. The cervical section (neck) and the lower back curvature are ‘c-shaped’ and called lordosis. The portion of the spinal cord in the chest (thoracic spine) is ‘reverse c-shaped’ and is called kyphosis.

The natural curve of the spine is important for balance, stability, and mobility of the body. Any abnormal or excessive angles of curvature can affect these normal functions.

What You Need To Know About Kyphoscoliosis

Scoliosis is an abnormal curvature of the spine in a sideways direction while kyphosis is an abnormal curvature of the thoracic spine beyond the normal 20-40 degrees, which causes the upper back to appear more rounded and prominent than usual. When both these conditions co-exist, it is known as kyphoscoliosis.

Kyphoscoliosis can result due to a number of factors such as genetics, poor posture, certain infections, etc. This condition is not merely a spine deformity but also has a number of associated complications such as difficulty breathing, pulmonary hypertension, difficulty performing everyday tasks, and psychological problems such as anxiety and depression.

Treatment Options 

Treatment for kyphoscoliosis can include physical therapy, medication, surgery, or any combination of these.

Minor cases of this spine deformity can be corrected with exercise and physical therapy, along with medications if required. Placement of back braces can also be used to return the spine to a normal curvature.

Severe or progressive cases of kyphoscoliosis may not be completely corrected by non-invasive treatments and so corrective surgery may be needed.

Why Is Kyphoscoliosis Correction Surgery Difficult?

Surgery for kyphoscoliosis aims to correct the deformity, correct any nerve damage, and prevent further progression of the deformity.

The surgical procedure is a spinal fusion surgery with instrumentation. During the surgery, the area of the spine that needs to be corrected is exposed via a long incision. 2-inch titanium screws are placed into hard struts of bone called pedicles which are on either side of the vertebra. Once all the screws are in place, the surgical team corrects the angle of curvature. 

While the success rates of this corrective surgery are overwhelmingly positive, there are certain risks that need to be considered. Risk factors can include nerve damage leading to permanent paralysis, failure to correct the deformity, excessive bleeding, and infections.

The risk of paraplegia or complete paralysis can be the most troubling for many patients. However, this should not be a reason to delay or refuse surgery if it is required.

As with any other surgical procedure, it is important to analyse the risks and benefits. Hospital infrastructure, the presence of an experienced and expert multidisciplinary team, and the technique of the surgery are important factors that can improve the chances of success for patients undergoing corrective surgery.

What We Do Differently At Sakra

At Sakra World Hospital, we are committed to using the best medical technology available to better the lives of our patients. Our combination of expert doctors, evidence-based medical practices, and the latest technology allows us to achieve high success rates in our surgical procedures.

We understand the complex nature of surgical procedures such as spinal fusion and instrumentation. All our surgical patients undergo a comprehensive pre-surgical medical check to ensure that they go into surgery in the best possible condition. This, in turn, improves chances of success and recovery.

Spinal surgeries at Sakra are conducted by experienced multidisciplinary teams that include spine surgeons, neurosurgeons, orthopaedic surgeons, specialised nurses, and paramedical staff. We treat the body as a whole and not part by part. Spinal disorders are multifaceted and complex and a multidisciplinary approach is the best way to ensure complete correction of deformities and better quality of life after surgery.

One of our outstanding features is our extensive and up-to-date technology. We always use the latest in medical technology in our surgeries. For spinal surgeries such as spinal fusion, we supplement the expertise of the surgical team with state-of-the-art neuronavigation systems, neuromonitoring, and intraoperative CT guidance during pedicle screw placement and correction of curvature.

Ultimately, we are dedicated to bringing relief and a better life for our patients. Everyone deserves to live their best life, unencumbered by ill health. At Sakra World Hospital, we give you the strength and confidence to live your life to the fullest.

References:

1. https://www.hopkinsmedicine.org/
2. https://www.ncbi.nlm.nih.gov/
3. https://www.nhs.uk/
4. https://orthoinfo.aaos.org/
5. https://journals.lww.com/
6. https://www.healthline.com/
7. https://en.wikipedia.org/
8. https://en.wikipedia.org/
9. https://www.sciencedirect.com/

Knowledge Is Power. Learn About Stroke to Fight It Now.

What is a Stroke?

Stroke is also known as “Brain Attack”. It is similar to a heart attack in nature. It has the potential to affect people of all age groups. The stroke happens when the blood supply directed toward the brain is cut off abruptly. Without blood, the brain cells are deprived of oxygen and other nutrients and hence the brain cell begins to die. The damaged caused by it is relational to the area of the brain it affects. Stroke affects people’s most basic functional aspects such as speech, mobility and their ability to think, feel or respond. Consequences of a stroke on a person depend on where it occurs in the brain and the amount of damage caused by it.

Is a Stroke treatable?

Though Stroke is a complex medical issue, there are effective ways to minimize its effects. Identifying early signs of stroke and seeking emergency medical care in the dedicated “stroke unit” minimizes the effects of it. 
Stroke can be treated effectively if one seeks emergency stroke treatment in the initial 3-4.5 hrs. Also, an early access to the best professional care can significantly improve results.

What are the warning signs of a Stroke?

Symptoms of a stroke are sudden and unexpected. Here are the warning signs of a stroke: 

1. Sudden, severe headache 
2. Sudden trouble seeing in one or both eyes
3. Sudden weakness of the face, arm or leg, particularly on one side of the body
4. Sudden trouble speaking or understanding
5. Sudden trouble in walking, coordination and a significant loss of balance or dizziness

 If you notice one or more of these signs, don’t worry or panic.
Call your emergency medical services and get to a hospital immediately. 

6 Key facts about Stroke Treatment

1.  You can make a positive difference by recognizing the signs of Stroke
Recognizing the signs of Stroke and getting the treatment on time saves lives and accounts for a speedy recovery. 
If you think someone may have had a stroke, check for these signs quickly:
1. Face – Is one side drooping? 
2. Arms – Raise both arms. Is one side weak?
3. Speech – Is the person able to speak? Are words jumbled or slurred?
4. Time – Act quickly. Seek emergency medical attention immediately.

2. When cared for in a specialized stroke unit, around 1 in 10 diagnosed people make fast recovery 
All the patients with stroke (ischaemic or haemorrhagic) should be admitted to a specialized stroke unit, which involves a designated ward with a specialized team. This team includes a Neurologist, Neurosurgeon, Neurointerventionist, Neuroradiologist and a Stroke rehabilitation specialist. 

3. Provide the patient with clot-busting drugs (tPA or thrombolysis) and enhance his or her chances of recovery by 30%
Clot-busting drugs break up blood clots. This treatment can be administered up to 4.5 hours of symptom onset in many patients with ischaemic stroke. The earlier it is given, the greater the effect.

4. Provide the patient with clot retrieval treatment and enhance his or her chances of recovery by 50%
Clot retrieval treatment (mechanical thrombectomy) involves removing a blood clot from the large arteries by Neurointerventionists in the cath lab. Clot retrieval can improve survival rates and reduce disability for many people with ischaemic stroke caused by large artery blockage.

5. The most critical step in the treatment process is rehabilitation 
Rehabilitation starts in the hospital by neurosurgeons as soon as possible post a stroke. It can improve the patient’s functionality and assist him or her in regaining maximum independence with time.

6. One in four survivors will have another stroke.
Stroke risk can be reduced by treating risk factors for stroke. Treatments that prevent another stroke include drugs to lower blood pressure and cholesterol, antiplatelet therapies, anticoagulation for atrial fibrillation, surgery or stenting for selected patients with severe carotid artery narrowing.

“Right  Stroke Care Makes a Difference”

Join the fight against stroke.

Stroke affects all of us. So let’s take an action, a drive awareness and push for a better access to stroke treatments.
Learn how to contribute in spreading awareness and access with regard to a stroke. 

Individuals

1. Be aware. Learn the signs of stroke and know to take immediate action.
2. Share this information with family and friends.

Learn How To Prevent A Stroke 

Here are six steps anyone can take to reduce the risk and danger of a stroke:

1. Know your personal risk factors: High blood pressure, diabetes, and high blood cholesterol.
2. Be physically active and exercise regularly.
3. Maintain a healthy diet-  High in fruits and vegetables and low in salt to keep the blood pressure low.
4. Limit alcohol consumption.
5. Avoid cigarette smoke. If you smoke, seek help to stop now.
6. Learn to recognize the warning signs of a stroke.

To know more visit our best neurologists in Bangalore at our hospital

Seven Year Old Undergoes Awake Brain Surgery

Bengaluru doctors claim it to be first-of-its-kind on a child

Seven-year-old Nitin (name changed), who complained of a persistent headache and frequent bouts of fits, was diagnosed with a brain tumor around vital blood vessels in the speech area. He required surgery immediately, without which he would lose the ability to talk.

Doctors at the Institute of Neurosciences, Sakra World Hospital, where he was admitted, realized that the patient’s speech and limb movements had to be monitored during resection of a tumor.

“This is a preferred technique for operations to remove lesions close to or involving functionally important regions of the brain,” institute director Satish Rudrappa told The Hindu.

A team of neurosurgeons, led by Dr. Rudrappa and neuro-anesthetists led by Sunil Kumar, who performed the awake craniotomy surgery, claimed it to be the first in the world on a patient so young.

“Awake craniotomy has been a great success in adults, but among children, a different set of challenges are involved like the ability of a seven-year-old to be able to cooperate during the five-hour procedure,” Dr. Rudrappa said.

Nitin was given regional skull block anesthesia and the craniotomy was performed using conscious sedation (sleeping and easily arousable). Once the brain and the tumor were reached, the boy was kept awake to speak, answer simple questions and identify simple objects using pictures, while the surgeons removed the tumor and preserved important blood vessels without coagulation, Dr. Rudrappa explained. At the end of the procedure, after a closure of the skull, the boy could talk normally without pain or discomfort. He was discharged within 48 hours and is on regular follow-up, he added.

The patient plays guitar during surgery

Meanwhile, 37-year-old musician Abhishek Prasad, who had musician’s dystonia (difficulty in moving left-hand fingers), a rare nervous disorder, underwent a brain circuit surgery at Bhagwan Mahaveer Jain Hospital recently.

During the surgery, the patient was fully awake and played the guitar, to give the doctors feedback to locate the exact location of the target to be lesioned. 

Media Coverage: 

1. http://www.thehindu.com/news/national/karnataka/seven-year-old-undergoes-awake-brain-surgery/article19319203.ece

2. http://www.newindianexpress.com/cities/bengaluru/2017/jul/25/7-yr-old-stays-awake-calm-while-doctors-operate-brain-1633032.html

3. http://bangaloremirror.indiatimes.com/bangalore/others/rare-surgery-that-gave-7-yr-old-his-speech-life/articleshow/59672730.cms

Pituitary Adenoma

A pituitary adenoma is a slow-growing and typically benign tumor arising from cells in the pituitary gland. Because they originate from cells in the pituitary gland, they often cause problems related to hormonal dysfunction. A large proportion of these tumors grow to a size where they cause symptoms because they compress surrounding structures. For these reasons, larger pituitary tumors (called macroadenomas) often present with headache, visual loss and pituitary gland dysfunction. Changes in energy level, sexual function and libido, and many other symptoms may be a result of a dysfunctional pituitary gland (called hypopituitarism).

Other types of tumors and cysts are also often seen in the pituitary area, and some require surgical management. These include craniopharyngiomas, Rathke’s cleft cysts, meningiomas, and other less common neoplasms and inflammatory processes.

Causes of pituitary adenomas
The specific cause of pituitary adenoma development is unknown, although they are likely to be caused in part by random mutations in cells of the pituitary gland. Congenital syndromes known to be associated with some pituitary adenomas make up only a minority of patients with these tumors.

Treatment for pituitary tumors involves various options, including removing the tumor, controlling its growth and managing your hormone levels with medications.

Signs and symptoms of pressure from a pituitary tumor may include:

• Headache

• Vision loss, particularly loss of peripheral vision

• Nausea and vomiting

• Symptoms of pituitary hormone deficiency

• Weakness

• Less frequent or no menstrual periods

• Body hair loss

• Sexual dysfunction

• Increased frequency and amount of urination

• Unintended weight loss or gain

Risk factors:

Although pituitary tumors can occur at any age, they're most likely to occur in older adults. People with a family history of certain hereditary conditions, such as multiple endocrine neoplasia, type I (MEN I), have an increased risk of pituitary tumors. In MEN I, multiple tumors occur in various glands of the endocrine system. Genetic testing is available for this disorder.

COMPLICATIONS

Vision loss, permanent hormone deficiency and diabetes insipidus.

A rare but potentially serious complication of a pituitary tumor is pituitary apoplexy, when sudden bleeding into the tumor occurs. Pituitary apoplexy requires emergency treatment, usually with corticosteroids and possibly surgery.

• Tests and diagnosis: Blood and urine tests to determine whether there is any over production or deficiency of hormones.

• Brain imaging: CT and MRI to judge the location and size of pituitary tumor.

• Vision testing: Such tests can determine if growth of a pituitary tumor has impaired your sight or peripheral vision.

Treatment involves a team of medical experts, possibly including a brain surgeon (neurosurgeon), endocrine system specialist (endocrinologist) and a nervous system specialist (neurologist). Doctors generally use surgery, radiation therapy and medications, either alone or in combination, to treat a pituitary tumor and return hormone production to normal levels.

• Surgery include: Endoscopic transnasal transsphenoidal and Transcranial approach (craniotomy).

• Radiation therapy include: External beam radiation and Gamma Knife stereotactic radiosurgery.

Craniosynostosis

Craniosynostosis is derived from the terms cranio, syn and ostosis that relates to the bone. It is a birth defect in which one or more of the joints between the bones on an infant's skull close prematurely, before the infant's brain is fully formed. Craniosynostosis transpire in one in 2000 births. An infant’s skull has seven bones. In general, these bones don’t fuse until the age of 2, giving enough time for the infant’s brain to develop. These bones are held together with a joint called cranial sutures, made of strong fibrous tissue.

Symptoms of Craniosynostosis

• Increase of pressure inside the skull such as intracranial pressure

• A distorted skull having the shape that depend upon which of the cranial sutures are affected

• Development of a hard or raised ridge near the affected sutures

• No or slow growth of the head as the baby grows

• Abnormal disappearing or feeling of a soft spot on the skull of the baby

Craniosynostosis can be categorized into many types. Some of the most commonly found types are:

Sagittal synostosis (scaphocephaly)
Premature fusion of the sew up at the top of the head forces the head to grow long and thin, rather than wide. Scaphocephaly is the most common type of craniosynostosis.

Coronal synostosis (anterior plagiocephaly)
The premature fusion of a coronal suture may force the infant’s forehead to flatten on the affected side. It can as well cause a deviated nose and slanted skull.

Bicoronal synostosis (brachycephaly)
In this stage, the baby may have a flat, elevated forehead and brow. This happens when both of the coronal sutures fuse prematurely.

Treatment of Craniosynostosis
The overall health and medical history of the child has to be taken into priority. The only treatment for craniosynostosis is an intervention of surgery. An open surgery is performed for reshaping the skull of the child. This is made at the top of the head by an incision. Followed by the affected suture is removed by a neurosurgeon, giving a more normal shape to the skull bones by a craniofacial plastic surgeon. Screws and plates are used for holding the new shape till the time bone heals. The screws and plates are made up of special material that absolutely dissolves in 1-2 years. Only one surgery is required if a baby has single suture craniosynostosis. More than one surgery is required if a child has craniosynostosis caused by craniofacial syndromes.

Back and Neck Pain a paradise of myths

For a vast majority of us, Back and Neck Pain is a fact of life. The timescale of it may vary, but it does visit each of us at some point of time in our lives. Fortunately, majority (90%) of them will resolve on their own in 2-3 weeks, during which symptomatic treatment and physiotherapy is the mainstay of treatment aimed at maintaining range of movement during the episode. Back and Neck pain is an epidemic of modern day society and not surprisingly, conflicting messages are bound to contribute in spoiling the broth. The scale of the problem in a diverse society, with multiple professional contributing in the care, is bound to feed confusing and conflicting messages. The aim of this article is to present commonly encountered myths among my patients of back and neck pain.

Myth 1

“I can’t get back/ neck pain, I am way too healthy for it”

As I said in the introduction, nearly 70- 80 % of us will suffer with it at some point in our lives, even if it is for short period lasting days / weeks. Having a balanced range of activities to strength all muscle groups is the key.  Even athletes / sportspersons are affected if the sport involves excessive strain on a certain muscle group or body part. Habitual body posture / activity predisposes for injury or pain.

Health tip: Prevention is better than cure. Practicing good technique for our daily activities like sitting, standing, walking, lifting contributes in keeping pain at bay.

Myth 2

“My back / Neck hurts, I need bed rest”

The current consensus for optimal course of action is to stay as active as is feasible. Any extended periods of rest beyond 2-3 days, sows the seeds for persistent chronic pain (greater than 3 months). It is reasonable to modify your activities, but avoid taking complete bed rest. Attempt to return to your daily routine activity.  The health and strength of posture supporting muscles around your spine are just as important as your spine bones. Scientific studies have demonstrated weakening of your back muscles after just 2 days of rest (disuse atrophy). So, it time to jump (I mean climb) out of bed and attempt to return to your daily routine as much as possible.

Tip: Minimise any rest period and attempt return to daily routine.

Myth 3

“I have to give up my favorite activity like sport, jogging, etc”

Your back pain may act as a dampener to your intentions to continue your desired activity. Your doctor / physiotherapist will guide you in an individually tailored exercise regime to assist returning to your favorite activity. A combination of flexibility exercise, core muscle exercises, and appropriate posture will assist you in returning to most or all of your favorite activities.

Tip: Adapt rather than sacrifice your favorite activity and sport.

Myth 4

“I need an xray or scan to find out the cause of my back and neck pain before starting treatment”

Majority of back and neck pain episodes get better on their own with symptomatic treatment and scan should not delay the onset of treatment. In most situations, further investigations are required when pain does not get better after 2-3 weeks. Your doctor is the best placed to assess the need for scan.

Tip: The professional’s assessment and advice should guide your treatment plan.

Myth 5

“My scan and x-ray will find the cause of my pain”

The sophisticated scan provide nice images of your back / neck that might show an abnormality. However, such changes are a common (30-40%) in over 40 year olds people routinely carrying non-painful spine changes. However, your doctor is best placed to guide you in correlating your pain pattern with your scans. It is fairly common to not identify a specific cause on your scans for your pain. After all, the body does not live all day lying flat like in the tunnel of the MRI scanner. The constant weight bearing, strain of posture and movement are something that can’t be replicated in any scanner.

Tip: Your tests will guide and supplement the professional’s meticulous assessment, but can’t replace it.

Myth 6

“I have back / neck pain, and I need surgery”

The indications for surgery for back and neck pain are very few, and only a small proportion of people need it. You would need to be assessed in detail before considering surgery, usually to relieve pressure on nerves (not irritation of nerves). There are many simple treatment options including minimally invasive procedures that may be suitable before considering surgery as a treatment option.

Myth 7

“I have always been overweight, how can this be the cause of my back pain”

The skeleton supported by its ligaments and muscles carries all your weight. Any weight you carry squeezes the disc in your spine and hence does correlate with pain. Moreover, a large belly tilts your pelvis forwards making an abnormal curve in your spine. This can contribute in causing your pain. Any exercise you undertake in reducing your weight has an added benefit of promoting production of endorphins (body’s own painkillers).

Tip: Reducing weight and maintain it have multiple ancillary benefits like sense of wellbeing, self-confidence, improved muscle endurance and activity tolerance.

Myth 8

“Back and Neck pain is a very disabling condition”

Excessive fear and unwarranted misinformation will harm your chances in helping yourself. Staying motivated, leading a healthy lifestyle, maintaining active lifestyle and social engagements. People who return to normal routine activities without excessive rest or overdoing exercises will fair better in the long run.

Tip: How you adapt and accommodate to your medical condition determines the severity of disability.

Myth 9

“All the heavy lifting, I have been doing and continue to do is bad for my back and neck”

Lifting with knees rather than your back is the key message in lifting hygiene. It is more about how you lift, than how much you lift. Of course, excessive weight, does mean more chances of back and neck pain. Having the right help, aids and lifting technique will keep you in good health.

Tip: Often poor lifting hygiene rather than lifting weight is the culprit.

Myth 10

“No doctor can find the cause for my pain, it is all in my head”

Pain is real and pain is what you say it is, irrespective of what the tests and doctors say. You need assessment by a qualified professional (like pain physician, rheumatologist, neurosurgeon, orthopedician). Pain experience has many dimensions inclusive of an emotional component that drains a lot of energy and motivation. You need help with a meticulous assessment and guidance from an experienced professionals to guide you in your fight against pain.

Summary: Back and neck pain are inevitable short term visitors in our lives (self or relatives). For the unfortunate few left with chronic pain, a plethora of misinformation contributes to the suffering and experience of pain. A plethora of myths accumulated along the way do more harm than good for this long term condition. High quality evidence based treatments are now available, many without the need for surgery. Getting the right qualified help and advice in your fight against persistent back and neck pain is the best thing you can do for yourself.

Health Warning at your desk to work can be injurious to health.

Can we imagine a life without computers? Electronic s and computers have percolated into our life at an alarming pace and magnitude. This has occurred at a scale to make me wonder if typing skills in my children are at par, if not more significant than handwriting skills. Needless to say many of us spend hours in form of a computer at work and top it up with a few more hours in front of Mr. Computer at home. As a pain physician involved in helping desperate patients with persistent pain, I see an epidemic of occupational hazards.

“@your Desk to work can be injurious to health” is not a tagline I would associate with undertaking a routine relaxing job on a posh comfy expensive chair. The sound of it resonates with health hazards of smoking. The sheer volume of time spend in front of Mr. Computer in its many forms , small and big, is making a generation regress back to the dark ages …really?

Musculoskeletal disorders due to sustained unhygienic postures is creating epidemic of health problems centered mostly around the neck, shoulders, arms and upper back. You could argue, I don’t think our ancestors with similar postures suffered with health problems. Well…… probably not since they were not ashamed and frequently to ambulate on all fours (limbs).

We have to take charge and modify our workplace, accommodate our schedules to reduce the impact of our activities on our health. I draw inspiration from the “Microsoft Healthy computing Guide” to suggest modifications in our work / leisure related Mr. Computer activities to ensure we continue to benefit with the marvels of the rapidly developing / evolving world we live in. We should aspire to be comfortable and productive with Mr. Computer.

This guide is designed for anybody spending more than 2 hours with Mr. Computer. This is relevant and probably equally important even if you are fortunate enough to have had no aches and pain in top half of your body. The commonly issues are occasional discomfort in hands, arms, shoulders, neck, upper back and even headaches. Any persistent aches, tingling numbness, burning / shooting pains in your arms / fingers warrant an assessment by a qualified doctor. The suggestions / advice below are generic and applicable across a wide spectrum of people. However, I recommend an individual detailed assessment, if you continue to experience ongoing discomfort. If you have access to an occupational therapist / physician professional guidance to arrange tour workstation will be beneficial.

Tip 1: Position Yourself

Avoid sustained postures for extended periods of time with any activity to avoid discomfort, fatigue and pain. Workstation redesign is essential to avoid unhygienic and awkward sustained postures. The workstation should promote and maintain a comfortable relaxed posture.

To support your back, try the following:

• Use a chair that supports your lower back preventing arching with convexity pointing behind you. (See detail 1).

• Adjust your work surface and chair height to assume a comfortable and natural body posture (see detail 2).

To promote comfortable leg postures, try the following:

• Clear away items from beneath your desk to allow comfortable leg positioning and movement.

• The height of seating should ensure a rested foot on the floor and horizontal thighs on the seat.

Tip 2 - For a comfortable shoulder and arm postures:

• Place your keyboard and mouse or trackball at about elbow level. Your upper arms should fall relaxed at your sides (see detail 3).

• Centre your keyboard in front of you located close to it (see detail 4).

• Place frequently used items comfortably within arm's reach (see detail 5).

Tip 3 - For comfortable wrist and finger postures:

• Keep your wrists straight while typing or mouse navigation. Avoid bending your wrists up, down or to the sides.

Tip 4 - For Comfortable neck posture:

• The top of the screen should be positioned at your eye level. If using bifocal glasses, it may be useful to lower the screen.

• Centre your monitor or document holder in front of you depending on what you refer to most often.

• Consider using a document holder to position your documents near eye level.

Tip 5 - To reduce eye strain:

• Position your monitor an arm's length away from you when seated comfortably in front of it.

• Place monitor away from sources of glare.

• Maintain a clean screen and glasses if you wear some.

• Optimize the monitor's brightness and contrast, along with a good font size.

Tip 6 – Avoid repetitive strain injuries – Be gentle to yourself

• Repeated monotonous work maneuvers, or sustained pressure / impact on body parts can result in body injuries. Common examples include pressing the keys while typing, clicking the mouse buttons, holding your mouse or cradling the phone and resting your wrists on the edge of your desk. You can dampen the effect of these.

• Be gentle to yourself - Type with relaxed hands and fingers ensuring a light touch that is sufficient to activate the keyboard keys, clicking a mouse button, when using a joystick or other gaming controller.

• Try maintaining a floating wrist and hands (see detail 7). The palm rest, if provided, should only be used during breaks from typing.

• Relax your arms and hands when you are not typing or using your mouse. Avoid resting hands on furniture edges.

• Adjust your chair so the seat does not press into the back of your knees (see detail 8).

Tip 7 - Take Breaks

• In a supercharged workplace taking breaks may not be feasible. You can certainly take a break from repetitive task and resort to change in activity. Take a walk out supervising juniors. Stretch yourself during a telephonic conversation. These breaks can be tailored to you and your work place.

Tip 8 – Balance between work and play to limit strain on same body part:

• Organize your diary to have a good admixture of activities that do not strain the same body part for extended periods of time.

• Utilize the different Mr. Computer input devices to accomplish the same task. E.g. scrolling with move wheel versus arrow keys.

• Understand feature in Mr. Computer to work efficiently. E.g. Ctrl C instead of mouse right click copy.

• Eat a balanced diet and get adequate rest.

• Regular exercise for overall fitness and to improve the strength and flexibility of your body.

• Manage stress of and home by good scheduling and time management.

Tip 9 – A healthy body and mind

• A healthy peaceful mind ensures productivity and higher tolerance for repetitive tasks. A tensed, stressed mind tightens / strains the muscles in your upper back and neck limiting the tolerance of MR. Computer related activities.

Maintain good health by:

• Eat a balanced diet and get adequate rest.

• Regular exercise for overall fitness and to improve the strength and flexibility of your body.

• Manage stress of and home by good scheduling and time management.

To conclude:

I wish you a healthy, productive, efficient, happy relationship with Mr, Computer who is likely to encroach into all domains of our lives. We wish you a happy computing experience, and don’t forget to look after yourself.

If you are concerned about any aspect of your health at work or home, please speak to a qualified professional. He may be able to guide to with possible contributing factors along with customized solutions for your problems. You can access further resources to help yourself from the “Healthy Computing Guide” on the Microsoft website.