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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Introduction: Traumatic spinal cord injury (SCI) is an emerging public health problem reaching epidemic proportions. Reduced functional capacity after SCI not only affects the quality of life (QOL) of the patient, but also creates an added social, financial, and psychological burden on the family. Caregiver is responsible for providing the patient with physical, emotional, and functional support. Therefore, the increasing burden on the caregiver worsens all the domains constituting the QOL of the patient. Thus, the understanding of caregiver burden in terms of demographic profile of caregivers, severity of SCI, cost of care, mode of treatment adopted, and employment and education of the caregiver is important in the rehabilitation of patients with SCI. Materials and methods: A cross-sectional analytical questionnaire survey was performed with 50 SCI patients and their primary caregivers at a tertiary care institution between June and September 2016. The caregiver burden was assessed using the Zarit burden interview scale, and its relation with severity of injury and type of treatment was analyzed using nonparametric statistics. The demographic variables influencing caregiver burden were also studied. Results: About 38% of patients had complete SCI. About 34% of caregivers of patients were their own spouse. The mean age of caregiver was 42.9 ± 1.2 years. The majority (44%) of caregivers had moderate burden. Completeness of SCI significantly influenced caregiver burden (p = 0.02). Type of treatment adopted did not influence the caregiver burden (p = 0.52). Employment status and education of caregiver were found to be significantly associated with caregiver burden (p = 0.001 and p = 0.046 respectively). Conclusion: Caregivers had significant burden of care in terms of severity of SCI. Age, employment status, education, and marital status affect caregiving burden. We hope the results of the study will guide experimental research in this field, motivating the health care professionals in providing early psychological intervention leading to positive belief and attitude change in society. The study will encourage society in focusing on community-based rehabilitation, which can potentially reduce the overall burden.

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Introduction: Intramedullary spinal cord tumors are rare, representing 4 to 10% of all central nervous system tumors. They account for 20% of all intraspinal tumors in adults and 35% of all intraspinal tumors in children. Study design: Observational study. Purpose: Understanding the natural progression of an intramedullary spinal cord tumor. Materials and methods: To report a case of silent intradural intramedullary spinal cord tumor in a 38-year-old patient, on regular follow-up in the outpatient department since 6 years. Investigations: Magnetic resonance imaging thoracic spine revealing intramedullary tumor which is localized, central, uniformly enhancing on contrast and is associated with syrinx formation from D1 to D7. Management: Conservative. Conclusion: The rare incidence of intradural tumors commonly results in misdiagnosis and improper diagnostic workup, resulting in delayed diagnosis and treatment. Dilemma exists in the management of clinically silent intramedullary tumors as no specific guidelines have been formulated.

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Introduction: Complications occurring during surgery are not uncommon and may lead to abandoning of the procedure. Discussed here is one such case where complication was managed and optimal surgical treatment was carried out as was planned preoperatively. Case report: A 72-year-old male planned for posterior dynamic stabilization (PDS) broke his spinous process during surgery without any undue stress or force. Spinous process was reconstructed and PDS done as planned with improvisation on table. Conclusion: A broken spinous process during surgery was successfully reconstructed and stabilized with two Coflex dynamic devices at either end.

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Background: Intraspinal dermoid cysts are rare and benign tumors that occur primarily due to the defective closure of the neural tube, an ectodermal derivative, during the process of development. They can appear subdurally, extramedullary or intramedullary, with intramedullary presentations being relatively rare. Case presentation: We present here a 24-year-old lady with low backache radiating to both lower limbs, with tingling and numbness of both lower limbs for 3 years. MRI study of the lumbosacral spine revealed a heterogeneous intradural mass lesion in the conus medullaris region at L2-L3 level (low lying cord) displacing the traversing nerve roots. Total excision of the tumor was tone and sent for biopsy which revealed keratinocytes with keratin flakes,based on which a diagnosis of dermoid was made. Conclusion: The intramedullary location of a primary dermoid cyst an adult is rare and thus makes this case a very unique and rare entity Keywords : dermoid cysts, intramedullary lesions, spinal cord tumours.

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Os odontoideum is a relatively common developmental anomaly of the craniovertebral junction (CVJ), which is usually an incidental finding on spine imaging. But the dystopic variety of os odontoideum is uncommon and can be baleful. This anomaly can be a cause of atlantoaxial instability requiring surgical fixation. But the diagnosis of this variety requires considerable knowledge of anatomy of the CVJ as this unfamiliar entity needs to be differentiated from other CVJ anomalies like persistent os terminale, accessory ossicle of anterior arch of atlas, assimilation of atlas, and, most importantly, from orthotopic variety of os odontoideum. Here, we present a 34-year-old lady who presented with gradual-onset weakness of right side of the body. A computed tomography scan of the cervical spine revealed dystopic os odontoideum.

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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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High-grade spondylolisthesis is better dealt with surgical methods. There are various methods to achieve solid fusion and decompression in the presence of symptomatic spinal stenosis. In our case report, we have compared delta fixation with interbody fusion methods, especially in high-risk patients (American Society of Anesthesiologists grade III) with its various merits and demerits, and we have attempted to discuss it with respect to the literature available.

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Introduction: There are numerous biomechanical studies, but no clinical study to support or refute the use of transverse connectors (TCs) in scoliosis constructs. The aim of the study is to critically assess the role of TCs in scoliosis constructs. Material and methods: All patients of scoliosis that underwent pedicle screw constructs without the use of TCs between July 2007 and July 2011 were evaluated. The immediate postoperative erect radiographs were compared with the erect radiographs at the last follow-up (at least 12 months) by two independent observers (spine fellows). The radiographs were assessed critically for any rotation at the apical vertebra using the Nash–Moe technique. The intraobserver and interobserver reliability were analyzed. The radiographs were additionally evaluated for any loss of correction and implant failure. Results: There were 28 cases in the study. The total number of levels fused was 277. The average follow-up was 33 months. The average preoperative Cobb angle of the major curve was 72.5° (40–110°) and postoperative angle was 24.75° (5–50°). The mean percentage correction in the preoperative and postoperative Cobb angle of the major curve was 68.88% (46.80–92.3%). The intraobserver reliability was 100%; there was no change in the rotation of the levels evaluated by either observer. The interobserver reliability was 100%. There were no cases of implant failure. There were two cases of distal junctional kyphosis requiring extension of construct distally, not attributable to implant characteristics. Conclusion: The TCs are not essential to maintain derotation and do not add to stability of long scoliosis constructs. The authors make a strong statement that TCs may not be necessary to maintain derotation in scoliosis constructs. Clinical significance: The additional complications of implant prominence, metal corrosion, skin breakdown, pseudoarthrosis, and costs can be prevented by excluding TCs from the scoliosis constructs.

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