A 44-year-old male presented with acute onset retention of urine and low back pain. Magnetic resonance imaging (MRI) of the lumbar spine demonstrated an extradural mass extending from the lower border of the L3 vertebra to upper border of L5 vertebra. Axial imaging showed the posterolaterally located mass lesion on left side, producing significant compression and displacement of thecal sac and exiting nerve root. Following contrast administration, there was a peripheral ring enhancement. Diagnosis of extradural mass lesion was made. In view of urinary retention, urgent laminectomy was performed. The massive sequestrated lumbar disk was found on an exploration that was excised completely. This resulted in prompt relief of backache. Bladder took 2 weeks for complete recovery. Here, an unusual case of sequestrated dorsally placed lumbar disk mimicking tumor is presented.

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Spinal intramedullary tubercular abscess is very rare. We present a 3-year-old boy, with subacute paraparesis and incontinence for 1 day. His MR imaging showed a contrast ring enhancing intramedullary lesion at D10-D12 with central T1-hypointense, T2-hyperintense core and cord expansion. He underwent laminectomy, evacuation of abscess, with antituberculous drugs and steroids postoperatively. There was pus evacuated intraoperatively showing positive acid fast bacilli, and the wall biopsy showed inflammatory cell infiltrate and no giant cell or granuloma formation. Child improved well and discharged well. This is a very rare case of intramedullary spinal tubercular abscess satisfying all of Whitner's criteria.

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Objectives: To study the surgical outcome of lumber disk herniation and factors influencing the surgical outcome. Materials and methods: A case series study of 200 patients with herniated lumbar disk were studied in setting of tertiary hospital in the Department of Neurosurgery at Vijayanagara Institute of Medical Sciences, Bellary, Karnataka during the period of June 2013 to January 2015. Among the selected patients, the sociodemographic profile, clinical profile, radiological profile, and the surgical interventions were undertaken and the outcome was noted. The MacNab scale was used to determine the clinical outcome after surgery. All patients were followed for a period 6 months postoperatively for the presence of complications. Results: Mean age of the patients was 45.63 ± 18.54 years with 61% of males and 39% of them were females. L4-L5 interspace was involved in 138 cases (68.0%), disk was protruded in 54% of the cases, and extruded in 28% of the cases. According to MacNab's criteria, in this study “Excellent” outcome was seen in 146 patients (73%), outcome was “Good” in 45 (22.5%) patients, “Fair” in 7 (3.5%) patients, and “Poor” in 2 cases (1%). Better surgical outcomes were associated with younger patients (p = 0.002), disk prolapse at the level of L4-L5 (p < 0.001), extruded and protruded type of disk prolapse (p = 0.034), and disk prolapse precipitated by lifting inappropriate weight (p = 0.002). Conclusion: The outcome of lumbar discectomy depends more on patient's age, level and type of disk prolapse, factors precipitating disk prolapse, and patient selection than on surgical technique.

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Giant cell tumor (GCT) is a low-grade malignant tumor that commonly involves ends of the long bone. The most common site for GCT of the spine is sacrum. These are rare above the sacrum. We present a case of GCT involving dorsal vertebral body and review regarding the treatment modalities.

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In the cervical spine, the combined ossification of the ligamentum flavum (OLF) and ossification of the posterior longitudinal ligament (OPLL) is rarely seen. Patients are usually treated with cervical laminectomy or laminoplasty with OLF resection. In most of the cases, OLF is adhered to the dura and there is a risk of dural tear or cerebrospinal fluid (CSF) leakage during its resection. In this case report, authors present results of laminectomy with debulking instead of complete excision of OLF for spinal cord decompression in a cervical myelopathy case where OLF was adhered to the dura. A 69-year-old man presented with insidious-onset weakness in bilateral lower limbs and unsteady gait since 1 month. He had a history of neck pain with left upper limb radiation for 2 years. Magnetic resonance imaging (MRI) showed C5 to C6 severe central canal stenosis with underlying myelomalacia. Computed tomography (CT) showed OPLL and OLF contributing to severe central canal stenosis at C5 to C6 level. Patient underwent C4 to C6 laminectomy, debulking of OLF, posterior instrumentation, and fusion with autogenous bone graft from C3 to C6. Histological specimen showed osseous tissue within the ligamentum flavum. After surgery, patient's symptoms improved, and no recurrence was observed at 4 years after surgery. The symptoms of myelopathy were successfully treated with debulking instead of complete excision of OLF, thus reducing the risk of dural tear or CSF leakage.

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Spinal schwannomas are benign, slow-growing nerve sheath tumors presenting as insidious lesions. Acute presentation is rare with spinal schwannomas. An intratumoral bleed causing acute presentation with paraplegia and its recovery after surgical intervention is rarely reported in the literature. We report one such case and discuss the possible mechanism for such presentation and the available literature on the subject.

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Degenerative osteophyte formation in cervical spine is common and anterior osteophytes are usually asymptomatic. Esophageal perforation due to a prominent anterior osteophyte and a hyperextension injury to neck is rare. We report a case and review its literature.

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History: A 54-year-old female presented with complaints of backache since 6 to 8 months, weakness in both lower limbs and difficulty in walking. She had past history of cervical and lumbar decompression surgery. Imaging findings: On MRI, a focal kink was seen in the dorsal spinal cord at T8-T9 level. Anterior displacement of the spinal cord was also seen at this level with prominent posterior subarachnoid spaces. Along with other findings described, it was suggestive of idiopathic spinal cord herniation. Management: Management strategy along with the etiopathogenesis and differential diagnosis is described in the text. Conclusion: Despite the fact that MR imaging appearances of this entity are pathognomonic, missed diagnosis and misdiagnosis are common. Careful imaging study would avoid this.

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Intraspinal epidermoid cyst is a rare tumor. The incidence in adults is lesser than 1% and in children lesser than 3%. Epidermoid cyst is predominantly seen at the dorsal spinal level. A large percentage of epidermoid cysts are intradural extramedullary. Intramedullary epidermal cysts are rarer, with about 70 cases reported in the literature. These may be congenital or acquired with known association with spinal dysraphism. We hereby report a case of thoracic epidermoid cyst in a 22-year-old male with an extramedullary exophytic component and intramedullary cyst with accompanying split cord malformation at the level of lesion.

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Foreign bodies inside the cervical spinal canal causing injury to spinal cord are seen very rarely. Very few cases of glass fragments in the cervical spinal canal were reported till date. In this report, a 17-year-old boy, who was accidentally injured by a glass piece, which penetrated into the cervical spinal cord, was operated upon and, he recovered dramatically. This case report is to emphasize the morbidity caused by small foreign bodies accidentally introduced by trivial injuries.

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Study design: A case report and literature review. Summary of background data: Hemangiomas are frequently considered as hamartomatous congenital vascular malformations. Hemangiomas of the spine are usually lesions of the vertebral bodies, but they can occur at other locations, such as the intramedullary or epidural space. Purely epidural hemangiomas are rare and most of them are of cavernous type. Materials and methods: This is a case report of a 70-year-old male with a D6, D7 dumbbell-shaped capillary hemangioma with extraforaminal extension on the left side. Patient underwent D6-8 laminectomy and en bloc resection of the lesion. Results: Microscopic evaluation showed a fibrofatty tissue with a proliferation of small-sized vascular structures with areas of myxoid appearance. To date, there have been nine epidural capillary hemangiomas of the thoracic and lumbar spine reported in the literature. Conclusion: It is important to consider hemangiomas in the differential diagnosis of epidural lesions with dumbbell-shaped appearance in the magnetic resonance imaging study, especially at the thoracic level. These benign lesions usually present as a progressive myelopathy, so early treatment may prevent permanent neurological deficits and result in complete cure.

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Rhombencephalosynapsis is a rare congenital intracranial malformation. Partial rhombencephalosynapsis is a variation of this anomaly with few reported cases. We report a unique case of a patient with partial rhombencephalosynapsis associated with Chiari II, and various spinal malformations, which is very rare, and only few such cases have been reported in literature. These findings suggest that rhombencephalosynapsis can be associated with spinal malformations and, furthermore, that cases with the common features of rhombencephalosynapsis and Chiari II malformation can exist. Such an association likely represents a new anomaly of the hind brain with spine.

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Introduction: Intramedullary spinal tuberculoma (IMT) combined with abscess is rare. Because of such rarity, there is no standardized treatment protocol for this condition. We present a case of intramedullary tuberculoma combined with abscess in a female child who was successfully treated with surgery and antituberculosis medicine. Case report: We present a case of spinal intramedullary tuberculoma in a 2-year-old female child who was receiving antituberculous treatment for tuberculous meningitis presented with weakness in both lower limbs. Magnetic resonance imaging (MRI) lumbar spine showed heterogeneously enhancing intramedullary lesion in the lumbosacral region which was hypointense on T1-weighted images and hyperintense on T2-weighted imaging. Lesion was explored in view of neurological deficit. Pus containing solid lesion was removed. Histopathology confirmed intramedullary tuberculoma with abscess. Conclusion: Intramedullary tuberculoma with abscess is a rare cause of paraparesis. In spite of antituberculous treatment, patients are susceptible for development of intramedullary tuberculoma with abscess. One has to keep this pathology in mind when patients present with intramedullary space occupying lesions with tuberculous lesions elsewhere.

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Introduction: Ganglioneuroma is a very rare tumor and rarely found bilaterally in association with neurofibromatosis patient. Very few cases of dumbbell ganglioneuroma in the cervical region have been reported in the literature. Materials and methods: A 36-year young male presented to us with a complaint of progressive spastic quadriparesis for 4 years. We did MRI of the cervical spine with contrast and found bilateral symmetrical dumbbell mass at the C1-C2 level severely compressing the spinal cord. Rest of the spine and brain imaging showed normal findings. Result: We operated the patient. Bilateral decompression of the cervical spine at the corresponding level was achieved by complete removal of tumor. Patient's motor power of all limbs gradually improved. Histopathology was done which revealed ganglioneuroma of both the resected tumors. Conclusion: Bilateral symmetric dumbbell ganglioneuroma is extremely rare in C1-C2 region and can be associated with neurofibromatosis Type 1.

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The aim of this editorial is to share and discuss our experience of using diaphragm pacing (phrenic nerve stimulation) in a quadriplegic patient who was ventilator dependent following odontoid fracture and high-level spinal cord contusion. Performing diaphragm pacing is possible in India. However, case selection and involvement of team of specialists is essential. Awareness is lacking among medical professionals and in our society about rehabilitation of quadriplegics.

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The pioneer of neurological surgery in an era when no radiological investigation was available including X-ray, Sir Victor Horsley has earned recognition as the father of neurosurgery. His intellect, interest, and concern for humanity has earned him the knighthood. His association with Sir William Gowers was very appreciable, which helped in the introduction and progress of spinal surgery. The birth and growth of spinal surgery by Sir Victor Horsley and his contributions are briefly discussed in this article.

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Introduction: The use of pedicle screws in stabilizing all three columns of the spine is a well-known but technically demanding procedure. Various assisted techniques like intraoperative fluoroscopy and stereotaxy-guided techniques have marginally increased placement accuracy along with increased radiation exposure to the surgeon and the patient, with an increased operative time. Over the last two decades, a detailed understanding of the anatomy of the thoracolumbar pedicles has led to the emergence of the “free-hand” technique. Objectives: To analyze the pedicle screw placement in thoracic, lumbar, and sacral spine over a 3-year period in terms of the intraoperative and immediate postoperative procedural results using navigation-guided and free hand techniques. Materials and methods: A retrospective study was done over a period of 3 years from November 2012 to December 2015 in a tertiary care center by a single surgeon, involving 118 cases that were done using the C-arm navigation and the free hand technique. Results: The study involved a total of 118 patients and 546 screws over a period of 3 years. The indications consisted of degenerative diseases (72%), infection (12.7%), trauma (12.7%), and malignancy (2.54%). The initial 77 cases were done by image guidance under C arm navigation and the later 41 cases with free hand techniques. Among these, there were eight breaches noted (6.72%), five (6.49%) in the image-guided technique vs three (7.3%) in the freehand technique. The direction of breach was lateral in one case (12.5%) and medial in seven cases (87.5%). Three patients (37.5%) with suboptimal screw placement underwent revision surgery. Four patients (3.36%) in the present study had postoperative neurological deficit in the form of foot drop and preoperative durotomies noted in nine patients (7.62%). Postoperative surgical site infections were noted in four cases (3.38%). Conclusion: Free hand pedicle screw placement based on external anatomy alone can be performed with acceptable safety and accuracy in experienced hands and allows avoidance of radiation exposure encountered in fluoroscopic techniques.

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Aim: To study the outcome of a cohort of patients with atlantoaxial instability (AAI) treated with a combination of C1-C2 transarticular screws and C1 lateral mass fixation. Background: Several surgical techniques have been described for stabilization of the atlantoaxial complex. Each technique differs in its biomechanical properties, advantages, and disadvantages. In this series, we describe our experience with a combined four-point fixation technique that combines C1-C2 transarticular screws with C1 lateral mass fixation for AAI. Materials and methods: We present a single-center retrospective case series of 30 patients who were surgically treated for AAI over one decade. All patients presented with symptoms and signs of AAI and consequently underwent extensive clinical and radiological evaluation prior to surgery. The median follow-up of our cohort was 8.3 months (3–143) with three patients lost to follow-up. Pre and postoperative symptoms were compared, including the visual analog scale (VAS) scores for neck and C2 radicular pain. All patients' preand postoperative lateral dynamic cervical radiographs were evaluated and the posterior atlantodental interval (PADI) was measured. Ranawat functional disability score was used for pre and postoperative evaluation. Results: Of the 30 patients, 8 were male and 22 female. The mean age was 60.4 years (18-78 years). The median hospital stay following surgery was 5 days (2–25 days). The mean preoperative VAS score for neck pain was 6.3 vs 4.3 at the first postoperative review (p = 0.001) on paired comparison. Ranawat scores were available for 26 out of 30 patients. The scores improved following surgery in 8/26 (30.7%) patients, did not change in 17 (65.4%) patients, and deteriorated in only one patient (3.8%). Like the VAS score, improvement in Ranawat score following surgery was significant (p = 0.02). Complications in this series included two unilateral intraoperative vertebral artery injuries associated with placement of C1-C2 transarticular screws, another patient had worsening C2 pain following surgery, and three patients had numbness in the C2 distribution following the procedure. Radiologically, two patients had suboptimal unilateral C2 screw placement despite satisfactory intraoperative fluoroscopic imaging. There were no infections and no implant failure. Conclusion: The addition of C1 lateral mass screws to C1-C2 transarticular screw fixation for the treatment of AAI is an effective and safe procedure worthy of note. Our results and experience prove that this method is extremely beneficial where decompression of the posterior elements of C1 is required and may obviate the need of additional posterior wiring traditionally described. Further studies are necessary to look at the longterm fusion rates and compare them with other procedures.

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Objective: To find out the morphometric factors predicting outcome in Chiari I malformation (CM I) associated with syringomyelia. Materials and methods: In a series of 73 patients with CM I and syrinx who underwent posterior fossa decompression (PFD) between August 2013 and October 2015, a total of 54 subjects with sufficient clinical data and imaging suitable for morphometric measurments were evaluated. The parameters analyzed were posterior fossa volume (PFV), tonsillar descent (TD), foramen magnum (FM) diameter, supra-occiput length, clival length, the syrinx, and cord diameter. Patients were divided into two groups: With or without improvement. Improvement at follow-up was assessed with the Chicago Chiari Outcome Scale (CCOS). Results: Mean PFV was significantly higher in the improvement group (219.90 ± 30.20 vs 187.95 ± 12.51 cm³, p = 0.047). Syrinx to cord ratio was lower in the improved group (0.54 ± 0.21 vs 0.64 ± 0.27, p = 0.081). The cut-off value of preoperative PFV for prediction of improvement was found to be 198.58 cm³ (sensitivity 77.8%, specificity 100%). Conclusion: To the best of our knowledge, this is the largest series to evaluate the role of morphometry in prediction of surgical outcome in patients with CM I associated with syringomyelia. The PFV is the only radiological factor that differs significantly in patients with and without improvement.

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Introduction: To find the incidence of cervical injury in patients dying due to polytrauma observed during autopsy. Materials and methods: A total of 282 autopsies were studied. The cases included were those of polytrauma. The postmortem examination was done in these cases. Examination of Cervical Column was done from C1 to C7 and evidence of injury was noted and its incidence was found. Results: Spinal injuries were often secondary to head impacts, or to primary accelerations of the torso without head impact. At postmortem, cervical spine injuries were noted mostly at C5 to C6 level. The most common age group was 21 to 30 years and road traffic accident (RTA) was the most common mode of injury. Conclusion: We examined the cervical spine at autopsy and found significant results. Cervical spine injuries should always be suspected in polytrauma patients and cervical supportive care should be given right from the initial handling from site of injury till their transportation to emergency centers.

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Cervical spondylotic myelopathy (CSM) is a commonly treated either by uninstrumented laminectomy, carrying the risk of postoperative instability, or by anterior or posterior decompression with fusion resulting in postoperative stiffness and possibly adjacent segment degeneration. Cervical laminoplasty, initially developed for pediatric or OPLL patients could be an interesting surgical alternative to decompress and reconstruct cervical anatomy without fusion. Sixteen patients, mean age 63, who presented with CSM were treated surgically using multilevel laminoplasty, and reviewed after 1 month, 6 months, 1 and 2 years. Clinical evaluation was performed based on the Benzel-JOA and Nurick scores. The preoperative mean Benzel-JOA score was 13.43; preoperative mean Nurick score was 1.81. Intramedullary hyperintensity in T2 MRI was observed in five patients. The operation was performed on 2 levels (19%) 3 levels (69%) and 4 levels (12%). We used the open-door hinged laminoplasty technique, using metallic implants, without bone graft. At one month FU, mean JOA score was 15.44, and Nurick dropped to 1.05. At 6 months, mean JOA was 16.36 and Nurick was 0.72. At one year, the mean JOA score was 16.16, and Nurick was 0.83. At 2 years, mean JOA was 17.5 and Nurick was 0.25. We reviewed the possible advantages and complications of spinal cord decompression by open-door laminoplasty for CSM. We conclude that this technique allows significant clinical improvement observed progressively in the two years following surgery without increased rigidity or instability.

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Clinical translation of cell-based therapies in neurology, especially the spinal cord injury and damage to the brain, have been marred by several hurdles [Dedeepiya VD et al Expert Opinion on Biological Therapy (In print)] and one significant among them is the need for a suitable biocompatible scaffold, which can retain the transplanted cells, give an active or passive support to the cells, enable their proliferation, differentiation when needed and integration into the local niche until the restoration of the damage are complete, without any adverse reactions to the vicinity or to any of the systems of the animal or human being where it is applied. Scaffolds for neurological applications need to be biocompatible, biodegradable, non-immunogenic, must provide contact guidance for neurite outgrowth, should have porosity for vascularization and cell migration. Several natural scaffolds like collagen, alginate, silk fibroin, hyaluronic acid, chitosan, etc. and synthetic scaffolds like poly (lactic acid) (PLA), poly (glycolic acid) (PGA), poly (lactic-co-glycolic acid) (PLGA), polyethylene glycol (PEG), poly (lactide-co-caprolactone) (PLCL) have been employed for cell transplantation in neurology primarily for nerve injuries and stroke. In this review, we briefly outline the different studies utilizing these scaffolds employed for cell transplantation in neurology and we document the suitability of a unique poly (N-isopropylacrylamide-co-n-butyl methacrylate) (poly NIPAAm-co-BMA) and polyethylene glycol (PEG)-based thermoreversible gelation polymer for cell therapy applications in neurology.

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Bleeding and bleeding management both pose serious challenge to the surgeon and patients especially in complex surgeries, like spinal surgery. This paper evaluates clinical evidences published on use of topical absorbable hemostats in different bleeding scenarios in spinal surgery. Review of clinical evidence indicates clearly the need for further studies in this space.

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Background: The importance of sagittal plane alignment in adults involves both spinal and pelvic parameters. Most papers published in this field have studied white people and, to the best of our knowledge, there are only few studies on Asians and none in south Indian population. Materials and methods: Prospective study of 120 healthy individuals done in Sri Ramachandra Medical college, Chennai, India, from August 2012 to June 2014. The study was conducted in the department of spinal surgery at our center with the approval of the ethical committee. Informed consent was obtained from all volunteers. Inclusion criteria were healthy individuals more than 18 years of age both male and female. Exclusion criteria were those who had any kind of spine or hip surgery, carriers of any type of musculoskeletal syndrome, or had a pelvic limb discrepancy (2 cm). The following items like age, sex and lateral radiographs of the lumbosacral region with the individual standing, so as to obtain the pelvic parameters of PT, SS and PI were collected. Results: The mean pelvic parameters in our study were pelvic tilt 14.20 ± 7.32, sacral slope 41.20 ± 11.01 and pelvic incidence 58.64 ± 12.59. Conclusion: The pelvic parameters vary between different ethnicity was evident from our study. However, pelvic parameters of south Indian population have shown some similarity to the Mexican population.

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Introduction: The unique anatomy of the upper cervical spine in conjunction with its supportive role in the axial stabilization and rotatory function of the head increases the surgical risk and associated complications for corrective surgeries performed in this spinal region. C1-C2 posterior fixation is indicated in the occurrence of instability at the craniocervical junction; and it can be performed by specific surgical techniques, such as the Harms and Magerl techniques. In this technical note, the authors present a simplified modification of the Harms technique that increases the accuracy of screw placement in the lateral mass of the C1 vertebra and in the pedicle of the C2 vertebra. This modification provides a secure path for screw placement by obtaining fluoroscopic images of K-wires inserted in the lateral masses of C1 and the pedicles of C2 as in the original technique. According to this technique, a pin driver is used to guide a K-wire through the initially marked entry point to the lateral mass of C1. After fluoroscopic confirmation of the optimal position of the guidewire, a cannulated hand drill is placed over the guidewire. A pilot hole is drilled in the same trajectory for the screw placement under fluoroscopic control. Then the guidewire and the hand drill are removed and an appropriately sized 3.5 mm polyaxial screw is placed with a hand drill under confirmation of the correct position with anteroposterior and lateral fluoroscopy. The same procedure is followed for the placement of the C2 pedicle screws. Then, a small rod is placed and secured within the polyaxial screw heads of the C1 and C2 screws bilaterally. Decortication of the spinous processes of the involved vertebrae and the occiput is the final step before closure of the fascia, cervical muscle layer, subcutaneous tissue, and skin.

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