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ORIGINAL ARTICLES
Diagnostic and prognostic role of MRI in spinal trauma, its comparison and correlation with clinical profile and neurological outcome, according to ASIA impairment scale
Umesh C Parashari, Sachin Khanduri, Samarjit Bhadury, Neera Kohli, Anit Parihar, Ragini Singh, RN Srivastava, Deepika Upadhyay
January-June 2011, 2(1):17-26
DOI:10.4103/0974-8237.85309  PMID:22013371
Aims and objectives: To evaluate the role of magnetic resonance imaging (MRI) as a non-invasive diagnostic tool in patients with acute and chronic spinal trauma and to compare and correlate the MRI findings with those of patients' clinical profile and neurological outcome according to ASIA impairment scale to assess prognostic and clinical value of MRI. Materials and Methods: Sixty two patients of spinal trauma formed the study group in a prospective fashion. The patients undergoing MR imaging and magnetic resonance images were analyzed and correlated with findings on neurological examination according to American Spinal Injury Association (ASIA) impairment scale (AIS) at the time of MRI examination and subsequently at sub-acute interval to assess neurological outcome. Statistical Analysis : Sample profile was described in terms of 95% confidence limit and proportion. To describe strength of association between extent of spinal cord injury and outcome, odd's ratio, bivariate and multi variant analysis, was used. Pearson's chi square (χ) 2 statistics was applied to test the association between two categorical variables. Data were analyzed using statistical software package, STATA 9.2 and the difference was considered to be significant if 'P' value was <0.05. Observation and Results: The cord edema without hemorrhage was the most common MR finding (41.5%). The others were sizable focus of hemorrhage within the cord (33%), epidural hematoma (5.0%), and normal cord (26%). Majority of MR findings correlated well with clinical profile of the patient according to ASIA impairment scale. This study demonstrated that patients with presence of sizable focus of haemorrhage had larger cord edema and more severe grade of initial ASIA impairment scale( AIS) with poor recovery at follow up (P=0.032).Improvement in upper extremity was more than lower extremity. Severe cord compression was also associated with poor neurological outcome; however it was not statistically significant (P=0.149). Conclusions: With this study the authors concluded that various MRI findings in acute spinal cord injury correlated well with the initial clinical findings and on follow-up according to ASIA impairment scale. MRI is useful for initial diagnosis of acute spinal cord injury and its prognostication for predicting neurological recovery.
  13,265 17 4
Microdiscectomy or tubular discectomy: Is any of them a better option for management of lumbar disc prolapse
Pallav S Bhatia, Harvinder S Chhabra, Bibhudendu Mohapatra, Ankur Nanda, Gururaj Sangodimath, Rahul Kaul
July-September 2016, 7(3):146-152
DOI:10.4103/0974-8237.188411  PMID:27630476
Objectives: Various types of minimally invasive techniques have been developed for the treatment of lumbar disc herniation. The original laminectomy was refined into microdiscectomy (MD). MD is the gold standard in management of lumbar disc herniation and is used as a yardstick for comparison with newer procedures such as tubular discectomy. So far, no studies have been reported in Indian population comparing tubular discectomy and microdiscectomy. The aim of this study was to compare immediate postoperative and 1-year outcome of patients undergoing tubular discectomy with those undergoing MD and to evaluate the learning curve as well as complication rates of tubular discectomy. Materials and Methods: Forty-six patients of MD and 102 (48 early and 54 late) patients of tubular discectomy (TD) were operated at Indian Spinal Injuries Centre, which is a tertiary level center between July 2009 and January 2012. They were studied for the following data: Baseline characteristics, visual analog scale (VAS) for leg pain and back pain, Oswestry Disability Index (ODI) scores, length of hospital stay, time taken to return to work, duration of surgery, intra- and post-operative complications, and reoperation rates. Results: The VAS score for leg pain, back pain, and ODI scores showed improvement in both groups during the 1st year after surgery. Time taken to return to work and mean hospital stay was shorter in case of TD as compared to MD group. The mean duration of surgery was 34 min shorter for conventional MD. The incidence of dural tear was 6.5% in MD group and 10.4% in early TD and decreased to 7.4% in late TD group. Conclusion: This study revealed that rate of recovery is significantly faster for TD as compared to conventional MD. In contrast, we encountered fewer complications in MD approach as compared to TD which although were not statistically significant and which also decreased as we gained experience.
  11,604 19 -
Focal adhesive arachnoiditis of the spinal cord: Imaging diagnosis and surgical resolution
Hiroki Morisako, Toshihiro Takami, Toru Yamagata, Isao Chokyu, Naohiro Tsuyuguchi, Kenji Ohata
July-December 2010, 1(2):100-106
DOI:10.4103/0974-8237.77673  PMID:21572630
Background: Although adhesive arachnoiditis of the spinal cord can cause progressive symptoms associated with syringomyelia or myelomalacia, its surgical resolution based on the imaging diagnosis is not well characterized. This study aims to describe the use of imaging for the diagnosis of focal adhesive arachnoiditis of the spinal cord and its surgical resolution using microsurgical arachnoidolysis. Materials and Methods: Four consecutive patients with symptomatic syringomyelia or myelomalacia caused by focal adhesive arachnoiditis underwent microsurgical arachnoidolysis. Comprehensive imaging evaluation using constructive interference in steady-state (CISS) magnetic resonance imaging (MRI) or myelographic MR imaging using true fast imaging with steady-state precession (TrueFISP) sequences was included before surgery to determine the surgical indication. Results: In all four patients a focal adhesion was identified at the cervical or thoracic level of the spinal cord, a consequence of infection or trauma. Three patients showed modest or minor improvement in neurological function, and one patient was unchanged after surgery. The syringomyelia or myelomalacia resolved after surgery and no recurrence was noted within the follow-up period, which ranged from 5 months to 30 months. Conclusions: MRI diagnosis of focal adhesive arachnoiditis is critical to determine the surgical indication. Microsurgical arachnoidolysis appears to be a straightforward method for stabilizing the progressive symptoms, though the procedure is technically demanding.
  11,316 20 3
REVIEW ARTICLE
Primary spinal epidural lymphomas
Goutham Cugati, Manish Singh, Anil Pande, Ravi Ramamurthi, Mahalakshmi Balasubramanyam, Sumer K Sethi, Ajai Kumar Singh
January-June 2011, 2(1):3-11
DOI:10.4103/0974-8237.85307  PMID:22013369
An epidural location for lymphoma is observed in 0.1-6.5% of all the lymphomas. Primary spinal epidural lymphoma (PSEL) is a subset of lymphomas, where there are no other recognizable sites of lymphomas at the time of diagnosis. The incidence of this subset of lymphomas is much less. It, however, is increasingly diagnosed, due to the increased use of more sensitive imaging modalities. For the electronic search, Pubmed was used to identify journals that enlisted and enumerated PSEL from 1961 to January 2011. The following combination of terms: "primary," "spinal," "epidural," and "lymphoma" were used. The most significant articles and their bibliographies were analyzed by the authors. The symptoms, pathogenesis, diagnostic workup, histopathology, treatment, and outcome have been analyzed in a systematic manner
  11,020 26 6
REVIEW ARTICLES
Tuberculosis of spine
Vinod Agrawal, PR Patgaonkar, SP Nagariya
July-December 2010, 1(2):74-85
DOI:10.4103/0974-8237.77671  PMID:21572628
Tuberculosis of the spine is one of the most common spine pathology in India. Over last 4 decades a lot has changed in the diagnosis, medical treatment and surgical procedures to treat this disorder. Further developments in diagnosis using molecular genetic techniques, more effective antibiotics and more aggressive surgical protocols have become essential with emergence of multidrug resistant TB. Surgical procedures such as single stage anterior and posterior stabilization, extrapleral dorsal spine anterior stabilization and endoscopic thoracoscopic surgeries have reduced the mortality and morbidity of the surgical procedures. is rapidly progressing. It is a challenge to treat MDR-TB Spine with late onset paraplegia and progressive deformity. Physicians must treat tuberculosis of spine on the basis of Culture and sensitivity.
  10,379 17 10
ORIGINAL ARTICLES
Multilevel decompressive laminectomy and transpedicular instrumented fusion for cervical spondylotic radiculopathy and myelopathy: A minimum follow-up of 3 years
Kadir Kotil, Emine Ozyuvaci
January-June 2011, 2(1):27-31
DOI:10.4103/0974-8237.85310  PMID:22013372
Objective: Cervical laminectomies with transpedicular insertion technique is known to be a biomechanically stronger method in cervical pathologies. However, its frequency of use is low in the routine practice, as the pedicle is thin and risk of neurovascular damage is high. In this study, we emphasize the results of cervical laminectomies with transpedicular fixation using fluoroscopy in degenerative cervical spine disorder. Materials and Methods: Postoperative malposition of the transpedicular screws of the 70 pedicles of the 10 patients we operated due to degenerative stenosis in the cervical region, were investigated. Fixation was performed between C3 and C7, and we used resected lamina bone chips for fusion. Clinical indicators included age, gender, neurologic status, surgical indication, and number of levels stabilized. Dominant vertebral artery of all the patients was evaluated with Doppler ultrasonography. Preoperative and postoperative Nurick grade of each patient was documented. Results: No patients experienced neurovascular injury as a result of pedicle screw placement. Two patients had screw malposition, which did not require reoperation due to minor breaking. Most patients had 32-mm screws placed. Postoperative computed tomography scanning showed no compromise of the foramen transversarium. A total of 70 pedicle screws were placed. Good bony fusion was observed in all patients. At follow-up, 9/10 (90%) patients had improved in their Nurick grades. The cases were followed-up for an average of 35.7 months (30-37 months). Conclusions: Use of the cervical pedicular fixation (CPF) provides a very strong three-column stabilization but also carries vascular injury without nerve damage. Laminectomies technique may reduce the risk of malposition due to visualization of the spinal canal. CPF can be performed in a one-stage posterior procedure. This technique yielded good fusion rate without complications and can be considered as a good alternative compared other techniques.
  9,307 16 2
CASE REPORTS
Atlantooccipital dislocation in motor vehicle side impact, derivation of the mechanism of injury, and implications for early diagnosis
Kevin M Smith, Narayan Yoganandan, Frank A Pintar, Shekar N Kurpad, Dennis J Maiman
July-December 2010, 1(2):113-117
DOI:10.4103/0974-8237.77675  PMID:21572632
Numerous reports of atlantooccipital dislocations (AODs) have been described in frontal impacts and vehicle versus pedestrian collisions. Reports of survival after AOD in conjunction with side impacts have infrequently been reported in the literature. The objective of this study is to present a case of an AOD from a side impact vehicle collision, and deduce the mechanism of injury. A clinical and biomechanical reconstruction of the collision was performed to investigate the mechanism of the dislocation. A 51-year-old female was traveling in a four-door sedan and sustained a side impact collision with a compact pickup truck. At the time of extrication, the patient was neurologically intact with a Glasgow Coma Scale score of 15. After admittance to the hospital, the patient developed a decline in respiratory status, right mild hemiparesis, and left sixth-nerve palsy, and magnetic resonance imaging (MRI) and computed tomography (CT) reconstructions indicated a craniocervical dislocation. Surgical fixation was performed and all extra-axial hemorrhaging was evacuated. At discharge, the patient was neurologically intact on the left side, had right mild hemiparesis, left sixth-nerve palsy, and minor dysarthria. Survival rates of AODs have recently been increasing. Morbidity is still more prevalent, however. Due to the variety of symptoms that accompany AODs and the inconsistency of diagnostic imaging techniques, a thorough history of the etiology may lead to increased clinical suspicion of this injury and further raise survival rates.
  9,157 15 2
Dorsal spinal epidural cavernous hemangioma
Darshana Sanghvi, Mihir Munshi, Bijal Kulkarni, Abhaya Kumar
July-December 2010, 1(2):122-125
DOI:10.4103/0974-8237.77677  PMID:21572634
A 61-year-old female patient presented with diffuse pain in the dorsal region of the back of 3 months duration. The magnetic resonance imaging showed an extramedullary, extradural space occupative lesion on the right side of the spinal canal from D5 to D7 vertebral levels. The mass was well marginated and there was no bone involvement. Compression of the adjacent thecal sac was observed, with displacement to the left side. Radiological differential diagnosis included nerve sheath tumor and meningioma. The patient underwent D6 hemilaminectomy under general anesthesia. Intraoperatively, the tumor was purely extradural in location with mild extension into the right foramina. No attachment to the nerves or dura was found. Total excision of the extradural compressing mass was possible as there were preserved planes all around. Histopathology revealed cavernous hemangioma. As illustrated in our case, purely epidural hemangiomas, although uncommon, ought to be considered in the differential diagnosis of spinal epidural soft tissue masses. Findings that may help to differentiate this lesion from the ubiquitous disk prolapse, more common meningiomas and nerve sheath tumors are its ovoid shape, uniform T2 hyperintense signal and lack of anatomic connection with the neighboring intervertebral disk or the exiting nerve root. Entirely extradural lesions with no bone involvement are rare and represent about 12% of all intraspinal hemangiomas.
  9,057 17 4
ORIGINAL ARTICLES
Use of recombinant human bone morphogenetic protein-2 as an adjunct for instrumented posterior arthrodesis in the occipital cervical region: An analysis of safety, efficacy, and dosing
D Kojo Hamilton, Justin S Smith, Davis L Reames, Brian J Williams, Christopher I Shaffrey
July-December 2010, 1(2):107-112
DOI:10.4103/0974-8237.77674  PMID:21572631
Background: There have been few reports on the use of recombinant human bone morphogenetic protein (rhBMP)-2 in posterior spine. However, no study has investigated the dosing, safety, and efficacy of its use in the posterior atlantoaxial, and/or craniovertebral junction. Recent case report of the cytokine-mediated inflammatory reaction, following off label use of rhBMP-2 as an adjunct for cervical fusion, particularly in complex cases, has increased concern about complications associated with the product. Objective: To assess the safety, efficacy, and dosing of rhBMP-2 as an adjunct for instrumented posterior atlantoaxial and/or craniovertebral junction arthrodesis. Materials and Methods: We included all patients treated by the senior author that included posterior atlantoaxial and/or craniovertebral junction instrumented fusion using rhBMP-2 from 2003 to 2008 with a minimum two year follow-up. Diagnosis, levels fused, rhBMP-2 dose, complications, and fusion were assessed. Results: Twenty three patients with a mean age of 60.9 years (range 4 - 89 years) and an average follow-up of 45 months (range 27 to 84 months) met inclusion criteria. The indications for surgery included, atlantoaxial instability (n = 16), basilar invagination (n = 6), and kyphoscoliosis (n = 1). The specific pathologic diagnosis included type 2 dens fracture (n = 7), complex C1 and C2 ring fracture (n = 2), chordoma (n = 2), degenerative/osteoporosis (n = 3), rheumatoid disease (n = 8), and pseudogout (n = 1). The average rhBMP-2 dose was 2.38 mg/level, with a total of 76 levels treated (average 3.3 levels, SD= 1.4 levels). There were no complications. During the most recent follow-up, all patients had achieved fusion. Conclusions: In a series of patients with complex pathology and/or rheumatoid arthritis, 100% fusion rate was achieved with adjunct use of rhBMP-2, with a safe and effective average rhBMP-2 dose of 2.38 mg per level.
  9,052 10 2
Comparison of dural grafts in Chiari decompression surgery: Review of the literature
AA Abla, T Link, D Fusco, DA Wilson, V.K.H. Sonntag
January-June 2010, 1(1):29-37
DOI:10.4103/0974-8237.65479  PMID:20890412
Background: Decompression of Chiari malformation is a common procedure in both pediatric and adult neurosurgery. Although the necessity for some bony removal is universally accepted, other aspects of Chiari surgery are the subject of debate. The most controversial points include the optimal amount of bony removal, the use of duraplasty (and the type of material), the need for subarachnoid dissection, and the need for tonsillar shrinkage. Material and Methods: We critically reviewed the literature to elucidate the risks and benefits of different graft types and to clarify optimal treatment options therein. Based on our search results, 108 relevant articles were identified. With specific inclusion and exclusion criteria, we noted three studies that directly compared two tlpes of dural substitutes in Chiari malformation surgery. Results: Our review did not support the superiority of either autologous or nonautologous grafts when duraplasty is employed. Our institutional experience, however, dictates that when the pericranium is available and of good quality, it should be utilized for duraplasty. It is non-immunogenic, inexpensive, and capable of creating a watertight closure with the dura. Conclusions: Discrepancies between the three comparative studies analyzed are likely attributable to increases in pericranial quality and thickness with maturity. Future randomized studies with large numbers and the power to resolve differences in the relatively low rates of complications in Chiari surgery are warranted.
  8,527 199 18
Proposed clinical internal carotid artery classification system
Saleem I Abdulrauf, Ahmed M Ashour, Eric Marvin, Jeroen Coppens, Brian Kang, Tze Yu Yeh Hsieh, Breno Nery, Juan R Penanes, Aysha K Alsahlawi, Shawn Moore, Hussam Abou Al-Shaar, Joanna Kemp, Kanika Chawla, Nanthiya Sujijantarat, Alaa Najeeb, Nadeem Parkar, Vilaas Shetty, Tina Vafaie, Jastin Antisdel, Tony A Mikulec, Randall Edgell, Jonathan Lebovitz, Matt Pierson, Paulo Henrique Pires de Aguiar, Paula Buchanan, Angela Di Cosola, George Stevens
July-September 2016, 7(3):161-170
DOI:10.4103/0974-8237.188412  PMID:27630478
Introduction: Numerical classification systems for the internal carotid artery (ICA) are available, but modifications have added confusion to the numerical systems. Furthermore, previous classifications may not be applicable uniformly to microsurgical and endoscopic procedures. The purpose of this study was to develop a clinically useful classification system. Materials and Methods: We performed cadaver dissections of the ICA in 5 heads (10 sides) and evaluated 648 internal carotid arteries with computed tomography angiography. We identified specific anatomic landmarks to define the beginning and end of each ICA segment. Results: The ICA was classified into eight segments based on the cadaver and imaging findings: (1) Cervical segment; (2) cochlear segment (ascending segment of the ICA in the temporal bone) (relation of the start of this segment to the base of the styloid process: Above, 425 sides [80%]; below, 2 sides [0.4%]; at same level, 107 sides [20%];P< 0.0001) (relation of cochlea to ICA: Posterior, 501 sides [85%]; posteromedial, 84 sides [14%];P< 0.0001); (3) petrous segment (horizontal segment of ICA in the temporal bone) starting at the crossing of the eustachian tube superolateral to the ICA turn in all 10 samples; (4) Gasserian-Clival segment (ascending segment of ICA in the cavernous sinus) starting at the petrolingual ligament (PLL) (relation to vidian canal on imaging: At same level, 360 sides [63%]; below, 154 sides [27%]; above, 53 sides [9%];P< 0.0001); in this segment, the ICA projected medially toward the clivus in 275 sides (52%) or parallel to the clivus with no deviation in 256 sides (48%;P< 0.0001); (5) sellar segment (medial loop of ICA in the cavernous sinus) starting at the takeoff of the meningeal hypophyseal trunk (ICA was medial into the sella in 271 cases [46%], lateral without touching the sella in 127 cases [23%], and abutting the sella in 182 cases [31%];P< 0.0001); (6) sphenoid segment (lateral loop of ICA within the cavernous sinus) starting at the crossing of the fourth cranial nerve on the lateral aspect of the cavernous ICA and located directly lateral to the sphenoid sinus; (7) ring segment (ICA between the 2 dural rings) starting at the crossing of the third cranial nerve on the lateral aspect of the ICA; (8) cisternal segment starting at the distal dural ring. Conclusions: The classification may be applied uniformly to all skull base surgical approaches including lateral microsurgical and ventral endoscopic approaches, obviating the need for 2 separate classification systems. The classification allows extrapolation of relevant clinical information because each named segment may indicate potential surgical risk to specific structures.
  8,146 30 -
Craniovertebral junction 360°: A combined microscopic and endoscopic anatomical study
Sukhdeep Singh Jhawar, Maximiliano Nunez, Paolo Pacca, Daniel Seclen Voscoboinik, Huy Truong
October-December 2016, 7(4):204-216
DOI:10.4103/0974-8237.193270  PMID:27891029
Objectives: Craniovertebral junction (CVJ) can be approached from various corridors depending on the location and extent of disease. A three dimensional understanding of anatomy of CVJ is paramount for safe surgery in this region. Aim of this cadaveric study is to elucidate combined microscopic and endoscopic anatomy of critical neurovascular structures in this area in relation to bony and muscular landmarks. Materials and Methods: Eight fresh frozen cadaveric heads injected with color silicon were used for this study. A stepwise dissection was done from anterior, posterior, and lateral sides with reference to bony and muscular landmarks. Anterior approach was done endonasal endoscopically. Posterior and lateral approaches were done with a microscope. In two specimens, both anterior and posterior approaches were done to delineate the course of vertebral artery and lower cranial nerves from ventral and dorsal aspects. Results: CVJ can be accessed through three corridors, namely, anterior, posterior, and lateral. Access to clivus, foreman magnum, occipital cervical joint, odontoid, and atlantoaxial joint was studied anteriorly with an endoscope. Superior and inferior clival lines, supracondylar groove, hypoglossal canal, arch of atlas and body of axis, and occipitocervical joint act as useful bony landmarks whereas longus capitis and rectus capitis anterior are related muscles to this approach. In posterior approach, spinous process of axis, arch of atlas, C2 ganglion, and transverse process of atlas and axis are bony landmarks. Rectus capitis posterior major, superior oblique, inferior oblique, and rectus capitis lateralis (RCLa) are muscles related to this approach. Occipital condyles, transverse process of atlas, and jugular tubercle are main bony landmarks in lateral corridor whereas RCLa and posterior belly of digastric muscle are the main muscular landmarks. Conclusion: With advances in endoscopic and microscopic techniques, access to lesions and bony anomalies around CVJ is becoming easier and straightforward. A combination of microscopic and endoscopic techniques is more useful to understand this anatomy and may aid in the development of future combined approaches.
  7,857 26 -
Comparative quantitative analysis of osseous anatomy of the craniovertebral junction of tiger, horse, deer, and humans
Atul Goel, Abhidha Shah, Manu Kothari, Santosh Gaikwad, Prakash L Dhande
January-June 2011, 2(1):32-37
DOI:10.4103/0974-8237.85311  PMID:22013373
Aim: To compare the osseous anatomy of the craniovertebral junction of a horse, deer, and tiger with that of a human being. The variation in the structure of bones in these animals is analyzed. Materials and Methods: Various dimensions of the bones of the craniovertebral junction of the horse, deer, and tiger were quantitatively measured, and their differences with those of human bones were compared and analyzed. Results: Apart from the sizes and weights, there are a number of structural variations in the bones of these animals that depend on their functional needs. The more remarkable difference in joint morphology is noticed in the occipitoatlantal joint. The occipitoatlantal articulation is remarkably large and deep, resembling a 'hinge joint' in all the three animals studied. The odontoid process is 'C shaped' in the deer and horse and is 'denslike' in the tiger and humans. The transverse processes of the atlas are in the form of large wings in all the three animals. The arches of the atlas are large and flat, but the traverse of the vertebral artery resembles, to an extent, to that of human vertebral artery. The rotatory movements of the head at the craniovertebral junction are wider ranged in the horse and deer as compared with those of the tiger and humans. The bones of the craniovertebral junction of all the three animals are adapted to the remarkable thickness and strength of the extensor muscles of the nape of the neck. Conclusions: Despite the wide variations in the size of the bones, the basic patterns of structure, vascular and neural relationship, and joint alignments have remarkable similarities and a definite pattern of differences.
  7,812 16 -
CASE REPORTS
Delayed anterior cervical plate dislodgement with pharyngeal wall perforation and oral extrusion of cervical plate screw after 8 years: A very rare complication
Ravindranath Kapu, Manish Singh, Anil Pande, Matabushi Chakravarthy Vasudevan, Ravi Ramamurthi
January-June 2012, 3(1):19-22
DOI:10.4103/0974-8237.110121  PMID:23741125
We report a patient with congenital anomaly of cervical spine, who presented with clinical features suggestive of cervical compressive spondylotic myelopathy. He underwent C3 median corpectomy, graft placement, and stabilization from C2 to C4 vertebral bodies. Postoperative period was uneventful and he improved in his symptoms. Eight years later, he presented with a difficulty in swallowing and occasional regurgitation of feeds of 2 months duration and oral extrusion of screw while having food. On oral examination, there was a defect in the posterior pharyngeal wall through which the upper end of plate with intact self-locking screw and socket of missed fixation screw was seen. This was confirmed on X-ray cervical spine. He underwent removal of the plate system and was fed through nasogastric tube and managed with appropriate antibiotics. This case is presented to report a very rare complication of anterior cervical plate fixation in the form of very late-onset dislodgement, migration of anterior cervical plate, and oral extrusion of screw through perforated posterior pharyngeal wall.
  7,686 50 -
REVIEW ARTICLE
Neurenteric cysts of the spine
JJ Savage, JN Casey, IT McNeill, JH Sherman
January-June 2010, 1(1):58-63
DOI:10.4103/0974-8237.65484  PMID:20890417
Neurenteric cysts account for 0.7-1.3% of spinal axis tumors. These rare lesions result from the inappropriate partitioning of the embryonic notochordal plate and presumptive endoderm during the third week of human development. Heterotopic rests of epithelium reminiscent of gastrointestinal and respiratory tissue lead to eventual formation of compressive cystic lesions of the pediatric and adult spine. Histopathological analysis of neurenteric tissue reveals a highly characteristic structure of columnar or cuboidal epithelium with or without cilia and mucus globules. Patients with symptomatic neurenteric cysts typically present in the second and third decades of life with size-dependent myelopathic and/or radicular signs. Magnetic resonance imaging and computed tomography are essential diagnostic tools for the delineation of cyst form and overlying osseous architecture. A variety of approaches have been employed in the treatment of neurenteric cysts each with a goal of total surgical resection. Although long-term outcome analyses are limited, data available indicate that surgical intervention in the case of neurenteric cysts results in a high frequency of resolution of neurological deficit with minimal morbidity. However, recurrence rates as high as 37% have been reported with incomplete resection secondary to factors such as cyst adhesion to surrounding structure and unclear dissection planes. Here we present a systematic review of English language literature from January 1966 to December 2009 utilizing MEDLINE with the following search terminology: neurenteric cyst, enterogenous cyst, spinal cord tumor, spinal dysraphism, intraspinal cyst, intramedullary cyst, and intradural cyst. In addition, the references of publications returned from the MEDLINE search criteria were surveyed in order to examine other pertinent reports.
  6,528 228 13
CLINICAL CASE SERIES
Integrated intervertebral device for anterior cervical fusion: An initial experience
Manish K Kasliwal, John E O'toole
July-December 2012, 3(2):52-57
DOI:10.4103/0974-8237.116539  PMID:24082684
Objective: To analyze the clinical and radiographic results following the use of integrated intervertebral implant in patients with cervical spine degenerative disease. Background: Though excellent results have been reported following anterior cervical discectomy and fusion using iliac crest autograft/allograft with plating, the morbidity associated with autograft harvest and small chances of complications with plating always exists. Recently, there has been development of a cervical stand-alone cage with integrated fixation for cervical fusion and stabilization with a possible low morbidity and optimal clinical outcome. Materials and Methods: A retrospective study of 16 patients who underwent anterior cervical discectomy and fusion using the integrated intervertebral device was performed. Intra-operative parameters, clinical features [Neck Disability Index (NDI), visual analog scale (VAS) score for neck/arm pain], and presence or absence of dysphagia was recorded. Radiographs were evaluated for assessment of implant failure and fusion. Results: Mean age of patients was 54 years (range: 38-84 years) with male: female ratio of 1:3. Follow-up ranged from 6 to 12 months (mean: 10 months). In the early postoperative period, 2 of the 15 patients (13%) patients had mild dysphagia that resolved during follow-up with no patient having complaints of dysphagia at 3-month follow-up. One of the patients with diffuse idiopathic skeletal hyperostosis (DISH) and severe preoperative dysphagia had significant improvement in swallowing function at 3-month follow-up that was stable at 1-year follow-up. There was no evidence of implant failure, with fusion occurring in 95% (19/20) of operated levels. Analysis of follow-up VAS and NDI scores showed significant reduction in VAS score for neck pain (P < 0.019), radicular arm pain (P < 0.003), and NDI score (P < 0.007) in 77, 92, and 77% of patients, respectively, at a mean follow-up of 10 months (6-12 months). Conclusions: Our preliminary results with the use of this cervical stand-alone anterior fusion device with integrated screw fixation show its efficacy in anterior cervical decompression and fusion with stabilization with optimal clinical and radiographic outcome. Lower chances of dysphagia with no device-related complications are appealing, which needs to be verified in larger studies.
  6,584 27 1
CASE REPORTS
One-stage surgery through posterior approach-for L5-S1 spondyloptosis
Hikmet Turan Suslu, Erhan Celikoglu, Ali Borekci, Tufan Hicdonmez, Hüsnü Suslu
July-December 2011, 2(2):89-92
DOI:10.4103/0974-8237.100066  PMID:23125496
Grade 5 spondylolisthesis or spondyloptosis is a rare condition. Generally, the surgical management of spondyloptosis includes multi-staged procedures instead of one-staged procedures. One-stage treatment for spondyloptosis is very rare. A 15-year-old girl with L5-S1 spondyloptosis was admitted with severe low back pain. There was no history of trauma. The patient underwent L5 laminectomy, L5-S1 discectomy, resection of sacral dome, reduction, L3-L4-L5-S1 pedicular screw fixation, and interbody-posterolateral fusion through the posterior approach. The reduction was maintained with bilateral L5-S1 discectomy, resection of the sacral dome, and transpedicular instrumentation from L3 to S1. In this particular case, one-staged approach was adequate for the treatment of L5-S1 spondyloptosis. One-staged surgery using the posterior approach may be adequate for the treatment of L5-S1 spondyloptosis while avoiding the risks inherent in anterior approaches.
  6,278 17 1
An interesting clinical association of short neck with an unusual laryngeal anomaly
Rakesh Pinninti, E Thirulogachandar, KH Noorul Ameen
July-December 2011, 2(2):86-88
DOI:10.4103/0974-8237.100063  PMID:23125495
An elongated high-rising epiglottis can represent a normal variation of the larynx in a majority of pediatric patients. However, there are virtually no reports available for visible or high-rising epiglottis on routine oral examination in adult patients without upper respiratory tract inflammation. We report an unusual case with prominently visible epiglottis on oral examination. We diagnosed him with a rare congenital disorder based on associated physical examination and imaging evidence of short neck, low hair line, Sprengel's anomaly, left digital hypoplasia, restricted neck movements, cervical vertebra fusion, and mirror movements (synkinesia).
  6,080 10 -
Syringomyelia as a presenting feature of shunt dysfunction: Implications for the pathogenesis of syringomyelia
Natarajan Muthukumar
January-June 2012, 3(1):26-31
DOI:10.4103/0974-8237.110125  PMID:23741127
The pathogenesis of syringomyelia continues to be an enigma. The patency of the central canal and its role in the pathogenesis of communicating syringomyelia continues to elicit controversy. The case reported here provides an opportunity to retest some of the hypotheses of syringomyelia. A 33 year old female presented with sensory disturbances over the left upper extremity and trunk and was diagnosed to have panventriculomegaly with communicating syringomyelia. She was initially treated with ventriculoperitoneal shunting. As there was no change in her neurological status following shunt, this was followed by foramen magnum decompression with excision of an arachnoid veil covering the fourth ventricular outlet. She had clinical and radiological improvement after foramen magnum decompression. Five months later she had reappearance of the symptoms of syringomyelia and was found to have shunt dysfunction and holocord syrinx. She improved following shunt revision. This case is being reported to highlight the following points: 1. In patients with communicating syringomyelia and hydrocephalus, shunt dysfunction can present with symptoms of syringomyelia without the classical clinical features of shunt dysfunction, 2. In patients with communicating syringomyelia, the central canal of the spinal cord acts as an "exhaust valve" for the ventricular system, and, 3. studies about the patency of the central canal are reviewed in the context of this case and the role of the central canal in the pathogenesis of communicating syringomyelia is reviewed.
  5,717 16 -
CASE REPORT
Anesthesia management of a morbidly obese patient in prone position for lumbar spine surgery
V Baxi, S Budhakar
January-June 2010, 1(1):55-57
DOI:10.4103/0974-8237.65483  PMID:20890416
A morbidly obese, 45-year-old woman with a body mass index of 47 kg/m 2 , presented with a prolapsed intervertebral disc of the lumbar spine for decompression and fixation. Anesthesia and surgical positioning of morbidly obese patient carries 3 main hazards, namely, morbid obesity, prone position, and airway preservation problems. Morbid obesity has its own hazards of deep vein thrombosis and pulmonary embolus. Here we describe anesthetic management, successfully dealing with the specific problems of this patient due to obesity.
  5,527 171 1
EDITORIALS
Principlizing surgery
M Kothari, A Goel
January-June 2010, 1(1):1-4
DOI:10.4103/0974-8237.65474  PMID:20890407
  5,453 184 -
ORIGINAL ARTICLES
Gamma knife radiosurgery of meningiomas involving the foramen magnum
RM Starke, JH Nguyen, DL Reames, J Rainey, JP Sheehan
January-June 2010, 1(1):23-28
DOI:10.4103/0974-8237.65478  PMID:20890411
Background: Foramen magnum meningiomas represent a challenging clinical entity. Although resection is performed for those with a mass effect, complete resection is not always feasible. For some patients, stereotactic radiosurgery may be used as the primary treatment modality. We evaluatedthe long-term outcome of Gamma Knife radiosurgery (GKRS) for the treatment of patientswith a foramen magnum meningioma. Materials and Methods: Between 1991 and 2005, 222 patients with a meningioma in the posterior fossa were treated with GKRS at the University of Virginia. Of these patients, 5 had meningiomas involving the foramen magnum. At the time of GKRS, the median age of the patients was 60 years (range, 51-78). Three patients were treated with radiosurgery following an initial resection and 2 were treated with upfront radiosurgery. The patients were assessed clinically and radiologically at routine intervals following GKRS. Results: The median tumor volume was 6.8 cc (range 1.9-17 cc). The GKRS tumor received a marginal dose of 12 Gy (range 10-15), and the median number of isocenters was 5 (range 3-19). The mean follow-up was 6 years (range 4-13). One lesion increased in size following GKRS requiring a second treatment, resulting in size stabilization. At the time of the last follow-up, all meningiomas had either demonstrated no growth (n = 4) or reduction in size (n = 1). No patients experienced post-radiotherapy complications. Conclusions: GKRS affords a high rate of tumor control and preservation of neurologic function for patients with foramen magnum meningiomas. Further study of its role in the neurosurgical management of such patients seems warranted.
  5,433 132 10
Clinico-radiological profile of indirect neural decompression using cage or auto graft as interbody construct in posterior lumbar interbody fusion in spondylolisthesis: Which is better?
QR Abdul, MS Qayum, MV Saradhi, MK Panigrahi, V Sreedhar
January-June 2011, 2(1):12-16
DOI:10.4103/0974-8237.85308  PMID:22013370
Study design: A prospective clinical study of posterior lumbar interbody fusion in grade I and II degenerative spondylolisthesis was conducted between Mar 2007 and Aug 2008. Purpose: The objective was to assess the clinicoradiological profile of structural v/s nonstructural graft on intervertebral disc height and its consequences on the low back pain (LBP) assessed by Visual analog score (VAS) score and oswestry disability index (ODI) . This study involved 28 patients. Inclusion criteria: Age of 30-70 years, symptomatic patient with disturbed Activities of daily living (ADL), single-level L4/L5 or L5/S1 grade I or grade II degenerative spondylolisthesis. Exclusion criteria: Patients with osteoporosis, recent spondylodiscitis, subchondral sclerosis, visual and cognitive impairment and all other types of spondylolisthesis. All the patients underwent short-segment posterior fixation using CD2 or M8 instrumentation, laminectomy discectomy, reduction and distraction of the involved vertebral space. In 53.5% (n = 15) of the patients, snugly fitted local bone chips were used while in 46.4% (n = 13) of the patients, cage was used. Among the cage group, titanium cage was used in nine (32.1%) and PEEK cages were used in four (14.2%) patients. In one patient, a unilateral PEEK cage was used. The mean follow-up period was 24 months. Among the 28 patients, 67.8% (n = 19) were females and 32.14% (n = 9) were males. 68.24% (n = 18) had L4/L5 and 35.71% (n = 10) had L5/S1 spondylolisthesis. 39.28% (n = 11) were of grade I and 60.71% (n = 17) were of grade II spondylolisthesis. Conclusions: There was a statistically significant correlation (P < 0.012 and P < 0.027) between the change in disc height achieved and the improvement in VAS score in both the graft group and the cage group. The increment in disc height and VAS score was significantly better in the cage group (2 mm ± SD vis-a-vis 7.2 [88%]) than the graft group (1.2 mm ± SD vis-a-vis 5 [62 %]).
  5,544 16 3
CASE REPORTS
Supratentorial glioblastoma multiforme with spinal metastases
Abhidha Shah, Rakesh Redhu, Trimurti Nadkarni, Atul Goel
July-December 2010, 1(2):126-129
DOI:10.4103/0974-8237.77678  PMID:21572635
Glioblastoma multiforme is the most common malignant brain tumor in adults. Metastasis of intracranial glioblastoma via the cerebrospinal fluid to the spine is a rare occurrence. We present two cases of glioblastoma multiforme with spinal leptomeningeal spread who presented with back pain and paraparesis.
  5,503 4 8
REVIEW ARTICLES
Approaches to anterior and anterolateral foramen magnum lesions: A critical review
Ricardo J Komotar, Brad E Zacharia, Robert A McGovern, Michael B Sisti, Jeffrey N Bruce, Anthony L D'Ambrosio
July-December 2010, 1(2):86-99
PMID:21572629
Foramen magnum (FM) lesions represent some of the most complex cases for the modern neurosurgeon because of their location near vital brainstem structures, the vertebral arteries, and lower cranial nerves. In particular, anterior or anterolaterally located FM tumors have traditionally been most difficult to resect with high morbidity and mortality resulting from approaches through the posterior midline or transorally. For many neurosurgeons, the far lateral, extreme lateral approach, and more recently, endoscopic endonasal approaches have become the preferred modern methods for the resection of anterior or anterolateral FM tumors. In this review, we examine both operative and non-operative approaches to FM tumors, including surgical anatomy, surgical technique, and indications for operative intervention in these complex cases. In addition, we compared outcomes from prior series.
  5,421 17 -
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