50 patients with III/IV degree hemorrhoids and grade II hemorrhoid not responding to conservative treatment were randomized to LA (5 grade II, 15 grade III and 5 grade IV) and SA (7 grade II, 14 grade III and 4 grade IV). Assessment was carried out afterwards in terms of pain scores (using Numerical Rating Scale, NRS at 30 mins, 90 mins, 6 h and 24 h) and post operative analgesia. Secondary outcomes were complications like urinary retention, post operative headache and surgical complications, and overall stay. Median pain scores were comparable in both the treatment groups during the whole study period except at 6 h where significantly higher (p < 0.05) pain scores were noted in spinal anesthesia group. Complications were much higher in Spinal anesthesia [Hypotension (4patients); post operative headache (6patients); urinary retention (9patients)]. Mean time at first bladder evacuation was significantly higher in patients operated under spinal anesthesia [8 h (SA) Vs 1.5 h (LA)]. Average hospital stay was significantly longer in patients operated under spinal anesthesia (p value < 0.001). Local anesthesia is an alternative mode of anesthesia that surgeon can safely carry out by their own. In our study hemorrhoidectomy under local anesthesia was associated with a shorter hospital stay, lower pain scores and lower post operative complications which supports the routine use of local anesthesia for hemorrhoidectomy.

Background:Epidural application of morphine has been used for postoperative analgesia following spine surgery but short duration of action of single application limits its widespread use.Materials and Methods:One hundred and fifty patients undergoing lumbar laminectomy were randomly allocated to two groups of 75 patients each. Anesthetic technique was standardized in both the groups. In Group I, at the completion of laminectomy, a 5 × 1-cm strip of gelfoam soaked in 5 mg morphine (1 mg/ml) was contoured to be placed in the epidural space whereas, in group II, gelfoam soaked in saline was placed in the epidural space and 5 mg morphine (1mg/ml) was instilled over the intact epidural space. Analgesic consumption for 48 hours, time-of first analgesic request, time of ambulation, time of discharge from post anesthesia care unit (PACU) and hospital and adverse effects were recorded. The data was analyzed using appropriate statistical tests.Results:Mean analgesic consumption in 48 hours was significantly less in group I (8.47 ± 3.674 mg) as compared to group II (24.80 ± 6.009 mg). Supplemental analgesia was requested at 30.03 ± 6.796 hours in Group I, vs 10.25 ± 2.243 in group II (P < 0.001). Group I patients were discharged earlier from PACU as compared to group II (P < 0.001) though time of discharge from hospital was similar in both the groups. There were no major adverse effects except pruritis, which was observed in 30.6% patients in group I and 37.3% in group II (statistically insignificant (P > 0.01)).Conclusion:Epidural application of morphine soaked in gelfoam is an effective method for prolonging the postoperative analgesia after spine surgery.

Introduction:Decompressive craniectomy as a surgical treatment for brain edema has been performed for many years and for several different pathophysiologies, including malignant middle cerebral artery (MCA) infarct. The purpose of this article was to share author's experience with decompressive craniectomy in malignant MCA infarct with special emphasis on patients older than 60 years and those operated outside 48 h after onset of stroke.Materials and Methods:Totally, 53 patients who underwent decompressive craniectomy after malignant MCA infarction between January 2012 and May 2014 at tertiary care hospital were analyzed for preoperative clinical condition, timing of surgery, cause of infarction, and location and extension of infarction. The outcome was assessed in terms of mortality and scores like modified Rankin scale (mRS).Results:Totally, 53 patients aged between 22 and 80 years (mean age was 54.92 ± 11.8 years) were analyzed in this study. Approximately, 60% patients were older than 60 years. Approximately, 74% patients operated within 48 h (25 patients) had mRS 0–3 at discharge while 56% patients operated after 48 h had mRS 0–3 at discharge which is not significant statistically. 78% patients aged below 60 years had mRS 0–3 at discharge while only 38% patients aged above 60 years had mRS 0–3 at discharge which was statistically significant (P < 0.008).Conclusion:Decompressive craniectomy has reduced morbidity and mortality especially in people aged below 60 years and those operated within 48 h of malignant MCA stroke though those operated outside 48 h of stroke also fare well neurologically, there is no reason these patients should be denied surgery.

Cerebral venous sinus thrombosis is a rare type of stroke primarily affecting young women. Diagnosis is generally delayed or overlooked due to a wide spectrum of clinical symptoms. Subdural hematoma secondary to cerebral venous sinus thrombosis is very rare. We report a case of 40-year-old female with cerebral venous sinus thrombosis who presented to us with an acute subdural hematoma and subarachnoid hemorrhage besides venous infarct. Management of such patients is complicated due to the rarity of the condition and contraindication for the use of anticoagulation. We conducted a thorough literature search through PubMed and could find only nine cases of spontaneous subdural hematoma secondary to cerebral venous sinus thrombosis.

a b s t r a c tProblems considered: Phenytoin is the drug of choice for post operative seizures while some studies have shown lack of efficacy of phenytoin in reducing seizure frequency after craniotomy, which in turn may be due to fall in plasma phenytoin levels after craniotomy. Aims: The aim of the study is to describe changes, if any, in plasma phenytoin levels after craniotomy and its relation to intra operative blood loss. Methods: This was a prospective study in which total of 50 consecutive patients were enrolled after taking written informed consent, who were either on oral phenytoin for at least 7 days or had received intravenous loading dose prior to craniotomy. All patients had serum phenytoin levels monitored 24 h pre operatively, immediately pre craniotomy before skin incision and post craniotomy after skin closure, and 24 h after craniotomy. All patients had intra operative blood loss calculated with help of modification of Gross formula. Results: There was a mean fall of 23.6% in serum phenytoin level immediately following craniotomy which was statistically significant. Furthermore, analysis indicated that greater the operative duration and blood loss, greater was the fall in serum phenytoin level. Conclusions: The study concludes that routine measurement of perioperative serum phenytoin levels in high risk patients may be of benefit in preventing post craniotomy seizures and an additional bolus dose should be given towards the end of surgery to patients with significant intra operative blood loss. ScienceDirect journal homepage: www.elsevier.com/locate/ijnt t h e i n d i a n j o u r n a l o f n e u r o t r a u m a 1 1 ( 2 0 1 4 ) 1 0 9 e1 1 2 http://dx.

We report an extremely rare case of spontaneous complete disappearance of a large chronic subdural hematoma in a 78-year aged man with a significant mass effect and a large midline shift which was diagnosed around 6 weeks before admission. Repeat NCCT of the head in our department to everyone's surprise revealed almost complete spontaneous resolution. Spontaneous resolution of a large chronic subdural hematoma is extremely rare, and the scarce literature whatsoever is available is especially in cases of immune thrombocytopenic purpura where steroids may play a role in the stabilization of neomembranes. Our interest is in this case because of the benign clinical course despite a large size causing severe mass effect and large midline shift. Chronic subdural hematoma is a common entity in the elderly generally seen weeks following minor trauma. Surgical evacuation of a chronic subdural hematoma remains the gold standard treatment, but controversy exists regarding the best surgical option. Spontaneous resolution of a chronic subdural hematoma has also been reported rarely, but mainly in patients with immune thrombocytopenic purpura.

Lymphangiomas are benign congenital masses which occur most commonly in head and neck of children and incidence of mesenteric lymphangiomas is very rare. We report such a case of huge mesenteric lymphangioma in a 20 year old male who presented to us with acute abdomen. Pre-operative diagnosis is difficult due to silent clinical course and lack of awareness of the clinical and morphological features of this disease.

Background and Aims: To overcome the procedure-related complications associated with landmark-guided percutaneous dilatational tracheostomy (PDT) ultrasound is emerging as a promising tool. Present study was designed to compare landmark-guided PDT and ultrasound-guided PDT in terms of efficiency, efficacy, and accuracy. Material and Methods: Hundred intensive care unit patients requiring prolonged mechanical ventilation were prospectively randomized into 2 groups of 50 patients each. In land mark guided (LMG) group, patients underwent landmark-guided PDT, whereas in ultrasound guided (USG) group, patients underwent ultrasound-guided PDT. Results: Both the groups were comparable in terms of demographic data, sequential organ failure assessment score, ventilator settings, and mean days on mechanical ventilation prior to PDT. The mean assessment time in the ultrasound-guided group (1.56 ± 1 min) was significantly more (P-value = 0.000) than in the landmark-guided group (0.84 ± 0.72 min). The mean total procedure time for the USG group (5.98 ± 10.23 min) was more than that for the LMG group (4.86 ± 8.03 min) (P-value 0.542). Deviation of puncture site from the midline was seen in two patients in group A as compared to none in the USG group (P-value = 0.153). The number of patients requiring more than one attempt for successful needle insertion was more (P-value = 0.148) in the LMG group (20%) as compared to USG group (8%). Incidence of complications, like bleeding and desaturation was more in the LMG group as compared to the USG group. Conclusion: Ultrasound-guided PDT is associated with reduction in periprocedural complications as compared to landmark technique, although it takes slightly longer time.