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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Introduction: The ultrasonic bone scalpel (UBS) is an ultrasonic device that cuts the bone, but does not harm the surrounding soft tissue and duramater. Such a type of selectivity of bone scalpel, particularly for bone destruction, makes the bone scalpel ideal for spine surgeries where there is the need to remove only bone adjacent to the duramater and neural structures, with the sparing of the duramater. Moreover, dural tear is the most common unintended complication of spinal surgeries nowadays. Materials and methods: This is a retrospective study of 35 patients operated for spinal decompression – cervical, thoracic, or lumbar – between January 2015 and June 2016 at BJ Medical College, Ahmedabad. Aim: To analyze the result of the use of UBS in spinal decompression over the conventional method of decompression, such as using the Kerrison Rongeur, high-speed burr drills, and conventional osteotome. Observation and results: Out of the 35 patients in our study, 21 patients (60%) had cervical, 3 patients (8.6%) had thoracic, and 11 patients (31.4%) had lumbar pathologies. There is significant reduction in duration of surgery and need for blood transfusion. We considered the neck disability index (NDI) and oswestry disability index (ODI) scores to measure the clinical outcomes of using bone scalpel at the end of 1 year. Both the scores were significantly improved. We had one case of dural tear (2.9%) in a patient with lumbar canal stenosis. No neurological worsening in any patients was present. Conclusion: The UBS is a unique surgical device that reduces heat production and decreases the chances of dural tear, which makes it a suitable instrument for different spinal surgeries in recent days.

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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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Spontaneous spinal epidural hematoma (SSEH) is rare in pregnancy and only few cases have been reported in literature. Herein, author presents a case of a 26-year-old female with 17 weeks of gestation who developed progressive descending quadriparesis (tetraparesis) and numbness below the level of C4. Magnetic resonance imaging (MRI) of the cervical spine demonstrated an epidural hematoma extending from C3 to C7 vertebrae. Posterior decompressive laminectomy was performed with removal of the epidural hematoma. The patient's neurological function subsequently improved. The diagnosis and management of spontaneous epidural hematoma in pregnancy is presented with a review of literature.

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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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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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Spinal meningiomas are rarely reported as pure epidural tumors, and when present may cause diagnostic dilemma preoperatively. The unique combination of a wholly epidural tumor causing neural foraminal widening has not been previously described. We describe a case of pure epidural tumor in a 25-year-old female who presented with back pain. An apparent complete resection was performed. Intraoperatively, the surgeon observed an entirely epidural tumor with no dural attachment. Histological examination confirmed that the tumor was meningioma. In this study, we describe a case of extradural meningioma affecting the thoracic spine and present their clinical profiles, radiological findings, operative management, and follow-up data, along with discussion over its differential diagnosis.

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Ellis-van Creveld (EVC) syndrome is an autosominal recessive syndrome with features of chondroectodermal dysplasia. Involvement of craniovertebral (CV) junction in association with this syndrome is extremely rare. We present a case of 9-year-old boy who presented with myelopathy and the management options related to this anomaly. The atlanto axial instability was reducible in radiological examination so posterior occipito cervical fusion was performed. Considering the fact that patients with EVC syndrome may have spinal instability especially CV junction, they should also undergo a screening X-ray of the craniovertebral junction to rule out any instability.

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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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