Health Quotient ( HQ )

I wish to coin a new term "Health Quotient."  It will denote the relative well being and health of a person as compared to the health of a normal person of that particular age. As IQ is of relevance in younger age group , this term HQ will be of particular value in people of older age groups.
Assessment of health quotient includes intelligence, memory, locomotor strength & physical well being, any co-mobidity or disability, activity of daily living, physical and emotional independence, interest & motivation. For example a 40 year person is expected to have normal locomotor activity, normal hearing and a good respiratory function but a diseased person may have poor cardiac and respiratory reserve due to chronic smoking, alcoholism, sedentary life style. So, the health quotient may a good marker of socio-economic productivity of a person.
This quotient is of immense value in present time because of increased life expectancy and better health of people even after the retirement age. The age old norms of retirement age are becoming irrelevant because people are healthy and eager to continue wor even after fficial retirement age. In some professions, in fact, people gain maturity and wisdom with time. Many physicians, entrepreneuers, politicians, businessmen are well respected and active when they surpass the age of retirement.
So, there should be an objective criteria to evaluate the health quotient of a person and he or she should be asked to continue active contribution to the society.

Brain App

The human brain is truly astonishing structure and is probably most complex thing in the universe. Our brain constitutes 2 percent of our body weight, but inside the brain are approximately 86 billion neurons, surrounded by 180,000 kilometers of insulated fires connected at 100 trillion synapses. It is like vast supercomputer. The neurons communicate using electrical signals. Brain is an amazing structure which creates interest in people of all age groups. It is very interesting that a tiny brain of small animals can perform almost all activities necessary to sustain life. Human brain is about 1200 grams to 1500 grams in weight. But if there is damage to the brain in neurotrauma or in stroke or birth anoxia, even a large part of the remaining brain is unable to help a person to perform all activities.
So, in small creatures like ants a tiny brain is self sufficient but in an adult person with about 1 Kilogram of injured brain becomes severely impaired. Therefore, a large brain of a patient of brain disease cannot perform all functions.
It may be possible that brain of an ant may be like a brain app which may be having a limited but complete set of basic applications necessary for a normal person. It may be possible that a new born ant may be born with this app but a newborn infant of human beings may not be able to take care of themselves due to lack of this app in the brain of human beings.
Speculations of a brain app needs to be explored.
A further research in this area may help a lot of newborns with cerebral palsy or birth anoxia. As these children have almost normal sized brain but are unable to perform even normal daily life activities independently.
Although human brain has infinite potential but takes lot of time to become mature but is also vulnerable to injuries during the process of development. Neuronal Plasticity allows other parts of brain to takeover the function of the injured part, but there is need to identify an app in the brain which may be very small , transplantable or amenable to modifications.
Although, a lot of research has been done in other fields but the clinical applications of such research will benefit millions of patients suffering from stroke, cerebral palsy, birth anoxia, Alzheimer's disease and other neurodegenerative disorders.
Technological advancements in artificial intelligenc, robotics, bionics, etc, may be replicated in neurosciences to find solutions to brain deficits. 

Chondrosarcoma of spine

Chondrosarcomas are malignant cartilage forming tumors. Chondrosarcoma is the second most common primary tumor of the spine after multiple myeloma.  

Chondrosarcoma may be classified as primary ( arising de novo) or secondary ( arising from a pre-existing osteochondroma or enchondroma).

Although chondrosarcoma is second most common primary malignat tumor of the bone but chondrosarcoma of spine is uncommon. It rarely grows inside the spinal canal [ Arockiaraj et al, 2012].

Chondrosarcomas arising from the vertebral axis usually present as slowly growing mass with an insidious onset, associated with pain and local tenderness, usually associated with neurological deficits at the time of presentation.

Chondrosarcomas usually appear as osteolytic lesions with endosteal scalloping and cartilaginous matrix calcifications. Punctate , pop-corn like calcifications , arcs and ring types have been described for matrix mineralization which is pathognomonic for chondrosarcoma.

Chondrosarcomas of the spine usually belong to the mesenchymal or clear cell histological types.

The ideal treatment consists of total “en-bloc” resection, not always achievable due to limitation of location, compromise of stability and risk of inducing neurological deficits.

References:

Justin Arockiaraj, Krishnan Venkatesh, Rohit Amritanand, Gabriel David Sundararaj, Gurusamy Nachimuthu.  Chondrosarcoma of the Spinous Process: A Rare Presentation. Asian Spine Journal Vol. 6, No. 4, pp 279~283, 2 012

C. Ruivo, Hopper. Spinal chondrosarcoma arising from a solitary lumbar osteochondroma, JBR–BTR, 2014, 97: 21-24.

 

Daniel Monte-Serrat Prevedello, Joacir Graciolli Cordeiro, Andrei Koerbel, Léo Fernando da Silva Ditzel, João Cândido Araújo. Management of primary spinal Chondrosarcoma.Report of two cases causing cord compression . Arq Neuropsiquiatr 2004;62(3-B):875-878

 

Ratliff J, Voorhies R. Osteochondroma of the C5 lamina with cord compression: case report and review of the literature. Spine (Phila Pa 1976). 2000 May 15;25(10):1293-5.

 

Nick Vertzyas, John Cummine, Sandra Biankin and Michael Bilows. Chondrosarcoma of the thoracic spine in an 8-year-old child with 12 years follow-up: A case report. Journal of Orthopaedic Surgery 2000, 8(1): 89–92.

Osteoblastoma of Spine

In 1935 Jaffe described a new bone lesion , which he named osteoid osteoma.  In 1956, Jaffe and Lichenstein independently proposed the term “ benign osteoblastoma”. Osteoid osteoma and osteoblastoma are bone producing lesions that are frequently localized in long bones and posterior elements of the vertebra^1-5.

Primary osseous tumors of the spine are uncommon  lesions that are much less frequently encountered than metastases, multiple myeloma, and lymphoma⁴. Osteoid osteoma (OO) and osteoblastoma ( OB) are rare primary bone tumors that usually do not arise in the spine⁴.

Benign osteoblastoma is a very rare lesion presenting 1 percent of all primary bone tumors. Osteoblastoma is histologically similar to osteoid osteoma, but Osteoblastoma  occurs in slightly older patients, has a greater propensity for the spine and more aggressive , often eroding through spinal cortical bone and creating large soft tissue masses. Some distinguish the two based on size with lesions less than 1.5 cm classified as Osteoid Osteoma , and those larger than 1.5 cm are considered Osteoblastoma^6,7. Moreover, Osteoblastoma  of the spine may have soft tissue masses, which initially may encroach on the spinal canal and later may surround the dural sac or adjacent nerve roots or both⁴. Osteoblastomas  occur predominantly in patients younger than 20 years of age. Clinically, the pain of Osteoblastoma is not as severe at night, nor is it relieved by aspirin or NSAIDs , as is the pain of Osteoid Osteoma. Unlike osteoid osteoma no spontaneous regression has been reported with osteoblastoma⁸.

When these lesions occur in the spine,  common manifestations are pain, scoliosis and neurological involvement^4,9.  The primary histologic difference between Osteoid Osteoma & Osteoblastoma is the tendency of OB to form a less sclerotic but more expansile mass. The nidus characteristic of OO is not found in OB. Also, large vascular spaces seen in OB are rare in OO⁴.

On histological examination osteoid osteoma consists of small yellowish to red nidus of the osteoid and woven bonewith interconnected trabeculae, and a background and rim of highly vascularised fibrous connective tissue. Varying degrees of sclerotic bone reaction may surround the lesion⁴.

Benign osteoblastoma is virtually indistinguishable from osteoid osteoma. The usual appearance included a fibrovascular stroma with numerous osteoblasts, osteoid tissue, well formed woven bone, and giant cells.⁴. Osteoblastomas have an abundantly vascularised stroma containing a great number of very active osteoblasts ( creating osteoid and primitive osseous trabeculae with somewhat more regular orientation). Osteoblasts are usually larger with atypical nuclei and more frequent and somewhat pathological mitoses. Mineralization of bone trabeculae is uneven and irregular, osteoblasts are numerous especially around the zones of hemorrhage⁵.

In a histological aggressive osteoblastoma bone trabeculae are broad and irregular. The deposited osteoid is usually stacked in layers ( lamelated) but not trabeculated. Swollen, enlarged osteoblasts coating trabeculae or osteoid are a typical feature. The stroma is fibrous, made of spindle cells, with an increased cellularity and focus whirling cellular agglomerations⁵.

Patients of osteoblastoma usually present with back pain. Patients may also present with progressive focal or radicular pain exacerbated by movement. The other common symptom is stiffness. The  time from onset of symptoms to diagnosis is typically several months because it is rare entity and radiographic studies are often negative early in the course of the disease⁶. Many patients will progress to manifest neurological sequelae or a painful scoliosis⁶.

 The plain x-ray, CT scan and MRI aid in the diagnosis. Radigraphically the tumor is often radiolucent. On x-rays osteoid osteomas are usually about 2 cm size with a sclerotic rim and osteoblastomas are usually  larger in size. Both osteoid osteoma and osteoblastomas are more common in posterior elements occurring predominantly in the pedicles, transverse processes, lamina and spinous processes. Osteoblastomas may have soft tissue masses, which initially may  encroach on the spinal canal and later may surround the dural sac or adjacent nerve roots, or both⁴. Extent of the osseous involvement is assessed by x-ray and CT scan of the spine. MRI reveals the nidus,  intra- and extraosseous reactive changes and the possible infiltration of adjeacent soft tissues. MRI is the best to show the effects of the tumor on the spinal canal and cord⁴.

Technitium bone scanning may accurately localize the lesion as it demonstrates an intense focal accumulation of the bone seeking agent. The site of the tumor appears as a typical “ hot spot” on a technetium bone scan.But, if lesion is already discernible on x-ray films, the scintigram is unnecessary⁴.

Surgery is the most common treatment for this disease, and prognosis after total resction is favourable.The recommended treatment is excision. Most OB are multilobular with extension into the  paraspinal mass may not allow en bloc resections. Recurrence is the result of incomplete resection . these lesions hardly ever undergo malignat transformation into osteosarcoma and metastasize. Differentiation between these tumor and fibrous dysplasia , osteosarcoma, giant cell bone tumor, or aneurismal bone cyst is necessary which usually have different radiology and histology⁴.

Lesions may be  well-circumscribed margins confined within the vertebral structure (Enneking Stage 2), or ill-defined margins with soft-tissue extension (Enneking Stage 3). The staging system for benign musculoskeletal tumors based on radiographic characteristics consists of three categories: ie, latent, active, and aggressive. Latent means lesions with well demarcated borders, active lesions have indistinct borders and aggressive lesions reveal indistinct borders on radiography. Well-defined lesions are treated with curettage, with excellent results. The more extensive lesions are treated by intralesional excision and adjuvant radiation therapy^10,11.  

So, the well-defined lesions are excised or removed completely with curettage. The more extensive lesions were treated by intralesional excision and adjuvant radiation therapy⁹.

There are few data about the effectiveness of chemotherapy or radiotherapy in the treatment of recurrent osteoblastoma. Surgery remains the treatment of choice for osteoblastoma. Radiotherapy and chemotherapy either alone or together may be useful in selected patients with recurrent, aggressive tumor or in patients with surgically unresectable disease¹².

Resection of the tumor may be done either through the anterior approach or posterior approach depending upon the location of the tumor in the vertebra. Surgical approaches, bone grafting , implants and spinal fixation may also vary depending upon the site of the lesion in vertebral column.

So, to achieve the safe resection many studies have been published in English literature, highlighting the modern technologies and multimodality approaches. Samsadi et al proposed the preoperative angiography to confirm hypervascularity of the lesion and consequent embolization and resection⁶.

The resection of the abnormal pedicle, transverse process, pedicle and facet joint may lead to instability of the spine and requires spinal stabilization with instrumentation.Video assisted thoracoscopic surgery (VATS)  and  Video assisted thoracoscopic surgery guided by a navigation system ( VATS-NAV) allows accurate localization and guidance for complete excision of a spinal osteoid osteoma through a minimally invasive approach without compromising spinal stability¹³.

An underlying osteoid osteoma and osteoblastoma must be suspected in all young patients presenting with pain, painful scoliosis and stiffness. Early diagnosis is possible with x-ray, CT scan, MRI and technetium bone scan. Early diagnosis and treatments prevents scoliosis & permits complete resection without jeopardizing the stability of the spine¹⁴.

 

References

1. Jaffe HL, Mayer L. An osteoblastic osteoid tissue-forming tumor of a metacarpal bone. Arch Surg. 1932;24:550–564.
2. Jaffe HL. Benign osteoblastoma. Bull Hosp Joint Dis. 1956;17:141–151
3. Lichtenstein L. Benign osteoblastoma : a category of osteoid- and bone-forming tumors other than classical osteoid osteoma, which may be mistaken for giant-cell tumor or osteogenic sarcoma. Cancer. 1956;9:1044–1052.
4. Zileli M, ÇAGL S, BASDEMIR G, ERSAHIN Y . Neurosurg Focus 15 (5):Article 5, 2003,1-6.
5. Poleksi Z. R., Lalosevic V. J., Milinkovi Z. B. Osteoblastoma of spine ACI Vol. LVII , 63-68.  

6. Samsadani A, Torre-Healy A, Chou D, Cahill AM, Storm P B. Treatment of osteoblastoma at C7: a multidisciplinary approach. A case report and review of literature. Eur Spine J ( 2009) 18 ( Suppl 2): S196-S200.
7. Mc Cleod RA , Dahlin DC, Beabout JW (1976) The spectrum of osteoblastoma . AJR Am J Roentgenol 126;321-325
8. Peivandi M T, Ameri E, Ganjavian S, Behtash H, Mobini B. Osteoblastoma of the spine. MJIRC, Vol.8, No.1, May 2005,52-56.
9. Boriani S, Capanna R, Donati D, Levine A, Picci P, Savini R. Osteoblastoma of the spine. Clin Orthop Relat Res. 1992 May;(278):37-45.
10. Javad M U, Scully S P. Enneking classification: Benign and manalignat tumors of the musculoskeletalsystem. Clin Orthop Relat Res (2010), 468: 2000-2002
11. Enneking WF, Spanier SS, Goodman MA. A system for the surgical staging of musculoskeletal sarcoma.1980. Clin Orthop Relat Res. 2003;415; 4-18
12. Berberoglu S, Oguz A, Aribal E, Ataoglu O. Osteoblastoma response to radiotherapy and chemotherapy. Med Pediatr Oncol. 1997 Apr;28(4):305-9.
13. Alessandro Gasbarrini , Stefano boriani, Case report: curetting OO of the spine using combined video-assisted thoracoscopic surgery and navigation . Clinical Orthopedics and related research, Feb 2013, vol 471, issue2, 680-685.
14. Kirwan E.O’G, Hutton P A N, Pozo J L, Ransford A O, Osteoid osteoma and benign osteoblastoma of the spine. Clinical presentation and treatment. The Journal of Bone and Joint Surgery, Vol.66-B, No.1, January 1984, 21-26.

Management of Pineal Region Tumors

The pineal gland develops during the second month of gestation as a diverticulum in the diencephalic roof of the third ventricle. It is flanked by the posterior and habenular commissures in the rostral portion of the midbrain directly below the splenium of the corpus callosum.  

Pineal tumors constitute 3-8% of pediatric brain tumor & 1% of brain tumors in adults.Germinoma is the most common tumor of Pineal tumor ( about 20 to 40%), followed by astrocytoma, teratoma and Pinealoblastoma.

Germ cell tumors, Ependymoma and Pineal cell tumors metastasize easily through the CSF ( “drop metastasis”).

Pineal region is situated at the posterior aspect of 3rd ventricle. Pineal stalk comprises of Posterior commissure and Habenular commissure. Many structures are situated in this region. Tectum of the mid brain and quadrigeminal plate ( superior and inferior colliculi) are situated beneath the Pineal gland. Splenium of the corpus callosum is situated above this gland. The CSF space around Pineal gland is known as Quadrigeminal Cistern.
Pineal region tumors are derived from cells located in and around the pineal gland. 

So, many types of lesions may be seen in the Pineal region:

1.Tumors arising from the Pineal Gland are tumors of neuroepithelial tissue & classified as Pineal Parenchymal Tumors (According to the revised WHO-2007 classification of CNS tumors: i. Pineocytoma, ii. Pineoblastoma, iii. Pineal parenchymal tumor of intermediate differentiation, iv. Papillary tumor of the Pineal region)
                   

                       Pineocytoma ( or Pinealcytoma) is well differentiated, arises from pineal                                                             epithelium.WHO Grade I, intense homogeous enhancement

                       Pinealoblastoma ( or Pinealblastoma) is malignant, WHO Grade IV,is a form of                                                   primitive neuroectodermal tumor (PNET), most often affects children, has                                             predilection for CSF dissemination, Lobulated, heterogenous enhancement
                        Both are radiosensitive 

2.Tumor from rests of germ cells: Germ Cell Tumors: Germinomas, Embryonal carcinoma, Endodermal sinustumor (Yolk sac tumor), Choriocarcinoma, Teratoma
                      Germinomas: Malignant
                      Non-germinomatous germ cell tumors (NGGCT); Embryonal carcinoma,                                                         choricarcinoma, & endodermal sinus tumor( also known as yolk sac carcinoma)                                    are usually malignat except Teratoma ( mature & immature)

3.Tumors from the glial cells ( Glial cyst or Pineal cyst, tectal Plate glioma which are usually pilocytic astrocytomas)

     Pineal Cyst
              Usually an incidental finding (ie,seen on about 4% of MRI of the patients who are not                                                                                       symptomatic due to lesion in the Pineal region)
              Commonly intra-pineal glial-lined cysts of less than 1 cm diameter.
              Etiology is not clear,  but considered as nonneoplastc and benign, and may be due to                                         ischemic glial degeneration or due to sequestration of the pineal diverticulum.
               It may contain clear or xanthrochromic or hemorrhagic fluid. Rarely it may enlarge &                                     become symptomatic as other Pineal masses. So, if size is less than 2cm, follow with                           annual imaging. If large & symptomatic: surgery( shunt, ETV,  cyst excision,                                       stereotactic or endoscopic aspiration)

4.Tumors from the Ependymal lining; Ependymoma

5. Tumors/lesions from arachnoid cells: Meningiomas, Arachnoid cysts

6. Tumors from sympathetic nerves: Chemodectomas

7. Tumors from remnant of ectoderm: Epidermoid, Dermoid

8. Tumors originating from elsewhere in the body: Metastasis (Absense of Blood Brain Barrier in the                                                                                                      Pineal land makes it susceptible site                                                                                                          for hematogenous metastasis)
9. Lesions which mimic tumors
                                      Vascular: Vein of galen aneurysm
                                      Infection: Neurocysticercus, Tuberculoma


Clinical Features of Pineal region masses
           Generally manifest in 3 ways: 
                           1. Symptoms of increased intracranial pressure from hydrocephalus 
                           2. Direct Brainstem and cerebellar compression
                           3. Endocrine dysfunction 


How to approach a case with a mass in Pineal Region? 

Take History:  History may give features of raised ICP like Headache, vomiting, or symptoms due to                         mass in the posterior third ventricular region: visual disturbances, lethargy, memory                             disturbances. 
Do Clinical examination : In infants: increased head circumference, seizures
                                          In boys with choriocarcinoma or germinomas with syncytiotrophoblastic                                                         cells: Precocious Puberty ( due to leuteinizing hormone-like effects                                                       of beta-hCG secreted in CSF
                                          Papilloedema
                                          Parinaud's syndrome (upward gaze palsy, converegence or retracction                                                                    nystagmus,light-near pupillary dissociation)
                                          Sylvian Aqueduct Syndrome (from further midbrain compression):                                                                      Paralysis of down-gaze or horizontal gaze, can be superimposed                                                            on Parinaud's syndrome
                                           Dorsal Midbrain Compression or infiltration can lead to lid retraction (                                                                Collier's sign) or ptosis. May appear as setting sun sign.
                                           Diplopia if 4th cranial nerve palsy.
                                           Ataxia
                                           Radiculopathy or myelopathy due to drop metastasis

Sometimes Blood & CSF investigations may give some clue to the diagnosis: 
       Germ cell tumor (GCT) may give rise to tumor markers in CSF
                   beta-human chorionic gonadotropin ( beta-hCG) is elevated in CSF in choriocarcinoma                                                and in about half of germinoma cases.
                   Alpha-fetoprotein (AFP) is elevated with endodermal sinus tumor, embryonal carcinoma                                              and immature teratoma.
                   Placental Alkaline Phosphatase (PLAP) is elevated in CSF & Serum of intracranial                                                      Germinomas. 
       CSF may be collected by ventricular tap if lesion is large or through Lumbar Puncture if lesion is                   small & if there is no risk of herniation, if a patient presents with hydrocephalus and                             patient is operated for CSF diversion procedure  like shunt or ETV then CSF should be                         collected and sent for tumor markers. 
                                   Although tumor markers alone are not usually sufficient for making a diagnosis                                    of a pineal tumorsince many of these tumors are mixed cell type.n But, when                                        positive, tumor marker can be followed serially to assess treatment and to                                              look for recurrence.
                  
Neuro-radiological evaluation : MRI of the brain with contrast with MR spectroscopy. It may                           diagnose neurocysticercus or tuberculoma.
              Some other investigations may be required if features are suggestive of systemic metastasis.
              MRI of cervical, dorsal & Lumbosacral spine to assess for drop metastasis.

Treatment:
Ideal situation is to know the histopathology of the lesion. o, ideal treatment is surgical excision followed by adjuvant therapy.But optimal management strategy is not to harm the patient. Pineal occupies a deep position near the geometric center. Since it is situated in the eloquent area of the brain and in close proximity to the splenium, superior colliculus and hypothalamus and close relation with the deep venous system including Vein of Galen, a judicious decision should be taken before operating the patient.
 
1. Observation & annual MRI if a lesion is asymptomatic as an incidental pineal cyst of less than 1              cm,
 
2. Radiosurgery: New modality of treatment , if tumor is less than 3 cm in size.
 
3. Surgery:
  Ventriculo-peritoneal shunt,
  Endoscopic Third Ventriculostomy (ETV),
  Endoscopic cyst excision,
  Computer Assisted Cisternal Endoscopic Approach (CACE): supracerebellar infratentorial approach
  Stereotactic or Endoscopic aspiration
  Craniotomy and Micro-neurosurgical excision of the mass:
               Midline infratentorial supracerebellar approach ( Horsley & Krause as refined by Stein)
                     Oppenheim & Krause in 1913 reported First successful removal of Pineal tumor.
                     Krause in 1926 reported 3 cases of infratentorial approaches without operative mortality
                           
               Occipital transtentorial approach ( Poppen's)
               Transcallosal approach : Dandy 1921
        The extensive variety of histologic subtypes found in the pineal region makes it imperative to             establish a tissue diagnosis. Aggressive Microneurosurgical resection followed by adjuvant                 therapy is mainstay of management.

4.Radiotherapy & Chemotherapy
 
If Biopsy is Germinoma: Radiotherapy and Chemotherapy
                    Germinomas are very sensitive to radiotherapy and chemotherapy. "Test dose" radiation                                 or "Trial XRT" of 5 Gy in a uniformly enhacing germinoma: if shrinks. Then XRT                               without surgery ( controversial as 36-50% of Pineal tumors are benign &                                                radioresitant}
 

Sources:

Mark S. Greenberg, Handbook of Neurosurgery, 7th ed., Thieme

emedicine.medscape.com/article/249945-overview ( Pineal Tumors, Author:Jeffrey N Bruce, MD; Chief Editor: Brian H Kopel)

Tandon PN, Ramamurthy R, Jain PKN. Ramamurthy & Tandon's Manual of Neurosurgery, Publisher: Jaypee

Jeffrey N.Bruce. Pineal Tumors. Chapter in Youmans Neurological Surgery, 6th ed. , H.Richard Winn, Elsevier Saunders,1359-1372.

Best Neurosurgical Center

Certain words create interest in almost everyone. Rocket science and Neurosurgery are common words used in most of the deliberations. When it becomes a talk about the best in Neurosurgery it will definitely be an interesting thing to know.
Search for the best Neurosurgical center on Google reveals names of various large hopitals and institutions offering neurosurgical services. The ranking may also be seen on Medscape,  Health US News Report of Best ranked US neurosurgical centers (health.usnews.com › Hospitals › Best Hospitals), etc.
All leading neurosurgical centers across the world provide services in different subspecialties of neurosurgery like Functional Neurosurgery, Cerebrovascular Neurosurgery, Pediatric Neurosurgery, Neurotrauma, Skull Base neurosurgery, Neuro oncology, Spinal Neurosurgery, etc with Neurosurgeons practising different subspecialties. All these subspecialties work as independent units and their work is primarily devoted to a particular branch. Basic & advanced Research and Laboratory task is also done by a dedicated neurosurgical team. Availability of the latest neurosurgical equipments along with world renowned neurosurgeons makes these centers unique.
These centers have achieved present status through decades of hard work & sacrifice. Employing best minds and striving hard to welcome excellent trainees and faculty adds glamour of academic & clinical excellence. Ultramodern infrastructure helps to achieve good clinical outcome of neurourgery.
 

Mayo Clinic, Rochester, Minnesota
                           Bed Count: 1132, Doctors in this specialty: 261

New York–Presbyterian University Hospital of Columbia and Cornell, New York City
                           Bed Count: 2262, Doctors in this specialty: 285

Johns Hopkins Hospital, Baltimore, Maryland
           

                                      Bed Count: 951,  Doctors in this specialty: 162

Massachusetts General Hospital, Boston
                            Bed Count: 779,  Doctors in this specialty: 191

University of California–San Francisco Medical Center
                          Bed Count: 650, Doctors in this specialty: 234


Cleveland Clinic, Ohio
                          Bed Count: 1268, Doctors in this specialty: 192


University of California–Los Angeles Medical Center
          Bed Count: 466, Doctors in this specialty: 223

New York University Langone Medical Center, New York City
                        Bed Count: 791, Doctors in this specialty: 118

Hospitals of the University of Pennsylvania–Penn Presbyterian

Northwestern Memorial Hospital, Chicago
                         Bed Count: 885, Doctors in this specialty: 150

National Hospital for Neurology and Neurosurgery (NHNN), Queen Square, London 

                   UK's largest dedicated neurological and neurosurgical hospital

Leading health care systems provide integrated multispecialty health care with world-renowned health professionals and facilities. The care is not ego-centric but patient-centric. The patient care is highly individualized. A treatment plan is developed for each patient to ensure best neurosurgical result. These institutes are setting the standard of excellence in medical education, research and clinical care. 

Multispecialty clinical care in large hospital setting, excellent infrastructure facilities in operation theaters, dedicated world- renowned neurosurgeons and other health professional, extraordinary laboratory facilities for the research and clinical trials, opportunities of excellent neurosurgical training for the resident doctors and fellows all over the world  have defined these centers of excellence. 

World's best neurosurgical centers are recognized due to clinical accolades, recognition in healthcare groups, contribution to the teaching, training and research and excellent working atmosphere for the faculty and  trainees across the globe.

Although there are many hospitals in other countries which may boast to be the best. But, they lack international vision, do not invite international talents, not open to competition, suffer from inbreeding and employ students from their own college, conventional, lack adequate quality faculty members with interest in subspecialties, and try to be famous just because these centers are relatively larger and better equipped than the adjoining hospitals in that region or country. Laboratory and research facilities are minimal and whenever present usually monopolistic. Majority of Resident doctors, fellows and faculty are from that particular country. A few international fellows may have attended just for the grant or other purpose. The residency training is to used to get manpower and not to produce leaders. Lack of mentorship cripples many neurosurgical training centers across the globe. At many centers teachers compete with students and do not teach the advanced neurosurgical techniques to their students fearing potential competition in future. The attitude of the training center is to restrict the entry of international faculty and residents rather than inviting the best and promising students, residents, fellows and faculty, irrespective of race, religion and citizenship.

If someone wants to explore more,  websites of these hospitals may be viewed.
Don't compete with peers, compete with diseases which cripple the humanity. We are doctors and for us challenges are to find cure of dreaded diseases. Help your peers who work in resource constraints situations and work in anomity but focus on helping patients.  

Excellence is not by chance but it is achieved through hard work, visionary approach and eagerness to consistent progress by best professional who sacrifice their personal interests.

I saw a nice quote on Twitter post of Mr Edward  Relf:

                  “Perfection is not attainable, but if we chase perfection we can catch excellence” 

Many Neurosurgical centres across the World offer very efficient care. Many neurosurgeons aspire to work at these renowned centres. In India very good hospitals are in Government setup and offer affordable neurosurgical services without any profit. These government hospitals serve lot of patients and these are mostly overcrowded. They cater best neurosurgical care to the best of their abilities and produce the best neurosurgeons who mostly work in Private set up because very few get appointments in government superspecialty hospitals. The best neurosurgical training and patient care in India is provided by All India Institute of Medical Sciences (AIIMS, Delhi), G.B.Pant Post Graduate Institute, Delhi (G.B.Pant Hospital),  Sanjay Gandhi Post Graduate Institute ( SGPGI, Lucknow), JIPMER, Pondicherry, Shree Chitra, Trivandrum, Christian Medical College, Vellore, Post Graduate Institute ( PGI, Chandigarh). Private corporate hospitals in India are providing best neurosurgical services at par with best institutions across the world. Max Healthcare, Saket, Delhi, Medanta Hospital, Gurgaon, Apollo Hospital Delhi are located in Delhi NCR region in India. In Mumbai Hinduja Hospital, Jaslok Hospital are located.

Thorough Neurological Examination- All in One Page

Never ever presume a neurological diagnosis without interacting with a patient and just by seeing the radiology report or just by listening the patient's complaints. Examine a patient without any presumption & bias, You will always feel rewarded.
Listen to the patient. Patient is the best guide and will provide you the important clue for the diagnosis. History taking is an opportunity to interact with people from diversified background. 
While taking history of a patient who is suspected to have a neurological disorder it should always be prudent to take history pertaining to lesions of brain, spinal cord and peripheral nerves. In this manner you can complete and cover the entire central and peripheral nervous system.
So, if you suspect a lesion of the cerebral hemisheres, History of Seizure, Headache, Vision and , Deterioration of conscious level or loss of consciousness, Weakness of the face or limbs should be taken into detail. 
If you suspect a lesion of cerebellum, then history of imbalance, ataxia and difficulty in walking should always be taken.
And if you suspect a lesion of the brain stem ( Midbrain , pons, medulla Oblongata), the symptoms of multiple cranial nerve deficits ( speech abnormality, nystagmus, difficulty in deglutition, loss of Gag reflex),  and long tract signs ( weakness in limbs, hyperrelexia, increased tone in limbs, positive Babinski sign) are expected.
In patients with lesions of the spinal cord history must include details about  weakness of the limbs, bladder and bowel involvement.

History of headache must include Onset ( sudden, gradual), Site ( holocranial, hemicranial , temoral)Frequency, duration, severity, Character ( Aching, throbbing), timing ( e.g., morning , evening), Precipitating factors (coughing, strenuous work) , Relieving factors ( analgesics, rest) , Associated features ( nausea, vomiting, visual disturbance).
History of Visual Disorder should include onset, frequency, impairment ( uniocular or both eyes, partial or total), diplopia, Precipitaing factor, Associated features
History of Loss of Consciousness may be due to syncope because of cardiac causes or vasovagal shock or due to neurological causes like a part of seizure or neurotrauma or a space occupying lesion in the brain. Loss of consciousness may also be due to low blood sugar level in a patient on diabetic treatment or alcohol or drug abuse.
Speech disorder may be a difficulty in Articulation or Expression or Understanding.
Weakness in the limbs may be Quadriparesis, Hemiparesis or Monoparesis with or without involvement of facial muscles.
History of Sensory system abnormalities  may expressed by the patient as Numbness, feeling of crawling of ants or insects, Tingling or inability to feel a part of the body.
History of cranial nerve deficits may be expressed by the patient as inability to smell, inability to read, loss of vision, diplopia, frequent changes of spectacle, partial closure of the eyelid ( Ptosis)loss of sensation over the face, drooling of saliva from the side, difficulty in closing eye, slurring of speech or change in voice, difficulty in hearing or Deafness, Tinnitus, Vertigo or Dizziness, inability to swallow, inability to shrug and turn face and inability to protrude tongue.

Neurological examination is straight forward, It is like substraction and addition of numbers, like 2+2=4. So, if there is right hemiparesis of body and face and the deep tendon reflexes are increaded, there must be some lesion on the left side of the brain. There is nothing wrong in rechecking the neurological examination findings. But, be sure of your neurological examination findings. Your examination may have a great impact on clinical outcome and plan of the treatment. In Neuroscience most of the things are evident. As students we used to think that many things may be theortical. But, with the advent of newer and advanced neuroradiology, microneurosurgery and functional neurosurgery, lot of procedures are now based on physiological and neuroanatomical localization.
One should begin with systemic examination. See Pallor ( anemia), Icterus ( jaundice), Lymhadenopathy. Anemia may explain many symptoms. Lymhadenopathy may indicate infection, lymphoma or metastasis.

Examine Pulse:  Bradycardia is an omnious sign of raised intrcranial pressure ( ICP)
                           Irregular Pulse may indicate syncope
Blood pressure :  Hypertension may indiacte raise ICP
Respiratory Rate: Irregular Respiration, Bradycardia and Hypertension are parts of Cushing reflex which is due to raised ICP.
Neck rigidity may indicate meningitis or subarachnoid hemorrhage. Restriction of neck movement may be due to cervical spondylosis. One should be very careful while examining a patient with head injury. if a patient is unconscious and his GCS is 8 or less, it is presumed that there may be associated cervical spine injury. So, in severely head injured patient , neck should be immobilized by putting a cervical collar while shifting the patient
Neurological examination begins with higher mental function. orientation to time, place and person should be asked.
cranial nerve examination: Soap may be used to examine olfaction. Vision should be seen in both eyes. If patient is unable to count fingers, then perception of light should be examined with a torch. Pupillary light reflex,ie, constrction of both the pupils when light is projected in eye , gives a clue about both second and third cranial nerves. because second cranial nerve (Optic Nerve) is afferent and third cranial nerve ( Occulomotor nerve) is efferent of this light reflex. Although this is very simple examination but it has great value. We often presume that vision is normal and miss it. A child with craniopharyngima, an adult  with  clinodal meningima or pituitary adenoma may not have any vision in one eye but even patiets or their parents may not be aware about the uniocular visual loss. So, if a doctor misses this finding, there may be catastrophic consequences. As immediately following the surgery , there is natural tendency in everyone to check the vision and it could be concluded that this visual loss be due to surgery. Optic nerve tumor, optic nerve injury, retinal detachmentmay also present with uniocular visual loss.
3,4,6 cranial nerves function may be examined by seeing the conjugate eye movements of both eyes together.
5th cranial nerve, 7th cranial nerve is by examining the face. sensation over the face is mainly by the Vth cranial nerve ( Trigeminal nerve). There are three sensory divisions of Trigeminal nerve ( V1, V2, V3). 7th cranial nerve is the motor supply to the face.
Hearing is through 8th cranial nerve. Ideally 8th cranial nerves should be examined by Tuning forks. If patient hears the rubbing of fingers of the examiner close to each ear, it may give some clue to the intact hearing.
If the gag reflex is intact, 9th and 10th cranial nerves are intact. 
Patient is asked to Shrug the shoulder and turn the face against the resistance to examine sternocleidomastoid and trapezius muscle which are suppled by the spinal accessory nerve.
Protrusion of tongue is possible with the 12th cranial nerve. If Hypoglossal nerve is damaged the tongue deviates to the injured side on protruding. 
Sensory nervous examination should be done before motor examination. Because patients usually are cooperative and sensory system examination is subjective and needs patient,s cooperation.
Motor examination : Movement of all four limbs. Power in all four limbs should be checked separately and should be compared with your own strength. Deep tendon reflexes and tone should also be examined.
Gait; If a patient is able to walk, gait should alsio be examined to complete the thorough neurological examination