Current Issue Volume 5, Number 2 , April-June 2018

ORIGINAL ARTICLE
Sachin Chemate, Chandrasekar Kalavakonda, CV Shankar Ganesh, Shailendra Markad, Prasad Temkar, Bagatheesh Sugathan, Ratnika Joshi, Anandkumar Shah, Mayank Nakipuriya, Harshal Agrawal, Mangaleswaran Balamurugan

Role of Kinematic Magnetic Resonance Imaging for Evaluation of Cervical Spondylotic Myeloradiculopathy: Diagnostic Accuracy and Surgical Planning

[Year:2018] [Month:April-June] [Volumn:5 ] [Number:2] [Pages:48] [Pages No:53-56]



Objective: The dynamic part of cervical spondylotic myeloradiculopathy (CSM) is conventionally being evaluated using static magnetic resonance imaging (MRI), which does not address dynamic changes in flexion and extension of the cervical vertebral column. The objective of the study is to evaluate the utility of kinematic MRI imaging in diagnostic accuracy and surgical planning of evaluation of CSM.

Materials and methods: In a prospective study, 30 patients with CSM were evaluated with conventional standard MR cervical spine and kinematic MRI cervical spine with flexion and extension. Morphometric measurements were compared between neutral, flexion, and extension images.

Results: The cervical cord length and cervical canal length were significantly longer in flexion and significantly shorter in extension in all cervical cord sagittal lines. Flexion was associated with decrease in spinal cord compression in 40% of patients, whereas extension caused increase in compression (increase in the size of T2 hyperintensivity) in 75% of patients. Extension identified new subtle T2 hyperintensities. Interpretation of standard MRI findings and the clinical level of radiculopathy is poor, which improves when the neck is extended.

Conclusion: Our results suggest that integration of kinematic MRI with standard static MRI provides additional information in diagnostic accuracy and surgical planning.

Keywords: Cervical vertebrae, Magnetic resonance imaging, Spinal canal, Spondylosis.

How to cite this article: Chemate S, Kalavakonda C, Ganesh CVS, Markad S, Temkar P, Sugathan B, Joshi R, Shah A, Nakipuriya M, Agrawal H, Balamurugan M. Role of Kinematic Magnetic Resonance Imaging for Evaluation of Cervical Spondylotic Myeloradiculopathy: Diagnostic Accuracy and Surgical Planning. J Spinal Surg 2018;5(2):53-56.

Source of support: Nil

Conflict of interest: None


ORIGINAL ARTICLE
Toru Funayama, Toshinori Tsukanishi, Kentaro Mataki, Tetsuya Abe, Hiroshi Noguchi, Hiroshi Kumagai, Katsuya Nagashima, Kousei Miura, Masao Koda, Masashi Yamazaki

Dynamic Computed Tomography Myelography including the Prone Position as a Reliable Preoperative Imaging Method for Osteoporotic Vertebral Fracture with Neurological Deficits: A Preliminary Report of Three Cases

[Year:2018] [Month:April-June] [Volumn:5 ] [Number:2] [Pages:48] [Pages No:57-62]



Aims: Delayed paralysis after osteoporotic vertebral fracture (OVF) in the elderly is caused by severe compression on the spinal cord or the cauda equina from the collapsed vertebral fragment that is retropulsed into the spinal canal. Patients with retropulsion of the vertebral fragment that occupies approximately 40% or more of the spinal canal likely develop delayed paralysis, suggesting that narrowing of 40% is the critical point. However, whether or not a neural decompression procedure during posterior instrumentation surgery, such as laminectomy should be performed during the surgery is still controversial. We performed dynamic computed tomography myelography (CTM) including the prone (surgical) position with OVF to investigate if the severity of spinal cord and cauda equina compression during the surgery could be estimated in advance.

Materials and methods: The CTM was examined in 3 OVF patients (1 man and 2 women; mean age, 84 years) with neurological deficit in the supine and prone (surgical) positions to accurately estimate the necessity of decompression during surgery.

Results: The spinal narrowing was 50% or higher in the supine position, but was less than 40% in the prone position in two patients (fracture at the T11 and L1 vertebrae), indicating that decompression was not necessary. Decompression was required in one patient (fracture at the L2 vertebra) with a high narrowing rate of 57% in the supine position and 56% in the prone position.

Conclusion: Diagnostic imaging in the supine position alone will not help estimate the severity of intraoperative spinal cord or cauda equina compression because the degree of vertebral instability varies in each patient with OVF.

Keywords: Dynamic computed tomography myelography, Neurological deficits, Osteoporotic vertebral fracture, Prone position.

How to cite this article: Funayama T, Tsukanishi T, Mataki K, Abe T, Noguchi H, Kumagai H, Nagashima K, Miura K, Koda M, Yamazaki M. Dynamic Computed Tomography Myelography including the Prone Position as a Reliable Preoperative Imaging Method for Osteoporotic Vertebral Fracture with Neurological Deficits: A Preliminary Report of Three Cases. J Spinal Surg 2018;5(2):57-62.

Source of support: Nil

Conflict of interest: None

Key messages: Prone-position CTM is a new and simple preoperative imaging method to accurately evaluate whether intraoperative decompression will be required.


ORIGINAL ARTICLE
Vivek K Kankane, Neha Gupta, Vivek Sharma

Surgical Outcome of Spinal Intradural Extramedullary Tumors: A Single-center Prospective Study of 92 Cases—Assessment using Nurick’s Grade and Visual Analog Scale

[Year:2018] [Month:April-June] [Volumn:5 ] [Number:2] [Pages:48] [Pages No:63-68]



Introduction: To account the surgical outcome of 92 patients who underwent an entire removal of intradural extramedullary tumors (IDEMs) and evaluate the factors that have an influence on the neurological symptoms and prospects of spinal IDEM tumors.

Materials and methods: Ninety-two cases of histopathologically confirmed IDEM tumors were treated surgically between July 2008 and July 2016.
There were 32 females and 60 males with a mean age of 41.52 years. The mean postoperative follow-up period was 40.27 months. The histopathological result, locations of the tumors, and clinical outcome were analyzed. Backache was assessed by the visual analog scale (VAS) and the neurologic purpose was evaluated by Nurick’s grade.
The preoperative symptoms duration and the proportion of mass hold of the intradural space were evaluated. In adding up, all these factors were analyzed in relation to the degree of the preoperative symptoms and the prognosis. On the last follow-up, the magnetic resonance imaging (MRI) evaluated the tumor recurrence.

Results: The histopathological outcomes are as follows: 28 cases of meningioma, 48 cases of nerve sheath tumors (40 cases schwannoma and 8 cases neurofibroma) (in our study, we included only non-dumbbell-shaped with no extracanalicular extended, posteriorly situated nerve sheath tumors, so these groups of tumors were excised completely with only posterior approach with preservation of facet), 10 cases of an arachnoid cyst, 2 case of Tarlov cyst, 1 case of benign cystic teratoma, and 3 cases were metastasis, and our study included only posteriorly situated tumors.
The locations of the tumors were as follows: 64 cases in the thoracic region, 16 cases in the cervical region, and 12 cases in the lumbar region; postoperatively, there were two cases of cerebrospinal fluid (CSF) leakage; the majority of diagnosis consisted of nerve sheath tumors (52.1%), followed by meningioma (30.40%). The proportion of mass occupying the intradural space was 81.65 ± 9.01%. The VAS score was reduced in all cases from 7.56 ± 0.72 to 1.30 ± 0.47 (p = 0.001) and the Nurick’s grade improved in all cases from 3.69 ± 0.92 to 1.35 ± 0.57 (p = 0.001).
The preoperative symptoms were correlated with only the proportion of mass occupying the intradural space (VAS; r = 0.496, p = 0.016, Nurick’s grade; r = 0.431, p = 0.040). The Statistical Package for the Social Sciences (SPSS) version 22 was used for statistical study, and the Spearman correlation test and paired Student’s t-test were performed. Two cases of schwannoma recurred.

Conclusion: The IDEM tumors detected by MRI are frequently benign, and excellent clinical outcome can be obtained when treated surgically.
The extent of neurologic symptoms was associated with the proportion of mass occupying the intradural space. All the tumors were capable of being excised through the posterior approach. The ’postoperative neurological improvement was outstanding in the entire cases. Consequently, violent surgical excision is suggested even for cases with a long period of symptoms or a rigorous neurologic deficit.

Keywords: Intradural extramedullary tumor, Nurick’s grade, Prognosis, Schwannoma, Surgical outcome.

How to cite this article: Kankane VK, Gupta N, Sharma V. Surgical Outcome of Spinal Intradural Extramedullary Tumors: A Single-center Prospective Study of 92 Cases—Assessment using Nurick’s grade and Visual Analog Scale. J Spinal Surg 2018;5(2):63-68.

Source of support: Nil

Conflict of interest: None


ORIGINAL ARTICLE
MA Naveen, R Bharath

Surgical Management of Giant Thoracic Schwannoma in Adults: Our Experience

[Year:2018] [Month:April-June] [Volumn:5 ] [Number:2] [Pages:48] [Pages No:69-72]



Spinal schwannomas are the benign tumors arising from the nerve root sheath and account for 25% of all spinal tumors in adults. Giant spinal schwannomas are rare in the thoracic spine and pose a surgical challenge for complete excision. All the patients in our series underwent parascapular costotransversectomy approach, and this article aims at the surgical steps, merits, and demerits of the approach.

Materials and methods: Five patients with giant thoracic spinal schwannomas presented with nonspecific symptoms were diagnosed and operated by the authors at D3 to D5 levels. All the patients underwent complete tumor excision in a single stage by parascapular costotransversectomy approach.

Results: Totally, 5 patients (4 females and 1 male) with ages varying from 40 to 52 years underwent complete tumor excision in a single stage by parascapular costotransversectomy approach. No major complication was noted in our series. One patient developed transient nerve root deficit, which improved over 2 months.

Conclusion: Parascapular costotransversectomy approach for complete excision of giant thoracic spinal schwannomas is a safe and effective approach. It provides direct access to the lesion and does not necessitate spinal instrumentation.

Keywords: Cystic schwannoma, Giant thoracic schwannomas, Parascapular costotransversectomy, Spinal schwannoma.

How to cite this article: Naveen MA, Bharath R. Surgical Management of Giant Thoracic Schwannoma in Adults: Our Experience. J Spinal Surg 2018;5(2):69-72.

Source of support: Nil

Conflict of interest: None


REFLECTION ARTICLE
Premanand S Ramani

My Reflection as Neuro- and Spinal Surgeon at 80 Years

[Year:2018] [Month:April-June] [Volumn:5 ] [Number:2] [Pages:48] [Pages No:73-77]



Introduction: Most surgeons today do not retire at the stipulated age as dictated by the government.

Reasons for continuing to work: (1) Updating knowledge. (2) Mix with the students. (3) Continue having interactions with the patients. (4) Pleasure of pursuing surgical art that has been mastered. (5) Monetary gains.

Guidelines for retirement: Author has explained in detail the guidelines. Briefly if the assistants, the nurse, and the anesthetist feel that the surgeon’s dexterity has come down, then the surgeon has to retire irrespective of age.

Conclusion: Today’s pattern of medical practice is such that surgeons can carry on performing operative procedures much after their retirement age, provided their dexterity is not compromised.

Keywords: Dexterity, Retirement age, Surgeons.

How to cite this article: Ramani PS. My Reflection as Neuroand Spinal Surgeon at 80 Years. J Spinal Surg 2018;5(2):73-77.

Source of support: Nil

Conflict of interest: None


CASE REPORT
SJ Balaparameswara Rao, Jutty KBC Parthiban

Radiculopathy due to Bone Chip Extrusion following Transforaminal Lumbar Interbody Fusion

[Year:2018] [Month:April-June] [Volumn:5 ] [Number:2] [Pages:48] [Pages No:78-81]



Transforaminal lumbar interbody fusion (TLIF) is a commonly used technique for the treatment of degenerative lumbar spine disease. Success of surgery depends on the fusion that occurs between the vertebral body end plates. Local morselized bone graft is routinely used for achieving fusion with or without a cage or interbody spacer. Complications related to cage migration have frequently been reported. However, migration of bone chips into the neural foramen causing radiculopathy is rare and can be missed if not diagnosed early. Though such complications have been known to occur, they have not been reported frequently. Here, we present one such case of TLIF, who developed radiculopathy in the postoperative period due to migration of bone chips, which was detected early and managed.

Keywords: Interbody fusion graft migration, Radiculopathy, Transforaminal lumbar interbody fusion.

How to cite this article: Rao SJB, Parthiban JKBC. Radiculopathy due to Bone Chip Extrusion following Transforaminal Lumbar Interbody Fusion. J Spinal Surg 2018;5(2):78-81.

Source of support: Nil

Conflict of interest: None


CASE REPORT
Sachin A Giri, Batuk Diyora, Deepali Giri, Prajakta Giri, Alok Sharma

A Rare Case of Isolated Cervical Intramedullary Cysticercosis: A Surgical Dilemma

[Year:2018] [Month:April-June] [Volumn:5 ] [Number:2] [Pages:48] [Pages No:82-85]



Cysticercosis is the most common parasitic infection of the cerebral parenchyma and spinal cord involvement is rare. In spinal cord, it affects more commonly thoracic spinal cord while cervical involvement is rare. We report the case of a 30-year-old female patient with isolated cervical intramedullary cysticercosis. Patient presented with pain in neck and right upper limb. Her magnetic resonance imaging (MRI) cervical spine revealed dumbbell-shaped intramedullary lesion at C3 to C4 level. Patient underwent surgery with complete excision of cervical intramedullary lesion. Histopathological report confirmed cysticercosis. Postoperatively, patient had complete relief in her clinical symptoms. In this report, we also discuss the principles of diagnosis and treatment of intramedullary cysticercosis in combination with literature review. Spinal neurocysticercosis should be considered as a differential diagnosis of spinal mass lesion in patients residing in endemic area, such as India. Both surgical therapy and medical therapy have a role in the management of spinal cysticercosis.

Keywords: Cysticercosis, Intramedullary, Spinal cord.

How to cite this article: Giri SA, Diyora B, Giri D, Giri P, Sharma A. A Rare Case of Isolated Cervical Intramedullary Cysticercosis: A Surgical Dilemma. J Spinal Surg 2018;5(2):82-85.

Source of support: Nil

Conflict of interest: None


CASE REPORT
Sunit Mediratta, Ravi Bhatia, Sudheer K Tyagi, Aditendraditya S Bhati

A Rare Case of Primary Spinal Primitive Neuroectodermal Tumor with Long-term Follow-up

[Year:2018] [Month:April-June] [Volumn:5 ] [Number:2] [Pages:48] [Pages No:86-89]



Primary primitive neuroectodermal tumors (PNETs) of the spine are rare. There have been 108 reported cases in the literature. These are aggressive malignancies with poor survival rates even after surgery, chemotherapy, and radiation. Since this is a rare disease, there are no standard guidelines for the management of these malignancies. Long-term survival with these tumors is unusual. We report a case of a 47-year-old patient with a primary PNET with 12-year follow-up; this is the longest follow-up recorded in literature.

Keywords: Chemotherapy, Cluster of differentiation 99, Primitive neuroectodermal tumors, Spinal cord.

How to cite this article: Mediratta S, Bhatia R, Tyagi SK, Bhati AS. A Rare Case of Primary Spinal Primitive Neuroectodermal Tumor with Long-term Follow-up. J Spinal Surg 2018;5(2):86-89.

Source of support: Nil

Conflict of interest: None


CASE REPORT
Ramachandran Ramnarayan, Simon Herculus

Delayed Spontaneous Spinal Extradural Hematomas: Two Cases

[Year:2018] [Month:April-June] [Volumn:5 ] [Number:2] [Pages:48] [Pages No:90-92]



Aim: Spontaneous spinal extradural hematomas are uncommon disorders. They require a high index of suspicion for diagnosis.

Case report: This is a report of two patients, one lumbar and one cervical spontaneous extradural hematomas, who presented after a delay of a few weeks. A middle-aged male presented with progressive paraplegia with bladder involvement following a minor trauma 3 months back. Magnetic resonance imaging (MRI) showed an extradural hematoma at T11 to L2 levels. He underwent laminectomy and evacuation of hematoma and recovered completely. The other was a 52-year-old hypertensive lady who presented with right hemiplegia. She initially was thought to have a stroke but developed severe neck pain after 3 weeks, which induced the suspicion. The MRI showed a left-sided C3 to C5 extradural hematoma. She was operated and improved to normal.

Conclusion: These reports show that spinal extradural hematoma should always be kept as a differential diagnosis in any acute spine presentation and should be completely evacuated even if there is a delay in the patient presenting to produce good results.

Clinical significance: Spinal extradural hematomas should always be evacuated whatever time patient presents.

Keywords: Delay, Prognosis, Spinal extradural hematoma, Surgery.

How to cite this article: Ramnarayan R, Herculus S. Delayed Spontaneous Spinal Extradural Hematomas: Two Cases. J Spinal Surg 2018;5(2):90-92.

Source of support: Nil

Conflict of interest: None


CASE REPORT
Alok M Uppar, Nupur Pruthi, Sunil Malagi, Sandeep Kandregula, Mustafa I Chandshah

Nontraumatic Atlanto-occipital Dislocation: Rare Experience of Two Cases

[Year:2018] [Month:April-June] [Volumn:5 ] [Number:2] [Pages:48] [Pages No:93-99]



Introduction: Spontaneous or nontraumatic atlanto-occipital dislocation (AOD) is a rare entity and has been sparsely reported till now. These cases can either present in its exclusive form (AOD alone) or in association with atlanto-axial instability (AAI). In this study, the authors report two cases of spontaneous AOD: (a) AOD with AAI with basilar invagination (BI) and (b) AOD presenting as hypoglossal nerve palsy, both of which were surgically managed and followed up.

Materials and methods: CASE 1: A 12-year-old girl presented with neck pain, restricted neck movements, and head tilt. There was no history of trauma. A diagnosis of AOD with associated AAI and BI was made using X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) of craniovertebral junction (CVJ). After realigning the dislocated joints using skull traction, occipitocervical fusion was performed through a posterior approach. CASE 2: A 41-year-old male presented with neck pain and restricted neck movements for 2 years and deviation of the tongue to the right side for 3 months. There was no history of trauma. A diagnosis of posterior AOD was made based on X-ray, CT, and MRI of CVJ. After realigning the dislocated joints using skull traction, occipitocervical fusion was performed through a posterior approach.

Results: Both patients were stable at follow-up. Both patients had resolution of presenting symptoms and had no fresh complaints or deficits. Imaging shows proper alignment with bony fusion in both cases.

Conclusion: The present case series, to the best of authors’ knowledge, is the first article to report nontraumatic AOD presenting with isolated hypoglossal nerve palsy and nontraumatic AOD with coexisting AAI and BI, along with their surgical management and outcomes with follow-up. Reduction of dislocation and occipitocervical fusion is paramount in treating these rare cases.

Keywords: Atlanto-axial dislocation, Atlanto-occipital dislocation, Basilar invagination, Hypoglossal nerve palsy, Nontraumatic, Occipitocervical fusion.

How to cite this article: Uppar AM, Pruthi N, Malagi S, Kandregula S, Chandshah MI. Nontraumatic Atlanto-occipital Dislocation: Rare Experience of Two Cases. J Spinal Surg 2018;5(2):93-99.

Source of support: Nil

Conflict of interest: None


LETTER TO THE EDITOR
Harnarayan Singh, Kapil Agarwal, Hemant Sharma, Rohit Lamba

Bilateral L5 Transverse Process Fracture Implications: What Every Spine Surgeon Must Know

[Year:2018] [Month:April-June] [Volumn:5 ] [Number:2] [Pages:48] [Pages No:100-101]



Isolated fracture of transverse process does not imply mechanical instability and is managed conservatively. However, bilateral transverse process fractures have a high association with pelvic fractures. This warrants a high index of clinical suspicion for pelvic injuries in such patients.

Keywords: Bilateral L5 transverse process fractures, Transverse process fractures and abdominal injuries, Transverse process fractures and pelvic fractures.

How to cite this article: Singh H, Agarwal K, Sharma H, Lamba R. Bilateral L5 Transverse Process Fracture Implications: What Every Spine Surgeon Must Know. J Spinal Surg 2018;5(2):100-101.

Source of support: Nil

Conflict of interest: None


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