The C1-2 joints in cases of congenital atlantoaxial dislocation are often oblique in both sagittal and coronal planes giving rise to anteroposterior and vertical slip of C1 over C2. Asymmetry on either side gives rise to coronal/lateral angular tilt along with rotational component. The dislocation is a dynamic process though it may appear to be fixed. The compressing dens is effect of dislocation and not the cause. The treatment should be directed towards C1-2 joint manipulation that would realign the joints as well as the dens. The facetal osteotomies coupled with manipulation for realignment in all planes provides a composite solution for even the complex lateral dislocation or complete spondyloptosis with severely deformed C1–2 joints, obviating the need for transoral decompression.

Chiari malformation type 1 (CM 1) is defined as herniation of cerebellar tonsils 4-5 mm below the foramen magnum. Multiple developmental factors like defective development of pontine flexure and shallow posterior fossa are the proposed factors which predispose the development of this syndrome. These reports on familial occurrence of this syndrome correlates with the embryonal- developmental etiology of Chiari 1 malformation. Recent advances in the understanding of the influence of genes and pathogenesis of familial Chiari malformation are expected to improve management of affected patients and monitoring of at-risk family members.

Objectives: The purpose of this study was to describe the free hand method of pedicle screw placement without intraoperative imaging monitors and to evaluate the accuracy of the screw placement in quadriplegics patients. Methods: A free hand screw was inserted in the eleven cervical injury patients with quadriplegia. We studied the preoperative pedicle dimension in all the patients and assessed the clinical and radiological outcome and accuracy of the screw placement. Results: A total of 44 screws were inserted in the cervical pedicles of eleven patients. The postoperative images showed that 28 of the 44 screws had perforated the pedicles but none of them had breached the spinal canal. Among them 16 screws were grade 2 and 12 screws were grade 3. All the screws had penetrated the lateral wall. There were no neurovascular complications related to any malpositioned screw and there was no screw loosening or instrumentation failure in the patients. Conclusion: The free hand screw placement without intraoperative image guidance seems to be safe and effective method of fixation. But this technique requires sound knowledge of the cervical anatomy and experience and is useful in the places where navigation system are not available.

Background: Spontaneous Spinal Epidural Haematoma (SSEH) is a rare entity that results from spontaneous, non-traumatic haemorrhage in the spinal epidural space. While erring on the side of caution, few significant clues in the history can lead to an earlier differentiation from more frequently seen pathologies like acute disc herniation and spinal tumors. Once diagnosed, the decision of surgical versus conservative management is entirely clinical and situation-based. In ambiguous scenarios, the study of specific parameters can help to choose one over another. Objective: We are sharing here our experience of six such patients and review relevant literature, mainly focusing on the variables that can help to determine the best therapeutic plan. Material and Methods: We studied the parameters like age, gender, location, number of levels involved, drug history, duration to surgery, American Spinal Injury Association (ASIA) impairment scale grade at presentation, therapeutic plan, and their final ASIA score for six patients of SSEH who presented to our department. We also reviewed the published literature focusing on therapeutic decision-making in SSEH. Results: Five patients were managed surgically and one conservatively. Variables considered while opting for surgical treatment. One patient was managed conservatively based on his improving neurology. Conclusions: Patients with SSEH need to be cautiously selected for surgical or conservative management for their optimal outcome. The study's various variables highlight a few critical concerns while predicting the outcome and guide one to decide a therapeutic plan for this rare pathology.

Objective: This study aimed to predict the absolute criteria for surgical intervention and study the outcome of surgical intervention. Materials and Methods: A prospective study was conducted from June 2002 to July 2003. A total of 35 patients were included in the study. Pre- and postoperative Oswestry Disability Index (ODI) scores were evaluated for all the patients. All patients underwent magnetic resonance imaging (MRI). The surgical indications were disabling backache with radicular pain, limited walking capacity, and neurological deficits leading to a poor ODI score. Surgical procedures done were discectomy and laminectomy with or without fixation with pedicle screws on a case-to-case basis. Follow-up was done for up to 1 year at three-monthly intervals. The final ODI score was taken at the last follow-up and was compared with preoperative scores. Results: A 50 ± 10 years was the average age of patients included in the study. The average walking capacity was 40 m; the average duration of symptoms was 41 months. ODI improved from average score of 71% ± 4% preoperatively to 22% ± 6% postoperatively. L4–L5 was the level most severely narrowed, with a mean cross-sectional area of 75 mm². The most common surgical interventions done were discectomy and laminectomy, which were performed in 54% of the cases. We had good-to-excellent results in all our cases. None of the cases deteriorated after surgery. Conclusion: The findings in this study have important implications in clinical practice. The radiological findings in the MRI correlated well with the clinical signs and symptoms of the patients, i.e., patients with significant findings in the MRI had profound clinical symptoms and neurological deficits. Clinical Significance: Lumbar canal stenosis is a clinicoradiological diagnosis. ODI score is related to canal narrowing on MRI. Clinical improvement is related to preoperative disability and canal narrowing on MRI.

Laminectomy and fusion were surgical options to decompress neural structures and provide more space for the spinal cord in a stenosis patient with severe leg pain and progressive neurologic signs, such as numbness and weakness. The evolution of endoscopic spinal surgery techniques has created advantages for patients who require a laminectomy. The authors present a unique technique for endoscopic access to the central and lateral recess pathology as a minimally invasive procedure, which provides a good visualization. We performed two cases of endoscopic spinal surgery for single-level and consecutive three-level lumbar spinal canal stenosis using an 8 mm outer diameter, 5.5 mm working channel, 10° angled lens spinal endoscopic system (percutaneous stenoscopic lumbar decompression, MaxMore Spine Company, Unterföhring, Germany). Optimized endoscopic drills, forceps, and Kerrison punch were used to remove bony pathology and ligamentum flavum under direct endoscopic visualization. The first case had a narrow canal space in the L4/L5 segment with severe numbness at the same dermatome and did not respond with adequate conventional treatment. The second case had three-level canal stenosis with severe back pain and leg weakness. The purpose of this paper is to describe the technique, the efficacy, and feasibility of unilateral endoscopic laminectomy and bilateral decompression via posterior approach in lumbar spinal canal stenosis. Moreover, in this article, we present the technical details on endoscopic procedures and the prevention of complications and management during operation for spinal canal stenosis.

Spinal cord ependymomas are the most common neuroepithelial tumors in adults accounting for two-third of all spinal gliomas. Although most patients with spinal cord tumors present with typical symptoms, the presence of a nonspecific clinical presentation with low clinical suspicion results in delayed diagnosis. We report a case of spinal intramedullary ependymoma in a 39-year-old man who presented with atypical pain over the lower half of the right side of the face for 3 months. Magnetic resonance imaging revealed a high cervical intramedullary contrast-enhancing solid mass lesion. The lesion was excised via cervical laminectomy. Histopathological examination confirmed the presence of an ependymoma. Complete resolution of facial pain was achieved postsurgery. At 2 years of follow-up, there was no evidence of clinical or radiological recurrence. Atypical facial pain can be the presenting feature of spinal intramedullary ependymoma. Complete relief of facial symptoms can be achieved by microsurgical excision.

Mobile intradural extramedullary tumor is a rare entity with only 26 cases reported in the English literature. There is no case report of spinal paraganglioma migrating spontaneously and causing the acute neurological deficit, to the best of our knowledge. We present the first case report of a mobile spinal paraganglioma and review the literature.

Structural developmental anomalies affecting the vertebral column resulting in malformed vertebrae are numerous. It can arise secondary to errors of vertebral formation, fusion and/or segmentation and developmental variation. These anomalies can occasionally mimic acute trauma and predispose the affected individual to compressive myelopathy. A butterfly vertebrae is a rare form of congenital vertebral segmentation anomaly resulting from symmetric fusion defect. It can easily be confused with burst fracture, hence though rare, we should be aware of this anomaly for a correct diagnosis while treating a patient.

Kambin's triangle is a safe corridor for transforaminal endoscopic approach as it is devoid of any neurovascular structure. We came across an interesting case where we encountered a large conjoined lumbosacral nerve root (CNR) in Kambin's triangle during transforaminal endoscopic spine surgery. Patient had intraoperative sympathetic shock which recovered after administering atropine. A 50-year-old female presented with low back pain with bilateral lower limb radiculopathy for 3 years. Magnetic resonance imaging revealed left L4-5 foraminal annular fissure. Radiculopathy was in L5 dermatomal pattern which was confirmed by diagnostic discography and lateral recess block. Left-sided L4-5 transforaminal endoscopic lumbar discectomy was done where we encountered a large CNR in safe zone of Kambin's triangle. Transforaminal endoscopic spine surgery done under monitored anesthesia care with patient in awake and aware state allows identification, diagnosis, and prevention of injury to anomalous neural structure in Kambin's triangle to avoid incidence of failed back syndrome.