Journal of Spine

To date the posterolateral approach represents the best strategy for the surgery of the intradural ventro-lateral lesions of the cranio-vertebral junction (CVJ). Over the years, several authors have proposed different variations of this technique, but the principle on which all are based is the ability to access to the ventral region of the brainstem and high cervical cord with minimum retraction and maximum control of the neuro-vascular structures. However, comorbidity related to the surgical procedure is still very high. Posterolateral approach is actually considered the best technique to approach the intradural ventrolateral lesions located at the CVJ. Because the peculiarity of the CVJ, surgeons must know very well the anatomy of this region. Due to the high comorbidity of this approach a very precise surgical planning based on the characteristics of the lesion is required to correctly treat this particular anatomical region to manage correctly the pathology and to prevent any complications.

Purpose: To review our experience with surgical management of basilar invagination causing foramen magnum compression, focusing on selection of the surgical approach.

Methods: Twelve consecutive patients underwent posterior foramen magnum decompression with occipitocervical fixation and fusion for treatment of basilar invagination causing brain stem compression and instability. Gentle traction and reduction during positioning of the patients also were performed. Ventral decompression (odontoid resection) was performed in none of the patients. Pre- and postoperative neurologic status was graded according to JOA and Nurick scales.

Results: All patients had anterior spinal cord compression due to cranial settling of the cervical spinal column as well as instability at the craniocervical junction. The average follow-up period was 31 months (range, 24–42 months). All patients’ JOA and Nurick scores improved after surgery, but postoperative neurologic improvement and odontoid reduction were better in patients with atlas assimilation compared with patients with other pathologies.

Conclusion: Odontoid reduction using an occipitocervical fixation system and decompression of the foramen magnum through a single-stage posterior approach is an effective treatment for basilar invagination, particularly in patients with atlas assimilation. Since odontoid reduction and foramen magnum decompression can be achieved through a single-stage posterior approach in most patients, odontoid resection should remain as a secondary procedure when these decompression efforts are insufficient.

Purpose: To review our experience with surgical management of basilar invagination causing foramen magnum compression, focusing on selection of the surgical approach.

Methods: Twelve consecutive patients underwent posterior foramen magnum decompression with occipitocervical fixation and fusion for treatment of basilar invagination causing brain stem compression and instability. Gentle traction and reduction during positioning of the patients also were performed. Ventral decompression (odontoid resection) was performed in none of the patients. Pre- and postoperative neurologic status was graded according to JOA and Nurick scales.

Results: All patients had anterior spinal cord compression due to cranial settling of the cervical spinal column as well as instability at the craniocervical junction. The average follow-up period was 31 months (range, 24–42 months). All patients’ JOA and Nurick scores improved after surgery, but postoperative neurologic improvement and odontoid reduction were better in patients with atlas assimilation compared with patients with other pathologies.

Conclusion: Odontoid reduction using an occipitocervical fixation system and decompression of the foramen magnum through a single-stage posterior approach is an effective treatment for basilar invagination, particularly in patients with atlas assimilation. Since odontoid reduction and foramen magnum decompression can be achieved through a single-stage posterior approach in most patients, odontoid resection should remain as a secondary procedure when these decompression efforts are insufficient.

Objective: To evaluate the progression of Ossification of Ligamentum Flavum (OLF) in the thoracic spine based on cross-sectional Computed Tomography (CT) comparisons.

Method: OLF in spinal segments that did not require surgery because there were no cord compression of 17 patients who underwent laminectomies for treating symptomatic OLF were retrospectively reviewed (mean follow-up 6.3 years). Initial (preoperative or postoperative but before discharge) and final follow-up canal area unoccupied ratio (CAUR) of no-operated OLF were compared to evaluate the progression of OLF. Factors influencing OLF progression were also analyzed. Two-year follow-up and final follow-up results were assessed to evaluate the influence of OLF progression on long-term outcomes.

Result: Sixty OLF levels were compared between initial and final follow-up CT. The final follow up CAUR was significant lower than the initial in all OLF levels. Repeated measurement was used to reduce the effect of measurement error, and progression of OLF affected approximately 60% of patients and 33% of OLF segments, with annual growth rate in OLF area of 1.61%. CT mature/immature classification was an independent risk factor for the development of OLF. No patient exhibited neurological deterioration due to OLF progression.

Conclusion: Thoracic OLF that are not operated on still progress, and OLF classified as immature ossification on CT develop more significantly. Additionally, progression of OLF is not associated with neurologic regression in 5- 9 years follow-up, thus preventive laminectomy is unnecessary for OLF segments that do not compress the spinal cord.

It is quite rare for foreign bodies retained after surgery to display tumour-like clinical and radiological findings. A 60 year-old female patient presented to the clinic with low-back and left hip pain. She had undergone lumbar disc surgery 31 years ago. She had pain in her low-back and left hip for 3 months. The patient’s CT and MRI showed a well-defined mass lesion at left posterior S2-S3, measuring 3.5 to 4 cm, with circumferential scattered contrast enhancement, which extended to the canal and caused bone erosion. Only when the mass was completely resected with its circumference, it was found out that it was the gauze retained after the surgical procedure. Our case is the oldest one in the neurosurgery and spinal surgery literature, which showed clinical findings 31 years after the lumbar disc surgery.

Degenerative spondylolisthesis of the cervical spine is relative rare. We present a relative rare case of severe degenerative cervical spondylolisthesis with posterior corrective fusion. A 70-year-old female complained of neck pain and gait disturbance with cervical spondylotic myelopathy. Plain radiographs showed 8.3 mm anterolisthesis of C3/ C4, which gradually progressed during four years. The slip was not reduced by flexion and extension position. After releasing C3/C4 facet joint and yellow ligament, posterior reduction with instrumentation were performed and resulted in successful cervical correction and fusion.

Objective: Tarlov cysts are cerebrospinal fluid dilatations of the nerve root sheath at the dorsal root ganglion level. We report the incidental finding of a Tarlov cyst during a fluoroscopy-guided caudal epidural injection in a patient with acute lumbar radicular pain due to disc herniation.

Case report: A 76-year-old male was scheduled for an epidural steroid injection (ESI) for acute L5 radicular pain caused by a paracentral disc nucleous pulposus herniation. The ESI was administered via a caudal route because the patient had back surgery at the L3-L4 for Mal de Pott tuberculoses when he was 23-years old. The epidurogram revealed a fusiform image at the sacral level and the procedure was stopped. Afterwards, an MRI showed a sacral cyst of 50 × 18 mm and a left paracentral disc herniation at L4-L5 with L5 root compression.

Conclusion: The use of fluoroscopy with epidurogram during a caudal ESI allowed us to confirm epidural needle placement and to observe the cephalic flow of contrast medium into the level and side to treat. Without fluoroscopy, we would not have found this asymptomatic Tarlov cyst.

Background: The immense potential of structural and functional reorganization of central nervous system i.e., neuro-plasticity following any injury serves the key mechanism behind the recovery of sensory-motor functions. One of the ways of enhancing this reorganization is through the technique of mental imagery. Mental imagery has been studied in various neurological conditions such as stroke and spinal cord injury (SCI) and has been seen to be quite effective in bringing about functional gains. But the research and literature available, particularly in SCI, is quite diverse and inconclusive. This review was, hence, conducted with the aim of understanding the concept of mental imagery and its therapeutic potential in spinal cord injury.

Method: A systematic literature search, using PRISMA 2009 guidelines, was conducted according to the set inclusion and exclusion criteria. After the initial screening, 25 articles were finally selected for the review. These were independently reviewed by two reviewers. The articles selected included mixed designs (reviews, experimental studies and observational studies) and were published between 1990- September 2014.

Results: The review revealed that the common techniques used to study mental imagery were mental chronometry, mental rotation and questionnaires. Apart from these, the vividness of imagery perceived during movement simulation were assessed using Movement Imagery Questionnaire (MIQ), MIQ-R (Revised), Kinesthetic and Visual Imagery Questionnaire (KVIQ), Vividness of Motor Imagery Questionnaire (VMIQ), Time Dependent Motor Imagery (TDMI) screening test etc. Two types of imagery perspectives were discussed about: external (a perspective that involves primarily a visual representation of motor task, i.e., third person); and internal (involves kinesthetic and visual representation from inside, i.e., first person of the simulated movements).

Conclusion: The therapeutic benefits of mental imagery were mixed, with more weightage going towards motor recovery as compared to pain and other sensory areas. However, few questions still remained regarding the best methods of practice of mental imagery and the details of the techniques used with proper protocols.

A child with a very rare anomaly of spinal cord is described. The patient presented at 9 months of age with trifid cord at thoracolumbar region and extensive split cord malformation (SCM) from T12-L5. She had a composite type SCM including type II at T12-L1 and SCM type I from L2, L3, to L4 levels. The condition seemed to be something like three distinct cords at T12-L1 level composed of a thin cord at left side terminating before L2 level to a tiny fibrous band, and two thick middle and right cords which joined together at conus at L5 level.

The patient had a large hairy patch on her back with asymmetric legs without any movements in her smaller foot. Cord untethering and removing the bony ridge causing SCM were performed with laminectomy of L2 to L5 and laminotomy of T12 and L1, Her neurological status was unchanged after surgery and remained stable during 6 month follow up.

Study design: Case report of conservatively treated non-traumatic Atlanto-axial rotatory sublaxation.

Objective: To report our case with this rare condition (non-traumatic Atlanto-axial rotatory subluxation-Grisel Syndrome) in a 9-year old girl presenting with torticollis and neck pain and literature review.

Summary of background data: Atlanto-axial rotatory fixation or non-traumatic atlanto-axial subluxation which is usually secondary to an infection or an inflammation at the head and neck region is a rare subtype of subluxation in which a pathologic fixation of the atlas on the axis is present. It is most common in paediatric patients and it can be managed conservatively in the acute stage. In contrast, cases of chronic non-traumatic atlanto-axial rotatory subluxation are usually treated with operative reduction, according to literature data. Although high success rates have been achieved with operative reduction in chronic cases, a significant reduction in neck motion occurs due to the atlanto-axial fusion.

Methods: A 9-year-old girl developed torticollis established longer than 10 weeks as a result of an upper respiratory tract infection. Computed tomography showed a type 1 rotatory subluxation of the Atlanto-axial joint according to the classification of Fielding and Hawkins. The patient was treated by manual reduction according to Jeszenszky (Jeszenszky transoral Citation Nr 22) under general anaesthesia and fluoroscopy control, and then a halo vest had been applied for 6 weeks.

Results: We successfully treated this patient with chronic non-traumatic Atlanto-axial rotatory subluxation with manual reduction and immobilisation by applying a halo-body-jacket. She showed full recovery of neck motion and normal Atlanto-axial angle on clinical and radiological follow-up after 1 month and 3 months respectively.

Conclusion: Chronic non-traumatic Atlanto-axial rotatory subluxation is a rare condition which can easily escape the attention of physicians especially in children. Conservative treatment with complete reduction under anaesthesia and subsequent immobilisation via halo-body-jacket for at least 6 weeks is a viable option as presented in this case report. Surgical treatment should be reserved only for cases of failure of conservative management (recurrence or irreducible subluxation).

Study design: Case report of a rare case of spondylodiscitis due to Candida species (C. tropicalis).

Objective: To report our case with this rare condition (Fungal spondylodiscitis due to Candida tropicalis) in a 75- year old female immune-competent patient presenting with low back pain and literature review.

Summary of background data: Spondylodiscitis or discitis is an infection in the intervertebral disc space and adjacent end plates, this disease accounts for 2–7% of all cases of pyogenic osteomyelitis, which affects different age groups. There is a wide spectrum of causative agents: pyogenic, granulomatous or parasitic. Nowadays incidence has increased the rise in the prevalence of immunosuppressed patients and intravenous drug abusers, and the increase in spinal surgeries. Nonetheless, the microbiological diagnosis of infectious spondylodiscitis is often difficult to establish and the disease requires prolonged antibiotic treatment in combination with surgical intervention are the cornerstone of management. Candida spondylodiscitis usually affects immunocompromised patients after haematogenous dissemination.

Methods: A 75-year-old female patient, who developed low back pain, pain radiated intermittently to both lower limbs, not associated with any sensorimotor deficit. Imaging of the thoraco-lumbosacral spine at the same day (X-ray, CT and MRI) showed alteration of the inter-vertebral disc in Th11/12 and L1/L2. The patient was treated surgically under general anaesthesia and fluoroscopy control. Results: We successfully treated this patient with spondylodiscitis due to fungal infection. By surgical debridement, fusion and pharmaceutical agents: amphotericin and/or fluconazole. Thoraco-lumbosacral CT, 12 weeks after surgery showed decreased oedema of the vertebra, disc space and pre-spinal soft tissues, the patient was symptom less.

Conclusion: Candidal spondylodiscitis is a rare fungal infection should be suspected in immunocompromised patients and elderly with chronic diseases. Without treatment, the disease is progressive and leads to vertebral destruction and spinal cord and neural Preservation of the structure and function of the spine and pain alleviation. Established pharmaceutical agents are amphotericin and/or fluconazole for a minimum of 3 months and surgical debridement of the disc with instrumented fusion is highly recommended.

Background and purpose: Spinal cord injury can be one of the most fatal experience for the individuals who sustains it, as it not only endows one with devastating effects of disability but as well renders significant effects on personal, social as well as economic aspects of a person’s life. Wheelchair basketball is a sport which requires efficient respiratory capacity or function to sustain in the game for prolonged period of time. In higher thoracic Spinal Cord Injury, respiratory function reduces and due to fatigue patient becomes dyspneic easily even after small workout.

Objective: To evaluate the effectiveness of Inspiratory muscle trainer (power breathe) and breathing exercise on sprint timing and maximum inspiratory capacity or pressure inside the lungs.

Methodology: Samples of 45 subjects with upper thoracic (T1-T6 level) wheelchair basketball athletes was recruited and were randomly divided into three groups: IMT, breathing exercise and control. Baseline scores of PiMax and sprint time were assessed using inspiratory monometer apparatus and 20m shuttle test respectively. Six weeks training was given to both the experimental groups and post intervention scores were measured after every 2 weeks.

Results: Highly significant differences in IMT and breathing exercise groups were observed (p=0.005). However, at last week of training improvement was not so significant in IMT group. Significant differences were found within and between groups.

Conclusion: Our data indicates that IMT and Breathing exercise have a significant effect on PiMax, sprint and dyspnea in recreational wheelchair basketball players by assessing through Borg scale of perceived exertion.

Purpose: Sagittal imbalance of severe adult degenerative deformities requires surgical correction to improve pain, mobility and quality of life. Our aim was a harmonic and balanced spine, treating a series of adult degenerative kyphoscoliosis by a nonposterior subtraction osteotomy technique. Extreme lateral (XLIF) and transforaminal (TLIF) interbody fusion were used to restore lumbar lordosis and mobilize the coronal curve, while grade 2 osteotomy (SPO) was useful to further decrease kyphosis.

Methods: We operated 22 thoraco-lumbar and lumbar degenerative deformities, characterized by a sagittal compensated (hidden) imbalance (SVA<50 mm), with or without coronal deformity, and distinguished according to the SRS-Schwab classification. All patients were submitted to X-ray screening during pre, post-operative and follow-up periods.

Results: Mean age was 65.3 (50-74; M/F 1: 4). Sixteen deformities were type L and 6 type N. Loss of LL was moderate (+) in 14 cases and marked (++) in 8. We performed 39 XLIFs, 8 TLIFs, 32 SPOs. Complication rate was minimal. Pelvic tilt, lumbar lordosis, sagittal vertical axis and thoracic kyphosis improved (p<0.05), post-operative values were similar to those pre-operatively calculated in 90% of cases and clinical follow-up (mean 20.5; range 18- 24), scored using VAS and ODI, was satisfactory in all cases, except for two due to sacro-iliac pain.

Conclusion: Current follow-up does not allow definitive conclusions. However, the surgical approach reported seems to be a viable choice usable in these compensated adult deformities, avoiding risks and complications of more aggressive pedicle subtraction osteotomies.

Background: Fractures of the cervical spine are a frequent injury in the elderly with potentially devastating consequences. In most cases surgical therapy is required, in hyperextension fractures most often with anterior cervical fusion.

Methods: We report a case of an 88-year old patient with a fracture of C7 (AO-type B3) who underwent anterior cervical fusion with manubrium sterni osteotomy for application of the caudal screws.

Results: The insertion-angle of the caudal screws could be optimized; a dorsal instrumentation could be spared.

Conclusion: We want to describe a technique that potentially simplifies addressing the vertebral bodies of the cervicothoracic junction for anterior cervical fusion in patients with difficult anatomical conditions and allows a safe and stable insertion of the caudal screws.

Level of evidence: Level V (case report).