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   Table of Contents - Current issue
October-December 2021
Volume 8 | Issue 4
Page Nos. 1-65

Online since Friday, December 24, 2021

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Aberrant Vertebral Artery and Screw Placement in Lateral Mass of C1 in Atlantoaxial Fixation p. 1
J K. B. C Parthiban
Aberrant vertebral arteries at C1 and C2 facet regions are rare. These vessels can pose challenges while inserting screws into the lateral mass. However, mobilization of these vessels is possible to obtain specific screw entry points. In normal bony anatomy, these aberrant vessels are tortuous and hence can be mobilized quickly. Multiple screw entry points are available for safe screw placement. Aberrant vessels at this region do not preclude the placement of screws in lateral mass.
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Hippocrates and Ethics p. 4
PS Ramani
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Piriformis Syndrome and Variants – A Comprehensive Review on Diagnosis and Treatment p. 7
Anil Pande, Rathipriya Annan Gopinath, Sheena Ali, R Adithyan, Senguttuvan Pandian, Siddhartha Ghosh
Piriformis syndrome (PS) is an entrapment neuropathy caused by the compression of the sciatic nerve by the piriformis muscle (PM). PS pain is described as deep, aching type with tingling and numbness, radiating from the gluteal and perineal area down to the lower limb. Rarely, this nondisc sciatica can present with associated pudendal neuralgia due to added pudendal nerve (PN) Type 1 entrapment. Women are much more likely to develop PS than men. The diagnosis is difficult in the past due to the lack of standardized diagnostic tests. Cases can present with symptoms attributable to PS. They report sciatica, paraesthesia, numbness, and episodic sharp pain in the perineal area, which is exacerbated on prolonged sitting, standing, and walking. Magnetic resonance imaging (MRI) scans of lumbosacral spine and lumbosacral plexus are usually normal. Their clinical symptoms can be misdiagnosed with urinary tract infection. The treatment with antibiotics has no effect on pain and paraesthesia. The urine cultures are negative, consultation with a neurosurgeon is requested due to associated sciatic pain. The compression of sciatic nerve and PN by PM is rare but possible. These symptoms can be misdiagnosed and mistreated. Nondisc sciatica is no longer a rarity with the easy availability of MRI for most patients with lumbago and sciatica. The awareness of possible association of Type 1 pudendal neuralgia with PS is necessary.
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Post-Traumatic Cervicothoracic Junction Fracture–Dislocations: Technical Considerations and Outcome Analysis p. 15
Ravi Sharma, Sachin A Borkar, Ajay Kumar, Priya Narwal, Deepak Gupta, Deepak Agrawal, Shashank Sharad Kale
Aim: This study aimed to evaluate the factors determining the outcome after surgical management of C7–D1 fracture–dislocation and compare the various surgical approaches. Materials and Methodology: Retrospective analysis of 41 patients operated on for C7–D1 fracture–dislocation between 2015 and 2019 is assessed for the outcome. The data about preoperative clinicoradiological parameters and the surgical approach were collected and correlated with the outcome 1 week after surgery and final follow-up. Results: Forty-one patients were operated on for cervicothoracic junction (CTJ) fracture–dislocation during the study period. Out of these, 33 patients were treated via the anterior-only approach, while 4 were treated using the posterior-only and combined approach. Patients with American Spinal Injury Association (ASIA)-B score were found to have significant improvement as opposed to those with ASIA-A score at 1 week after surgery (54% vs. 10%, P = 0.005), at discharge (72.7% vs. 16%, P = 0.002), and at final follow-up (43.5% vs. 91%, P = 0.01). Pneumonia was the most common complication in the postoperative period developing in 36.5% of the patients. Other complications were sepsis (19.5%), bedsores (12.1%), and inhospital mortality (12.1%). Conclusions: CTJ is a notorious area for surgical management due to its unique biomechanical properties. The surgical approach should be customized according to the individual patient profile for optimum results in the postoperative period. CTJ injuries can be surgically managed with anterior, posterior, or combined approaches. Preoperative ASIA score can act as a valuable predictor of postoperative outcome in patients with CTJ injuries.
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Split Cord Malformation: Our Experience p. 20
VB Sandeep, Manpreet Singh Banga, Anantha Kishan, Arjun H Dev, Rajesh B Devabhakthuni, AM Arun Kumar
Background: Split cord malformation (SCM) is a rare form of neural tube defects. It belongs to closed type of neural tube defects. SCM constitutes around one-third of cases of spinal dysraphism. In SCM, there is a division in the spinal cord into two halves which may be equal or unequal. Objective: To analyse the clinical, radiological, intraoperative findings and surgical outcome of patients with SCM. Materials and Methods: This was a retrospective analysis of cases of SCM operated during 3-year period (2016–2019) in our institute. The data for the study were obtained from case records, operation notes, and radiology investigations. Results: There were 20 patients of spinal dysraphism in total, among which 6 cases were of SCM. All 6 cases were symptomatic with swelling in the back. Four had distal foot weakness, two had low backache, two had difficulty in walking, two had hypertrichosis, and one patient had foot deformity with trophic ulceration in the foot. Magnetic resonance imaging (MRI) revealed tethered cord in all 6 cases. Three had syringomyelia, three had lipomeningocele, and one case had intramedullary epidermoid. Computed tomography scan revealed bony spur in 4 cases. All patients underwent surgery. Conclusion: MRI is the investigation of choice and surgery is the treatment of choice. We have observed detethering done at the same sitting as that of the primary surgery has improved outcome. It also avoids the dilemma in attributing the postoperative neurological deficits if any, either to surgical complication or that due to tethered cord.
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Small-Cell Lung Carcinoma Diagnosed Only After Cervical Intradural Metastasis Caused Hemiparesis p. 25
Yoshitaka Hirano, Daichi Fujimori, Fumito Omi, Meitetsu Masawa, Hideo Sakuma, Kazuo Watanabe
We present a rare case of intradural extramedullary metastasis of small-cell lung carcinoma in the cervical spine. Optimal treatment strategies, including the indication for decompressive surgery, are discussed. A 70-year-old male who first presented with nuchal region pain suddenly developed right hemiparesis and was referred to our emergency service. Magnetic resonance imaging of his brain was unremarkable, but additional scanning of the cervical spine revealed an intradural tumor at the right C1–C3 levels. Urgent decompressive surgery was carried out, and gross total removal of the tumor was achieved. The histopathological diagnosis was metastasis of small-cell lung carcinoma. Computed tomography of the lung and abdomen revealed a primary tumor in his left lung, with multiple metastases to the mediastinal lymph nodes, liver, and adrenal gland. The patient was being considered for chemotherapy after some improvement of his hemiparesis and pain, but died on the 13th day due to sudden aggravation of the general condition. There was probably no surgical indication for the present case. Careful assessment and management of the primary disease should be considered the top priority even in patients with emergent neuronal insult.
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Delayed Adjacent Segment Infection After Anterior Cervical Discectomy and Fusion p. 29
Uddanapalli Sreeramulu Srinivasan
Adjacent level infection (ASI) is a rare but potentially serious complication of anterior cervical fusion. We report a case of spondylodiscitis occurring adjacent to level at which anterior cervical discectomy and fusion was performed. The objective is to describe a rare case of cervical ASI which occurred after an undetermined oesophageal injury which lead to a series of complications in the same patient as non-union of the bone graft followed by anterior migration of the bone graft, delayed occurrence of spondylodiscitis at the same level and ASI below that level due to Klebsiella Pneumoniae which was successfully managed.
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Delayed Epidural Hematoma Following Cervical Laminoplasty p. 35
Ravi Sreenivasan, Anirudha Mohite, Kanwaljeet Garg, Sachin Anil Borkar, Shashank Sharad Kale
Postoperative spinal epidural hematoma following posterior cervical spinal surgery is a well-known complication. We report a patient who developed epidural hematoma following C4-D1 laminoplasty on the 10th postoperative day and developed worsening quadriparesis (after significant improvement in the postoperative period), and patient had no coagulation or bleeding disorders. The patient was managed by emergent evacuation of hematoma and recovered well. Our case highlights the fact that a postoperative epidural hematoma can occur anytime following posterior spinal surgery even in patients without any predisposing factors. To the best of our knowledge, only three such cases have been reported in the literature previously and two out of the three cases were on anticoagulants.
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Giant Tuberculous Retropharyngeal Abscess with Associated Neurological Manifestations in Cervical Pott's Disease p. 39
Batuk Diyora, Gagan Dhall, Mehool Patel, Nilesh More, Subhasish Dey, Mazharkhan Mulla
Retropharyngeal abscess is a relatively uncommon pathology that predominantly occurs in the pediatric age group. Tuberculous retropharyngeal abscess (TBRPA) is relatively rare. TBRPA in a 13-year-old female child was reported. She presented with neck pain, restricted neck movements, right upper limb weakness, dysphagia, odynophagia, and weight loss. Radiological imaging showed upper cervical spine tuberculosis with a giant retropharyngeal abscess. She underwent drainage of pus and stabilization of the upper cervical spine. Subsequently, she received antituberculous therapy for 18 months. Postsurgery, her clinical symptoms improved. At a 1-year follow-up, there was no evidence of recurrence of the tuberculous lesion.
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Primary Osseous Solitary Fibrous Tumor of C3 Vertebral Body: A Rare Case Report and Literature Review p. 43
Ashutosh Kumar, Arun K Srivastava, Vipin Sahu, Jayesh Sardhara, Lily Pal, Kamlesh Singh Bhaisora, Ved Prakash Maurya, Sanjay Behari
Solitary fibrous tumor (SFT) is a recently adopted nomenclature in the 2021 WHO Classification of Central Nervous System Tumors, for a group previously recognized by the hybrid term “hemangiopericytoma/SFT.” This is the third case report of primary osseous cervical SFT and the first case wherein the vertebral body was the origin site. We reviewed the literature for its clinical profile and operative nuances. We also reviewed the possible role of the Ki-67 proliferation index in deciding the need for adjuvant therapy in these cases.
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“Crossed C1 Lateral Mass–C2 Subfacetal Screw and Rod Construct” for Atlantoaxial Fixation in Patients with High-Riding Vertebral Artery: A Technical Note p. 46
Vinu V Gopal, Geo Paul Kurikkattayil Jose, Paruvakkattil Kunjan Balakrishnan
Background: Goel–Laheri's posterior C1/C2 fixation technique is the gold standard procedure for atlantoaxial dislocation (AAD) and basilar invagination. Coexisitng vertebral artery anomalies such as high-riding vertebral arteries pose an increased risk of vertebral artery injury during instrumentation. Alternate technique for avoiding vertebral artery injury in such cases like translaminar screw fixation had been associated with a high chance for screw pull out, resulting in an unstable construct. This case report introduces a novel, cost-effective technique of atlantoaxial fixation with a “bilateral crossed C1 lateral mass-C2 subfacetal screw and rod construct” in patients with atlantoaxial subluxation with high-riding vertebral arteries. Case Presentation: A 63-year-old male presented with complaints of neck pain and difficulty in walking. On physical examination, he had features of high cervical myelopathy. Imaging revealed AAD with bilateral high-riding vertebral arteries. He was treated with “Crossed C1 lateral mass-C2 subfacetal screw and rod fixation” without evidence of vertebral artery injury or neurological deficits. Postoperatively, the patient showed significant improvement in pain and Nurick score. Conclusions: This technique has the uniqueness of providing a stable, rigid fixation of the atlantoaxial joint with screws inserted into the C2 body providing good bone purchase and at the same time avoid vertebral artery injury in high riding cases. The surgical technique is demonstrated in a detailed manner in this technical note.
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Dr. Vedantam Rajshekhar – A Passionate Neurospinal Surgeon p. 50
Ranjith K Moorthy
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NSSA President's Note p. 56
Vernon Velho
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Annual NSSA Conference Report-NSSA Spine 2021 p. 57
PK Sahoo
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Presidential Oration-NSSA 2021 p. 59
Sajesh K Menon
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Neurospinal Day Salutation p. 61
Selvan Rajendran
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Caudal Regression Syndrome with Craniovertebral Junction Anomaly p. 63
Ashutosh Kumar, Jayesh Sardhara
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Nightmare of a Spine Surgeon: Atlantoaxial Fixation in a Patient with Intractable Jerky Dystonia p. 65
Parth Prakashbhai Vala
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