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   2016| April-June  | Volume 7 | Issue 2  
    Online since May 5, 2016

 
 
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STUDENTS CORNER
Stem cell therapy in spinal cord injury: Hollow promise or promising science?
Aimee Goel
April-June 2016, 7(2):121-126
DOI:10.4103/0974-8237.181880  PMID:27217662
Spinal cord injury (SCI) remains one of the most physically, psychologically and socially debilitating conditions worldwide. While rehabilitation measures may help limit disability to some extent, there is no effective primary treatment yet available. The efficacy of stem cells as a primary therapeutic option in spinal cord injury is currently an area under much scrutiny and debate. Several laboratory and some primary clinical studies into the use of bone marrow mesenchymal stem cells or embryonic stem cell-derived oligodentrocyte precursor cells have shown some promising results in terms of remyelination and regeneration of damaged spinal nerve tracts. More recently,laboratory and early clinical experiments into the use of Olfactory Ensheathing Cells, a type of glial cell derived from olfactory bulb and mucosa have provided some phenomenal preliminary evidence as to their neuroregenerative and neural bridging capacity. This report compares and evaluates some current research into selected forms of embryonic and mesenchymal stem cell therapy as well as olfactory ensheathing cell therapy in SCI, and also highlights some legal and ethical issues surrounding their use. While early results shows promise, more rigorous large scaleclinical trials are needed to shed light on the safety, efficacy and long term viability of stem cell and cellular transplant techniques in SCI.
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CASE REPORTS
Syringomyelia secondary to "occult" dorsal arachnoid webs: Report of two cases with review of literature
Parag P Sayal, Arif Zafar, Thomas A Carroll
April-June 2016, 7(2):101-104
DOI:10.4103/0974-8237.181862  PMID:27217656
In a certain group of patients with syringomyelia, even with the advent of sophisticated magnetic resonance imaging (MRI), no associated abnormality or cerebrospinal fluid (CSF) block is easily identified. This type of syringomyelia is often termed idiopathic. Current literature has less than 10 reports of arachnoid webs to be the causative factor. We present our experience in the management of two cases of syringomyelia secondary to arachnoid webs. Both our patients presented with progressive neurological deterioration with MRI scans demonstrating cervical/thoracic syrinx without Chiari malformation or low-lying cord. There was no history of previous meningitis or trauma. Both patients underwent myelography that demonstrated dorsal flow block implying CSF obstruction. Cord displacement/change in caliber was also noted and this was not evident on MRI scans. Both patients underwent thoracic laminectomy. After opening the dura, thickened/abnormal arachnoid tissue was found that was resected thus widely communicating the dorsal subarachnoid space. Postoperatively at 6 months, both patients had significant symptomatic improvement with follow-up MRI scans demonstrating significant resolution of the syrinx. In patients with presumed idiopathic syringomyelia, imaging studies should be closely inspected for the presence of a transverse arachnoid web. We believe that all patients with idiopathic symptomatic syringomyelia should have MRI CSF flow studies and/or computed tomography (CT) myelography to identify such arachnoid abnormalities that are often underdiagnosed. Subsequent surgery should be directed at the establishment of normal CSF flow by laminectomy and excision of the offending arachnoid tissue.
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ORIGINAL ARTICLES
Cervical disc hernia operations through posterior laminoforaminotomy
Coskun Yolas, Nuriye Guzin Ozdemir, Hilmi Onder Okay, Ayhan Kanat, Mehmet Senol, Ibrahim Burak Atci, Hakan Yilmaz, Mustafa Kemal Coban, Mehmet Onur Yuksel, Umit Kahraman
April-June 2016, 7(2):91-95
DOI:10.4103/0974-8237.181854  PMID:27217655
Objective: The most common used technique for posterolateral cervical disc herniations is anterior approach. However, posterior cervical laminotoforaminomy can provide excellent results in appropriately selected patients with foraminal stenosis in either soft disc prolapse or cervical spondylosis. The purpose of this study was to present the clinical outcomes following posterior laminoforaminotomy in patients with radiculopathy. Materials and Methods: We retrospectively evaluated 35 patients diagnosed with posterolateral cervical disc herniation and cervical spondylosis with foraminal stenosis causing radiculopathy operated by the posterior cervical keyhole laminoforaminotomy between the years 2010 and 2015. Results: The file records and the radiographic images of the 35 patients were assessed retrospectively. The mean age was 46.4 years (range: 34-66 years). Of the patients, 19 were males and 16 were females. In all of the patients, the neurologic deficit observed was radiculopathy. The posterolaterally localized disc herniations and the osteophytic structures were on the left side in 18 cases and on the right in 17 cases. In 10 of the patients, the disc level was at C5-6, in 18 at C6-7, in 2 at C3-4, in 2 at C4-5, in 1 at C7-T1, in 1 patient at both C5-6 and C6-7, and in 1 at both C4-5 and C5-6. In 14 of these 35 patients, both osteophytic structures and protruded disc herniation were present. Intervertebral foramen stenosis was present in all of the patients with osteophytes. Postoperatively, in 31 patients the complaints were relieved completely and four patients had complaints of neck pain and paresthesia radiating to the arm (the success of operation was 88.5%). On control examinations, there was no finding of instability or cervical kyphosis. Conclusion: Posterior cervical laminoforaminotomy is an alternative appropriate choice in both cervical soft disc herniations and cervical stenosis.
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HISTORICAL VIGNETTE
Management of basilar invagination: A historical perspective
Abhidha Shah, Elena Serchi
April-June 2016, 7(2):96-100
DOI:10.4103/0974-8237.181856  
For a long time the terms basilar invagination and platybasia were used interchangeably. Basilar invagination has been defined as a prolapse of the vertebral column into the spinal cord. Platybasia is defined as an abnormal obtuse angle between the anterior skull base and the clivus. The authors review the existing literature and summarize the historical and modern perspectives in the management of basilar invagination. From radiological curiosities, the subject of basilar invagination is now viewed as eminently treatable. The more pronounced understanding of the subject has taken place in the last three decades when on the basis of understanding of the biomechanical subtleties the treatment paradigm has remarkably altered. From surgery that involved decompression of the region, stabilization and realignment now form the basis of treatment.
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CASE REPORTS
Late onset leptomeningeal and whole spine metastasis from supratentorial Glioblastoma multiforme: An uncommon manifestation of a common tumor
Divyam Sharma, Anshul Gupta, Gurupal S Dhillon, Satnam Singh Chhabra
April-June 2016, 7(2):118-120
DOI:10.4103/0974-8237.181878  PMID:27217661
Glioblastoma multiforme (GBM) is one of the most common and aggressive primary brain tumors, composing 12-20% of all the intracranial tumors in adults with a highly malignant course and average life expectancy of approximately 12-14 months following initial diagnosis. Leptomeningeal or intramedullary metastasis from primary GBM is a rare phenomenon with a poor prognosis. We present a rare case of GBM with late onset intramedullary, extramedullary, as well as leptomeningeal spinal metastasis.
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ORIGINAL ARTICLES
Inequality in leg length is important for the understanding of the pathophysiology of lumbar disc herniation
Mehmet Sabri Balik, Ayhan Kanat, Adem Erkut, Bulent Ozdemir, Osman Ersagun Batcik
April-June 2016, 7(2):87-90
DOI:10.4103/0974-8237.181829  PMID:27217654
Objective: Inequality in leg length may lead to to abnormal transmission of load across the endplates and degeneration lumbar spine and the disc space. There has been no study focusing on lumbar disc herniation (LDH) and leg length discrepancy. This subject was investigated in this study. Materials and Methods: Consecutive adult patients with leg length discrepancy and low back pain (LBP) admitted to our department were respectivelly studied. Results: A total number of 39 subjects (31 women and eight men) with leg length discrepancy and LBP and 43 (25 females and 18 males) patients with LBP as a control group were tested. Occurrence of disc herniation is statistically different between patients with hip dysplasia and control groups (P < 0.05). Conclusion: The results of this study showed a statistically significant association between leg length discrepancy and occurrence of LDH. The changes of spine anatomy with leg length discrepancy in hip dysplastic patients are of importance in understanding the nature of LDH.
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"Two-step" technique with OsiriXTM to evaluate feasibility of C2 pedicle for surgical fixation
Luis Miguel Sousa Marques, Goncalo Neto d Almeida, Jose Cabral
April-June 2016, 7(2):75-81
DOI:10.4103/0974-8237.181826  PMID:27217652
Background: Surgical treatment of craniovertebral junction pathology has evolved considerably in recent decades with the implementation of short atlanto-axial fixation techniques, notwhithstanding increasing neurovascular risks. Also, there is strong evidence that fixation of C2 anatomical pedicle has the best biomechanical profile of the entire cervical spine. However, it is often difficult and misleading, to evaluate anatomical bony and vascular anomalies using the three orthogonal planes (axial, coronal, and sagittal) of CT. Objectives: The authors describe an innovative and simple technique to evaluate the feasibility of C2 pedicle for surgical screw fixation using preoperative planning with the free DICOM (Digital Imaging and Communications in Medicine) software OsiriX TM . Materials and Methods: The authors report the applicatin of this novel technique in 5 cases (3 traumatic, 1 Os Odontoideum, and 1 complex congenital malformation) collected from our general case series of the Department in the last 5 years. Results: In this "proof of concept" study, the pre-operative analysis with the "two-step" tecnique was detrimental for choosing the surgical tecnique. Detailed post-operative analysis confirmed correct position of C2 screws without cortical breach. There were no complications or mortality reported. Conclusion: This "two-step" technique is an easy and reliable way to determine the feasibility of C2 pedicle for surgical fixation. The detailed tridimensional radiological preoperative evaluation of craniovertebral junction anatomy is critical to the sucess and safety of this surgeries, and can avoid, to certain degree, expensive intra-operative tridimensional imaging facilities.
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Prediction of surgical outcome in compressive cervical myelopathy: A novel clinicoradiological prognostic score
Rishi Anil Aggarwal, Sudhir Kumar Srivastava, Sunil Krishna Bhosale, Pradip Sharad Nemade
April-June 2016, 7(2):82-86
DOI:10.4103/0974-8237.181828  PMID:27217653
Context: Preoperative severity of myelopathy, age, and duration of symptoms have been shown to be highly predictive of the outcome in compressive cervical myelopathy (CCM). The role of radiological parameters is still controversial. Aims: Define the prognostic factors in CCM and formulate a prognostic score to predict the outcome following surgery in CCM. Settings and Design: Retrospective. Materials and Methods: This study included 78 consecutive patients with CCM treated surgically. The modified Japanese Orthopaedic Association (mJOA) scale was used to quantify severity of myelopathy at admission and at 12-month follow-up. The outcome was defined as "good" if the patient had mJOA score ≥16 and "poor" if the score was <16. Age, sex, duration of symptoms, comorbidities, intrinsic hand muscle wasting (IHMW), diagnosis, surgical technique, Torg ratio, instability on dynamic radiographs, and magnetic resonance imaging (MRI) signal intensity changes were assessed. Statistics: Statistical Package for the Social Sciences (SPSS) (version 20.0) was used for statistical analysis. The association was assessed amongst variables using logistic regression analysis. Parameters having a statistically significant correlation with the outcome were included in formulating a prognostic score. Results: Severity of myelopathy, IHMW, age, duration, diabetes, and instability on radiographs were predictive of the outcome with a P value <0.01. Genders, diagnosis, surgical procedure, Torg ratio, and intensity changes on MRI were not significantly related to the outcome. A 8-point scoring system was devised incorporating the significant clinicoradiological parameters, and it was found that nearly all patients (97.82%) with a score below 5 had good outcome and all patients (100%) with a score above 5 had poor outcome. The outcome is difficult to predict with a score of 5. Conclusions: Clinical parameters are better predictors of the outcome as compared to radiological findings, following surgery in CCM. A simple scoring system based on clinicoradiological parameters is suggested in this paper to predict the outcome following surgery in cases of CCM.
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CASE REPORTS
Congenital defects of C1 arches and odontoid process in a child with Down's syndrome: A case presentation
Catherine Hatzantonis, Samiul Muquit, Luigi Aurelio Nasto, Hossein Mehdian
April-June 2016, 7(2):115-117
DOI:10.4103/0974-8237.181877  PMID:27217660
We present the case of a 2-year-old child with Down's syndrome who presented to our unit with torticollis. Imaging studies revealed the rare occurrence of anterior and posterior C1 arch defects, absent odontoid process, and atlantoaxial subluxation. We managed her conservatively for 3 years without neurological deficits or worsening of atlantoaxial subluxation. We discuss the rare occurrences of anterior and posterior arch defects of the atlas, the radiological presentations of axis defects in patients, and the occurrence of atlantoaxial instability in patients with Down's syndrome. Management options with consideration to surgery in asymptomatic and symptomatic patients are also discussed.
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EDITORIALS
Interfacetal intra-articular spacers: Emergence of a concept
Atul Goel
April-June 2016, 7(2):72-74
DOI:10.4103/0974-8237.181825  PMID:27217651
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Atlantoaxial instability: Analyzing and reflecting on the Nature's reparative games
Atul Goel
April-June 2016, 7(2):69-71
DOI:10.4103/0974-8237.181823  PMID:27217650
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CASE REPORTS
Primary intradural sacral epidermoid in a nondysraphic spine: Case report and review of literature
Laxminadh Sivaraju, Sumit Thakar, Nandita Ghosal, Alangar S Hegde
April-June 2016, 7(2):105-108
DOI:10.4103/0974-8237.181866  PMID:27217657
The occurrence of epidermoids within the spinal canal is uncommon. Most of the reported spinal epidermoids (SEs) have been described in the thoracic or lumbar regions. They occur either following trauma or in the setting of coexistent spinal dysraphism. The authors describe an unusual case of a 28-year-old lady who presented with long-standing back pain and urinary incontinence. Magnetic resonance imaging (MRI) of her spine demonstrated a sacral SE without any coexistent spinal dysraphism. The diagnosis of an epidermoid was confirmed by histopathological examination following laminectomy and excision. To the authors' best knowledge, this is the third case of a sacral SE occurring in a non-dysraphic spine. The case is discussed in the light of a relevant literature review.
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Cervicomedullary intramedullary peripheral primitive neuroectodermal tumor with intratumoral bleed: Report of one case and review of literature
Pradeep Sharma, Kuntal K Das, Anant Mehrotra, Arun K Srivastava, Rabi N Sahu, Awadhesh Jaiswal, Rakesh Pandey, Sanjay Behari, Kamlesh S Bhaisora, Jayesh Sardhara
April-June 2016, 7(2):111-114
DOI:10.4103/0974-8237.181874  PMID:27217659
Primitive neuroectodermal tumors (PNET) are highly malignant, yet relatively uncommon neoplasms of the central nervous system. Although a host of different parts of the nervous system can be affected, intramedullary location of PNET is extremely rare. Most reports on intramedullary PNET have reported central PNET (cPNET); peripheral PNET (pPNET) affecting intramedullary spinal location is extremely rare. Till now, seven such cases of intramedullary pPNET have been described in medical literature in English. Here, we report an 11-year-old boy with cervicomedullary junction intramedullary pPNET who presented with intratumoral bleed, wherein the clinical presentation and radiological features gave us no clue preoperatively about the underlying diagnosis. In this report, we additionally review certain salient aspects of this dreaded disease in light of the existing evidence.
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Atlantoaxial dislocation adjacent to kyphotic deformity in a case of adult Larsen syndrome
Sushanta K Sahoo, Arsikere N Deepak, Pravin Salunke
April-June 2016, 7(2):109-110
DOI:10.4103/0974-8237.181869  PMID:27217658
Kyphotic deformity is often seen in Larsen syndrome. However, its progress in adults is not clear. The adjacent level compression in these patients adds to the difficulty regarding the level that needs to be operated. A 56-year-old male presented with neck pain and spastic quadriplegia. Radiology showed kyphotic deformity (sequelae of Larsen syndrome) with atlantoaxial dislocation. Cord compression was apparent at both levels but careful evaluation showed C1-2 level compression and some compression below the kyphotic deformity. The kyphotic spine was already fused and the canal diameter was adequate. The adjacent level C1-2 was fused and he improved dramatically. Correction of long-standing kyphotic deformity may not be necessary, as it unlikely to progress because of its tendency to fuse naturally. Rather, the adjacent levels are likely to compress the cord due to excessive stress. A proper clinical history and a thorough radiological examination help the surgeon to make an appropriate decision.
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