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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Introduction: Our hospital Sri RL Jalappa Hospital is located on the national highway in South India. We receive many patients with history of trauma following road traffic accidents and fall from height. Most of the patients have sustained injuries to head and spine including cervical spine. The general population also presents with neck pain of various etiologies (e.g., cervical myelopathy). Aim: To assess the morphometry of the subaxial cervical spine pedicles through computerized tomography and to determine the frequency of neurovascular injuries in patients who undergo pedicular mass fixation in cervical spine. Materials and methods: This study was a hospital-based prospective intervention study centered at RL Jalappa Hospital and Research Centre attached to Sri Devaraj Urs Medical College, Kolar, from November 2013 to July 2015 in which data of 200 patients who underwent computerized tomographic scans of the cervical spine and neck for various pathologies were collected and assessed. Results: The mean values of pedicle lengths and widths were found to be progressively increasing for both males and females from C3 to C6 vertebrae level and then slightly decreasing at C7 level. Also, it can be seen that the mean values for females are smaller than those for males, for both left and right side. We found that transverse and sagittal plane angulations were significantly dependent on spinal level. Transverse angulation was approximately 45° at C3 through C5 and decreased caudally to approximately 33°at C7 for both sexes. Conclusion: Through this study we found that there is less significance in the demographic profile. There was a progressive increase in the lengths, widths, and height of the pedicles from C3 to C7 vertebra pedicle transverse angle. Though the literature describes the use of 3.5 mm cervical pedicular screws, Indian population will require a smaller size.

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Though axial views at lumbar disk level in the plane of the disk and sagittal views at lumbar foramen level are routinely used in assessing the canal stenosis, lateral extent of thickened ligamentum flavum which is truly causing symptoms is well demonstrated in oblique coronal views in magnetic resonance imaging (MRI). Emphasis on this view in addition to the routine views will improve our understanding of lumbar canal stenosis, particularly in and around superior facet and axilla of the nerve root close to neural foramen.

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Autologous bone graft is the gold standard in cervical fusion. Obtaining autologous cancellous bone from adjacent vertebral body is unique and beneficial in anterior cervical interbody fusion. Sufficient amount of cancellous bone graft is curetted from adjacent cervical vertebral bodies and packed in the titanium cages placed in the intervertebral space. Cortical bone obtained from corticectomy and anterior osteophytes add to the volume along with cancellous bone. Fusion achieved is satisfactory and the technique obviates harvesting corticocancellous graft from iliac crest.

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Aim: To answer the question whether the postoperative pain intensity and individual satisfaction correlate with the extent of surgery in two distinct types of spinal surgery and whether the perioperative pain management differs between the two groups in the context of chronic preoperative pain. Materials and methods: The PAIN OUT assessment tool was used for this retrospective comparative study. One hundred and eighty five nonconsecutive patients were grouped into two surgical groups: Group A (= “minor” operations) were patients undergoing either kyphoplasty, microsurgical fenestration for disk hernia removal, or decompression of spinal stenosis. Group B (= “major” operations) were patients who underwent spinal instrumentation of at least one lumbar segmental level in addition to microsurgical decompression. Results: In group A (n = 146) the amount of fentanyl administered intraoperatively per hour was higher. Patients in group B (n = 39) underwent longer operation times and received more often remifentanil. They also indicated higher postoperative pain scores and longer pain duration, desired more often additional pain medication, and were less satisfied with analgesic treatment. There was no significant difference in preoperative chronic pain between groups A and B. Conclusion: More invasive spinal surgeries cause significantly more pain and less patient satisfaction, which we think is largely due to an insufficient perioperative pain management. Contrary to prior reports, the presence of chronic preoperative pain did not predict higher pain perception in the two groups. Clinical significance: Chronic low back pain is a high prevalent problem with significant clinical and socioeconomic consequences. Current pain management concepts – especially in a perioperative setting – are still unsatisfactory.

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Primitive neuroectodermal tumors (PNETs) are fast-growing undifferentiated tumors that share a common cell of origin. Primitive neuroectodermal tumors constitute less than 1% of all primary spinal tumors. They are further classified into central and peripheral types. Peripheral PNETs are considered to belong to Ewing's sarcoma family of tumors. After the advent of immunohistochemistry and cytogenetic analysis, differentiating central and peripheral PNETs becomes possible. We are reporting the second case of extradural peripheral PNET occurring in the cervical spine after Pinelopi et al. Though rare, primary PNET should be considered as differentials in an adult patient presenting with a spinal mass lesion. Surgical excision followed by chemoradiation is the treatment of choice with 5 years survival of about 50%

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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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Introduction: The management of pain after lumbar discectomy is a controversial subject. Effective postoperative analgesia is associated with lower rate of morbidity and results in shorter hospitalization, reducing overall cost. Wound infiltration widely used for the purpose is 0.25 or 0.5% bupivacaine and triamcinolone acetonide. We felt the need for a study to compare both in terms of their efficacy in our setup. Materials and methods: This is a prospective randomized, double-blind study comprising 60 patients of single-level prolapsed intervertebral disk, admitted in the Department of Neurosurgery at Vydehi Institute of Medical Sciences and Research Center, Bengaluru. Sample size: A t otal o f 6 0 c ases w ere t aken a nd d ivided into two groups. Thirty cases in group A were infiltrated by a mixture of 50 mg of triamcinolone in 5 mL of normal saline. Thirty cases in group B were infiltrated by a mixture of 5 mL of 0.5% bupivacaine and 5 mL of normal saline. Results: The time interval between surgery and first dose of opiate analgesia was significantly higher in the bupivacaine group (5 h 31 min ± 1 h 14 min) compared with the triamcinolone group (3 h 20 min ± 40 min). The visual analog pain scale (VAS) scores at 2nd hour (group A 2.034 ± 0.84 vs group B 0.931 ± 0.64) and 4th hour (group A 4.104 ± 0.97 vs group B 2.314 ± 1.14) were also found to be significantly lower in the bupivacaine group compared with the triamcinolone group. However, there was no significant difference in the amount of total opiate analgesic consumption in 24 hours (258 vs 248 mg). Conclusion: In the present study, the data suggest that intraoperative local infiltration of bupivacaine is safe and provides significant analgesia in the early postoperative period when compared with triamcinolone acetonide. Clinical significance: Based on the results of this study, we made departmental protocol to infiltrate all operative lumbar cases with bupivacaine.

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Gangliogliomas are relatively rare primary tumors of the central nervous system (CNS). It may occur throughout the CNS, predominantly the supratentorial area. Spinal cord ganglioglioma is a very rare entity. Majority of spinal gangliogliomas occur in the cervical region followed by the thoracic region. The involvement of conus is the least common site of affection. Here we present a case of intramedullary ganglioglioma involving D10 to conus in a middle-aged female with uncommon magnetic resonance imaging findings.

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Multiple extra cranial schwannomas are generally associated with neurofibromatosis (NF) syndromes. Presence of multicentric schwannomas in absence of NF2 is a very rare entity. Schwannomatosis is defined as an extremely rare tumor syndrome characterized by multiple schwannomas with no associated evidence of NF1 or NF2 syndromes. Numerous genetic and molecular analyses done for these tumors have established them as distinct clinical syndrome. Very few cases of schwannomatosis have been reported so far in English literature. The authors herein present a case of spinal schwannomatosis presenting as conus-cauda syndrome.

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