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   2016| October-December  | Volume 7 | Issue 4  
    Online since November 2, 2016

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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.
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Clinical anatomy and significance of the thoracic intervertebral foramen: A cadaveric study and review of the literature
Grigorios Gkasdaris, Grigorios Tripsianis, Konstantinos Kotopoulos, Stylianos Kapetanakis
October-December 2016, 7(4):228-235
DOI:10.4103/0974-8237.193266  PMID:27891032
Introduction: The literature is lacking information on the anatomy and the osseous dimensions of the thoracic intervertebral foramen (IVF). We describe the anatomy of the broader area, and we proceed with morphometric data of the vertebrae and the foramina. Depiction of these features is provided with imaging and illustrations. The purpose of this paper is to survey and present the anatomy of the foramen as a whole and provide baseline statistical data. Materials and Methods: We review relevant literature, and we present data obtained from skeletal samples of known population and sex. One hundred and nineteen thoracic vertebrae of ten cadaveric spines from the prefecture of Eastern Macedonia and Thrace, Greece, were selected. Statistical analysis measuring the vertical height and the foraminal width of each vertebra was made in accordance with sex. Results: No statistically important differences referring to the descriptive data of both sexes were found. However, statistically, important positive correlation between the vertebral height and the foraminal width was observed, especially for men. The components of the foramen including arteries and veins passing through or neighboring it, and the spinal nerves and roots are described and depicted. Conclusions: The osseous thoracic IVF reveals a glimpse of the in vivo structure and alterations of its width may be present in back pain and other degenerative diseases. Although it is crucial for surgeries and other interventional procedures of the thoracic spine, little is known about the precise anatomy and dimensions of this anatomical landmark.
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The anatomical perspective of human occipital condyle in relation to the hypoglossal canal, condylar canal, and jugular foramen and its surgical significance
Ranjana Verma, Shalini Kumar, Arpita Mahajan Rai, Iqra Mansoor, Raj D Mehra
October-December 2016, 7(4):243-249
DOI:10.4103/0974-8237.193258  PMID:27891034
Background: The transcondylar approach (TCA) has gained importance in recent era which enables shorter and direct route to access the lesions ventral to the brainstem. The important step in this approach is resection of the occipital condyle (OC). The detailed knowledge of bony anatomy of OC and its relation to the hypoglossal canal (HC), condylar canal (CC), and jugular foramen (JF) is very important to avoid any iatrogenic injury during craniovertebral surgeries. The aim of the present study is to conduct a morphometric and morphological study and note the variations of the OC and the structures surrounding it in North Indian population. Materials and Methods: The study was carried out on 100 OC. Morphometric measurements of OC and the distances of HC and JF from the posterior end of OC were noted. In addition, the extent of the HC and JF in relation to OC, presence or absence of CC, shape of the OC, and its articular facet were also noted. Results: The incidence of short OC was seen in 13% skulls. The most common shape of OC was oval or rhomboid. Even though the articular facet was convex in majority of skulls but flat (10%) and concave (1%) were also observed. The external and internal distance of HC from the posterior end of OC was13.83 mm and 10.66 mm on the right side and 15.02 mm and 11.89 mm on the left side. The OC was related in its middle 1/3 to the HC in 15% skulls and to the whole extent of JF in 3% skulls. Thirty four percent skulls displayed the septa in the HC. The CC was present bilaterally in 38% skulls and unilaterally in 40% skulls. Conclusion: The OC and related structures such as HC, CC, and JF are likely to have variations in respect to morphometry and morphology. This study may prove helpful to neurosurgeons operating in this field, especially during TCA where neurovascular structures emerging from these canals and foramen are more vulnerable to injury.
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The role of transforaminal percutaneous endoscopic discectomy in lumbar disc herniations
Sarang Gotecha, Deepak Ranade, Sujay Vikhe Patil, Ashish Chugh, Megha Kotecha, Shrikant Sharma, Prashant Punia
October-December 2016, 7(4):217-223
DOI:10.4103/0974-8237.193267  PMID:27891030
Objectives: To study 1)the efficacy of transforaminal percutaneous endoscopic lumbar discectomy in lumbar disc herniations.2) limitations and advantages of the surgical procedure. 3)morbidity and complications associated with the procedure. Materials and Methods: This study was carried out on 120 patients who had single level herniated disc Pre-operative assessment of VAS and MSS scoring systems were documented one day prior to surgery. Post operative results were determined by MacNab criteria and by modified Suezawa and Schreiber clinical scoring system (MSS score). Results: Maximum patients were in the age group of 31 to 40 years and 83.43% of the patients were males. 80% patients had lumbar disc herniation at L4-L5 level, The mean operative time of endoscopic discectomy was 52.28 minutes and the mean hospital stay was 2.1days .8 cases of L5-S I were abandoned due to high iliac bone and hence their disc could not be accessed.Out of 112 patients who underwent operation, 2 patients developed discitis and 1 was found to have dysesthesia. Also recurrent prolapsed intervertebral disc was seen in 6 cases The mean preoperative and 6 months follow up VAS score was 8.4 and 1.89 respectively. Mean preoperative and 6 months follow up Modified Suezawa And Schreiber Clinical Scoring System(MSS Score) was 3.47 and 7.92 respectively.MSS score showed excellent and good outcome in 82.12% patients and Modified Macnab Criteria showed excellent and good outcome in 89.3% patients at 6months follow up. Conclusion: TPELD can be a reasonable alternative to conventional microscopic discectomy for the treatment of patients with LDH. We also conclude that TPELD is not an effective procedure for L5 -S 1 disc and an open procedure should be opted for better outcomes.
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Intradiscal and intra articular facet infiltrations with plasma rich in growth factors reduce pain in patients with chronic low back pain
Fernando Kirchner, Eduardo Anitua
October-December 2016, 7(4):250-256
DOI:10.4103/0974-8237.193260  PMID:27891035
Context: Low back pain (LBP) is a complex and disabling condition, and its treatment becomes a challenge. Aims: The aim of our study was to assess the clinical outcome of plasma rich in growth factors (PRGF Endoret) infiltrations (one intradiscal, one intra articular facet, and one transforaminal epidural injection) under fluoroscopic guidance control in patients with chronic LBP. PRGF Endoret which has been shown to be an efficient treatment to reduce joint pain. Settings and Design: The study was designed as an observational retrospective pilot study. Eighty six patients with a history of chronic LBP and degenerative disease of the lumbar spine who met inclusion and exclusion criteria were recruited between December 2010 and January 2012. Subjects and Methods: One intradiscal, one intra articular facet, and one transforaminal epidural injection of PRGF Endoret under fluoroscopic guidance control were carried out in 86 patients with chronic LBP in the operating theater setting. Statistical Analysis Used: Descriptive statistics were performed using absolute and relative frequency distributions for qualitative variables and mean values and standard deviations for quantitative variables. The nonparametric Friedman statistical test was used to determine the possible differences between baseline and different follow up time points on pain reduction after treatment. Results: Pain assessment was determined using a visual analog scale (VAS) at the first visit before (baseline) and after the procedure at 1, 3, and 6 months. The pain reduction after the PRGF Endoret injections showed a statistically significant drop from 8.4 ± 1.1 before the treatment to 4 ± 2.6, 1.7 ± 2.3, and 0.8 ± 1.7 at 1, 3, and 6 months after the treatment, respectively, with respect to all the time evaluations (P < 0.0001) except for the pain reduction between the 3rd and 6th month whose signification was lower (P < 0.05). The analysis of the VAS over time showed that at the end point of the study (6 months), 91% of patients showed an excellent score, 8.1% showed a moderate improvement, and 1.2% were in the inefficient score. Conclusions: Fluoroscopy guided infiltrations of intervertebral discs and facet joints with PRGF in patients with chronic LBP resulted in significant pain reduction assessed by VAS.
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Accessory atlantoaxial ligament avulsion fracture of the axis: Are there any clinical implications?
Hamid Reza Niknejad, Frank van Calenbergh, Philippe Demaerel, Johannes van Loon
October-December 2016, 7(4):273-275
DOI:10.4103/0974-8237.193259  PMID:27891038
Injuries to the craniocervical support structures are frequently observed in neurotrauma cases. Stability of this region is of vital importance. Literature has mainly focused on three major ligaments of the craniocervical junction: The tectorial membrane, the transverse ligament, and the alar ligaments. However, the accessory atlantoaxial ligament (ALL) also seems to be involved in craniocervical stability as shown in cadaveric specimens. Still, the biomechanical importance of this structure needs to be determined, especially in trauma settings. Here, we describe a case of isolated traumatic injury to this structure and discuss the clinical outcome. A 64 year old polytrauma patient with a remarkable avulsion fracture at the site of the insertion of the ALL was admitted to our center. We evaluated the patient both clinical and radiological at admission, after 3 months and after 1 year. We clinically assessed the upper cervical rotational stability using the cervical flexion rotation test. We observed no rotational instability or any other clinical repercussions at the long term after an isolated ALL injury. This case shows that isolated traumatic damage to the ALL is possible. Unilateral damage to the ALL probably does not cause rotational instability of the craniocervical junction. In case a similar avulsion fracture is observed, we recommend performing a magnetic resonance imaging of the craniovertebral region to assess for any ligamentous lesions.
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Purely extradural spinal nerve root hemangioblastomas
Murat Hamit Aytar, Ulaş Yener, Murat Sakir Ekşi, Behram Kaya, Serdar Özgen, Aydin Sav, Ahmet Alanay
October-December 2016, 7(4):197-200
DOI:10.4103/0974-8237.193255  PMID:27891027
Spinal nerve root hemangioblastomas present mostly as intradural-extradurally. Purely extradural spinal nerve root hemangioblastoma is a very rare entity. In this study, we aimed to analyze epidemiological perspectives of purely extradural spinal nerve root hemangioblastomas presented in English medical literature in addition to our own exemplary case. PubMed/MEDLINE was searched using the terms “hemangioblastoma,” “extradural,” “spinal,” and “nerve root.” Demographical variables of age, gender, concomitant presence of von Hippel–Lindau (VHL) disease; spinal imaging and/or intraoperative findings for tumor location were surveyed from retrieved articles. There are 38 patients with purely extradural spinal nerve root hemangioblastoma. The median age is 45 years (range = 24–72 years). Female:male ratio is 0.6. Spinal levels for purely extradural spinal nerve root hemangioblastomas, in order of decreasing frequency, are thoracic (48.6%), cervical (13.5%), lumbar (13.5%), lumbosacral (10.8%), sacral (8.1%), and thoracolumbar (5.4%). Concomitant presence of VHL disease is 45%. Purely extradural spinal nerve root hemangioblastomas are very rare and can be confused with other more common extradural spinal cord tumors. Concomitant presence of VHL disease is observed in less than half of the patients with purely extradural spinal nerve root hemangioblastomas. Surgery is the first-line treatment in these tumors.
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Complete morphometric analysis of jugular foramen and its clinical implications
Sushant Swaroop Das, Sandeep Saluja, Neelam Vasudeva
October-December 2016, 7(4):257-264
DOI:10.4103/0974-8237.193268  PMID:27891036
Introduction: Tumors affecting structures in the vicinity of jugular foramen such as glomus jugulare require microsurgical approach to access this region. These tumors tend to alter the normal architecture of the jugular foramen by invading it. Therefore, it is not feasible to have correct anatomic visualization of the foramen in the presence of such pathologies. Hence, a comprehensive knowledge of the jugular foramen is needed by all the neurosurgeons while doing surgery in this region. Aim: Due to the inadequate knowledge of the accurate morphology of the jugular foramen in different sexes, the aim of this osteological study was to provide a complete morphometry including gender differences and describe some morphological characteristics of the jugular foramen in an adult Indian population. Materials and Methods:The study was done on 114 adult human dry skulls (63 males and 51 females) collected from the osteology museum in the department. Various dimensions of both endo and exocranial aspect of jugular foramen were measured. Presence and absence of domed bony roof of jugular fossa and compartmentalization of jugular foramen were also noticed. Statistical analysis was done using Chi square test and Student’s t test in SPSS version 23. Results: All the parameters of right jugular foramen were greater than the left side, except the distance of stylomastoid foramen from lateral margin of jugular foramen (SMJF) which was greater on the left side. Gender differences between various measurements of jugular foramen, presence of dome of jugular fossa, and compartmentalization patterns were reported. Conclusion: This study gives knowledge about the various parameters, anatomical variations of jugular foramen in both sexes of an adult Indian population, and its clinical impact on the surgeries of this region.
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Anaesthesia management in craniovertebral junctional anomalies
Oswald Mascarenhas
October-December 2016, 7(4):193-196
DOI:10.4103/0974-8237.193256  PMID:27891026
Craniovertebral Junctional (CVJ) anomalies are developmental disorders that affect the skeleton and enclosed neuraxis at the junction of cranium and cervical spine. The high prevalence of airway obstruction and restrictive pulmonary disease in combination with cardiovascular manifestations poses a high anaesthetic risk to these patients. This article provides a discussion of management of anaesthesia in patients with craniovertebral anomalies, the evaluation of risk factors in these patients and their management, including emergency airway issues.
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Spinal compression fractures due to pregnancy-associated osteoporosis
R Krishnakumar, Arun T Kumar, Mathew John Kuzhimattam
October-December 2016, 7(4):224-227
DOI:10.4103/0974-8237.193263  PMID:27891031
Objectives: To report on unique cases of spinal compression fractures due to pregnancy associated osteoporosis (PAO) and to suggest a satisfactory treatment modality. Materials and Methods: A single center retrospective study. We reviewed the data of 535 patients with osteoporotic spinal compression fractures over a period of 5 year. Two patients who developed spinal compression fractures due to PAO were identified and treated. Results: The clinical presentation and blood investigations ruled out other causes of osteoporosis. Dual energy X ray absorptiometry was used to confirm the diagnosis. All patients improved with medical management. Conclusion: Vertebral fractures due to PAO should be considered as a differential diagnosis in patients with back pain who are in the third trimester of pregnancy or in postpartum. Early recognition and appropriate conservative management would be necessary to prevent complications such as new vertebral fractures and chronic back pain.
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Is the existence of cervical rib an advantage for C7 posterior stabilization?
Sait Ozturk, Hanefi Yildirim, Metin Kaplan
October-December 2016, 7(4):201-203
DOI:10.4103/0974-8237.193269  PMID:27891028
Background and Aim: Defining a new screwing method for C7 posterior stabilization in case of a cervical rib existence aimed in this report. Materials and Methods: Ten adult patients, five of which without cervical rib (Group 1) and the other five of which (Group 2) with cervical rib that has been chosen from the radiology archive. Axial, sagittal, coronal sections of cervical computed tomography and three dimensional images were obtained. Lateral mass sizes of all cases were measured and compared between two groups. The relationship between cervical rib and lateral mass was identified in Group 2. Results: The mean length, width, and height of lateral masses were measured respectively, as 5.4, 17.6, and 12.7 mm in Group 1. The measurement of Group 2 (with cervical rib) revealed the mean length of 20.7, the width of 20.4, and the height of 15.9 mm. When both groups were compared, there were no significant differences between the width and height of the lateral masses. However, axial measurements of Group 2 revealed a remarkable and significant length for screwing. Conclusion: In patients with cervical rib, directing lateral mass screw toward cervical rib conjoint can present a simple and reliable alternative method in C7 posterior stabilization process.
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Inadvertent injection of potassium chloride instead of sodium chloride during treatment of chronic low back ache with epidural injection leading to paraplegia
Rahul Ranjan, Naiyer Asif, Sohail Ahmad, Syed Ifthekar
October-December 2016, 7(4):279-281
DOI:10.4103/0974-8237.193265  PMID:27891040
Epidural injection of steroid is given for back pain resistant to other conservative management. Normal saline (NS) is used as diluent in 80 mg methylprednisolone and a local anesthetic. Due to a similar looking ampoule of NS and potassium chloride (KCl), there is a probability of accidental use of KCl instead of NS. We present a case of a 50 year old male patient having low back ache refractory to other conservative treatments. Epidural injection of steroid was given, but accidently KCl was mixed with methylprednisolone instead of NS. He developed severe cramps in the lower limbs, pruritus, and sweating, and finally paraplegia. Electrocardiography and blood showed features suggestive of hyperkalemia. He was given calcium gluconate and potassium chelating agent along with supportive measures. The patient recovered within 8 h. It is concluded that calcium gluconate and potassium chelating agent can be used if accidentally KCl is injected in epidural space.
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Transthoracic approach for lesions involving the anterior dorsal spine: A multidisciplinary approach with good outcomes
Srikant Balasubramaniam, Devendra K Tyagi, Sheikh H Zafar, Hemant V Savant
October-December 2016, 7(4):236-242
DOI:10.4103/0974-8237.193254  PMID:27891033
Introduction: Anterior approach provides excellent visualization and access to the anterior thoracic spine. It may be used alone, in combination with a posterior midline approach or in a staged or sequential fashion. Aims: To analyse our institutional experience in transthoracic approaches and to determine the safety and benefit of this approach in our patient series. Materials and Methods: A total of 16 patients were operated for varying lesions of body of dorsal vertebra by the transthoracic approach. The study was for a period of 5 years from January 2011 to December 2015. Patients age ranged from 25 to 61 years with an average of 36.4 yrs. There were 7 males and 9 females. In our series 9 patients had Kochs spine, 4 patients were traumatic fracture spine and 3 had neoplastic lesion. Majority of patients had multiple symptoms with backache being present in all patients. Results: There was one post operative mortality which was unrelated to surgery. One patient had post operative delayed kyphosis. Remaining patients improved in their symptoms following surgery. Conclusion: With careful coordination by thoracic surgeons, neurospinal surgeons and anaesthetists, the anterior spine approach for dorsal spine is safe and effective. Adequate preoperative evaluation should stratify the risk and institute measures to reduce it. Accurate surgical planning and careful surgical technique are the key to yield a good outcome and to reduce the risk of complications.
  2,056 21 -
External syrinx introduction of a new term
Atul Goel
October-December 2016, 7(4):191-192
DOI:10.4103/0974-8237.193253  PMID:27891025
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Revisiting cruciate paralysis: A case report and systematic review
Benjamin Hopkins, Ryan Khanna, Nader S Dahdaleh
October-December 2016, 7(4):265-272
DOI:10.4103/0974-8237.193262  PMID:27891037
Objective: Cruciate paralysis is a rare, poorly understood condition of the upper craniovertebral junction that allows for selective paralysis of the upper extremities while sparing the lower extremities. Reported cases are few and best treatment practices remain up for debate. The purpose of this study was to conduct a systemic literature review in an attempt to identify prognostic predictors and outcome trends associated with cases previously reported in the literature. Materials and Methods: We conducted a systematic literature review for all cases using the term "Cruciate Paralysis," reviewing a total of 37 reported cases. All outcomes were assigned a numerical value based on examination at the last follow up. These numerical values were further analyzed and tested for statistical significance. Results: Of the 37 cases, 78.4% were of traumatic causes. Of these, there were considerably worse outcomes associated with patients over the age of 65 years (P < 0.001). Those patients undergoing surgical treatment showed potentially worse outcomes, with a P value approaching significance at P = 0.08. Conclusion: Numerous cases of trauma associated cruciate paralysis have been reported in the literature; however, there remains a strong need for further study of the condition. While certain risk factors can be elicited from currently reported studies, insignificant data exist to make any sound conclusion concerning whether surgical intervention is always the best method of treatment.
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Chronic Pseudomonas aeruginosa cervical osteomyelitis
Sujeet Kumar Meher, Harsh Jain, Laxmi Narayan Tripathy, Sunandan Basu
October-December 2016, 7(4):276-278
DOI:10.4103/0974-8237.193264  PMID:27891039
Pseudomonas aeruginosa is a rare cause of osteomyelitis of the cervical spine and is usually seen in the background of intravenous drug use and immunocompromised state. Very few cases of osteomyelitis of the cervical spine caused by pseudomonas aeruginosa have been reported in otherwise healthy patients. This is a case presentation of a young female, who in the absence of known risk factors for cervical osteomyelitis presented with progressively worsening neurological signs and symptoms.
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Spinal cysticercosis: A report of two cases with review of literature
Ishita Pant, Sujata Chaturvedi, Gurbachan Singh, Sanjeev Gupta, Rima Kumari
October-December 2016, 7(4):285-288
DOI:10.4103/0974-8237.193261  PMID:27891042
Neurocysticercosis is the most common parasitic infection of the central nervous system worldwide. However, Cysticercosis affecting the spine is considered extremely rare. We report two cases of spinal cysticercosis with review of literature.
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Spinal intradural hydatid cyst causing arachnoiditis: A rare etiology of cauda equina syndrome
Suyash Singh, Jayesh Sardhara, Amit Kumar Singh, Arun Kumar Srivastava, Kamlesh Singh Bhaisora, Kuntal Kanti Das, Anant Mehrotra, Rabi N Sahu, Awadhesh Kumar Jaiswal, Sanjay Behari
October-December 2016, 7(4):282-284
DOI:10.4103/0974-8237.193257  PMID:27891041
This study aims to focus on a rare presentation of spinal hydatid cyst as cauda equine syndrome and misdiagnosed as intradural extramedullary (IDEM) benign lesion on magnetic resonance imaging. In this article, we report a case of spinal hydatid cyst masquerading as IDEM tumor, and intraoperatively, we accidently find clumped granuloma with severe arachnoiditis and hydatid cyst in lumber region, which was present as bilateral S1 radiculopathy with cauda equina syndrome. An 11 year old boy who presented with symptoms and signs of cauda equina syndrome and planned for surgical excision. His radiological impression was IDEM possibly neurofibroma. To our surprise, we found multiple intradural cystic lesions with arachnoiditis. Dissecting in plane cyst was flushed out, and surgical cavity was irrigated with 3% saline. Postoperatively histopathology and serum tests confirmed the diagnosis of hydatid cyst. Hydatid disease is rare cause of cauda equine syndrome which can be miss diagnosed on radiological investigations. A high index of suspicion should be kept especially in a young patient from the Indian subcontinent.
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