Introduction: Respiratory dysfunction in craniovertebral junction (CVJ) pathology can be due to (1) direct compression of neural tissue, or (2) weakness of muscles of respiration. Majority of the times, this impairment is clinically occult. The outcome of a patient with CVJ anomaly is also dependent upon his/her respiratory function. Objective: To assess the respiratory function following relief of compression in the early postoperative (within first week of surgery) and late postoperative period (3 months or more after surgery) and to compare with preoperative status using pulmonary function tests (PFTs). Materials and methods: Twenty-five patients with CVJ pathology underwent bedside evaluation with single breath count (SBC) and respiratory system examination. Spirometry was performed in the preoperative phase and immediate postoperative phase and on follow-up (3 months), and the results were compared and analyzed between the preoperative and postoperative phases and also were compared with healthy, age- and sex-matched controls. Descriptive statistical analysis was carried out using Student's t-test. Wilcoxon signed rank test was used to find the significance of study parameters between pre- and postintervention in each group. Statistical software Statistical Package for the Social Sciences (SPSS) version 15.0, Stata 8.0, MedCalc 9.0.1, and Systat 11.0 were used for the analysis of the data. Results: Twenty-five patients underwent preoperative and early postoperative and late postoperative evaluation. Majority were in their second and third decades of life. Males were predominant (76%). Atlantoaxial dislocation (AAD) was the most common pathology. All parameters, viz., forced vital capacity (FVC), forced expiratory volume at 1 second (FEV1), ratio between FEV1 and FVC (FEV1:FVC), forced expiratory flow, maximal voluntary ventilation (MVV), and peak expiratory flow rate (PEFR) showed significant compromise in the preoperative period compared with normative data, and improvement in all these values occurred in late postoperative period only. Conclusion: Significant yet occult respiratory dysfunction exists in patients with CVJ anomalies. An objective evaluation of this occult respiratory dysfunction is essential to prevent respiratory complications and improve postoperative respiratory rehabilitation.

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Lumbar canal stenosis (LCS) is the most common cause of back pain and disability among the elderly. The natural history of degenerative spine is ongoing relentless degeneration. Very frequently, we see patients with multilevel degeneration (more than three levels) at the time of presentation, and they pose a significant dilemma in management. The choice of surgical procedure performed varies from simple decompression, which may not halt the natural progression of disease, to fusion procedures, which carry high morbidity and may not be necessary in all cases. Posterior dynamic stabilization (PDS) may be an appropriate middle ground for such cases as we are able to decompress the spine adequately without causing instability and, additionally, provide support by offloading the facets and halting the progression of disease. We describe here our initial experience of using PDS in advanced multilevel degeneration.

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Tubercular osteomyelitis, a form of extrapulmonary tuberculosis (TB), represents less than 2% of all TB cases and about 10% of all cases of extrapulmonary TB. Isolated involvement of the posterior elements of the spine and calvarial TB are rare manifestations of extrapulmonary TB, especially in immunocompetent patients. We, hereby, present a case of a 12-year-old female patient with the mentioned multifocal skeletal involvement presenting with spastic paraparesis. Magnetic resonance imaging (MRI) of the cervicodorsal spine was suggestive of lesion involving the posterior elements of the spine from C7 to D3 vertebra with marrow edema and without involvement of the vertebral bodies and intervertebral discs. The MRI of the brain was suggestive of a lenticular-shaped extra-axial lesion in the right frontal region arising from inner table of calvaria. The patient was first operated for the lesion in the cervicodorsal spine due to acute-onset paraparesis followed by complete excision of frontal lobe lesion, which was done after 2 weeks of removing the spinal lesion. Histopathological examinations of both the lesions were suggestive of TB. Majority of patients with multifocal skeletal TB have nonspecific generalized somatic symptoms and signs at presentation and inconclusive radiological findings. All these factors can lead to a delay in diagnosis in such cases. Hence, a high index of suspicion for TB is necessary for patients presenting with multiple somatic symptoms and multiple destructive skeletal lesions, particularly in areas where TB is endemic.

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Cauda equina syndrome (CES) is a rare occurrence, and its clinical presentation is often vague, mimicking other neurological or medical conditions. In our service area, general practitioners (GPs) and/or the A&E Department directly refers patients to the neurosurgical service. Initial assessment is delegated to neurosurgical and radiology specialists, basing on clinical symptoms and signs. In cases where the radiological investigations come back not suggestive of true cauda equina compression, medical management of the patients' symptoms and signs can be problematic, and often delays the discharge. We performed an analysis of the whole process of assessment and treatment of patients admitted with symptoms and signs of CES. We retrospectively reviewed all the data concerning referrals and admissions for CES in our department. Both patients' clinical details and referral details were considered and critically analyzed. In 1 year examination period, a total number of 93 patients were referred to our department. Out of this number, 69 patients were admitted in the department for clinical and radiological assessment, and treatment. Eight patients required emergency surgical decompression for CES. The mean time between referral and decompression in this group was 36 hours. The average length of hospital staying was 3 days and 16 hours (40 minutes to 1 month and 10 days). We identified several areas of possible service improvement. The clinical and radiological assessments might benefit from a standardized algorithm based on all possible presentations seen in our series and reported in literature. Aiming for better timing of transports, diagnosis, and surgical treatment, as well as more rapid bed turnover in the acute ward could also increase service efficiency and reduce costs.

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Objective: To find out the morphometric factors predicting outcome in Chiari I malformation (CM I) associated with syringomyelia. Materials and methods: In a series of 73 patients with CM I and syrinx who underwent posterior fossa decompression (PFD) between August 2013 and October 2015, a total of 54 subjects with sufficient clinical data and imaging suitable for morphometric measurments were evaluated. The parameters analyzed were posterior fossa volume (PFV), tonsillar descent (TD), foramen magnum (FM) diameter, supra-occiput length, clival length, the syrinx, and cord diameter. Patients were divided into two groups: With or without improvement. Improvement at follow-up was assessed with the Chicago Chiari Outcome Scale (CCOS). Results: Mean PFV was significantly higher in the improvement group (219.90 ± 30.20 vs 187.95 ± 12.51 cm³, p = 0.047). Syrinx to cord ratio was lower in the improved group (0.54 ± 0.21 vs 0.64 ± 0.27, p = 0.081). The cut-off value of preoperative PFV for prediction of improvement was found to be 198.58 cm³ (sensitivity 77.8%, specificity 100%). Conclusion: To the best of our knowledge, this is the largest series to evaluate the role of morphometry in prediction of surgical outcome in patients with CM I associated with syringomyelia. The PFV is the only radiological factor that differs significantly in patients with and without improvement.

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Aim: To conduct a detailed computed tomography (CT) assessment of dimensions of the subaxial cervical spine pedicle in volunteers without any cervical spine pathology. Materials and methods: Sixty-six asymptomatic subjects were analyzed in a single center using cervical spine CT, with imaging reconstruction of each vertebra in axial plane with 1 mm, and in sagittal plane reconstruction with 2 mm slice thickness. Height and weight of each volunteer were measured and body mass index (BMI) was calculated. Parameters, such as pedicle width (PW), pedicle axis length (PAL), pedicle transverse angle (PTA) in axial plane, and pedicle height (PH) in sagittal plane were measured and analyzed. Height and weight of each subject were measured and BMI was calculated as per the formula. Results: The analysis of CT scan images of the cervical spine of 66 asymptomatic subjects with mean age of 45 years with equal distribution of males and females gave mean BMI values as males: 24.58 ± 2.6 and females: 24.03 ± 2.07. Mean values of PAL were smaller in females compared with males, PAL progressively increased from C3 to C6 vertebrae level for both males and females, while C6 and C7 were similar. The PTA showed no gender variation. However, PTA among C3 to C7 demonstrated the same pattern among the left and right pedicles as they had wide angle in the upper subaxial cervical spine, C3 to C6, and became slightly narrow in the lower cervical region at C7. The PH was found to be smaller in females in comparison with males. The PH difference was observed between left and right-side values for men and women, men's right-side values were higher, whereas higher left-side values were observed in females. The PW was found to be smaller in females in comparison with males, PW increased from C3 to C7 vertebrae level, but we found little difference between left side and right side for both men and women. Conclusion: Our results are in correlation with previous studies, but our study showed strong correlation between BMI and PW, and the frequency of subjects with PW < 3.5 mm in our population especially in females is higher, suggesting an increased risk to the neurovascular structures while attempting transpedicular screw technique, especially in females.

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Long-term results of operations for symptomatic cervical and lumbar disk herniation were analyzed in 45,048 patients. Cervical disks: 6,000 patients were operated for cervical disk herniation and the results of operating anteriorly (anterior diskectomy with/without fusion) were compared to the results of operating posteriorly (laminoforamenotomy/“keyhole” facetectomy). The anterior group (mean follow-up: 5.9 years) had 80% good/excellent results, while the posterior group (mean follow-up: 8.5 years) had 94% good/excellent results (p < 0.05). Perhaps the more complete decompression of the nerve root over time is the reason for the superior long-term outcome. Lumbar disks: 39,048 patients were operated on for lumbar disk herniation. They were divided into three groups: microdiskectomy, endoscopic microdiskectomy and the classical operation (laminectomy/laminotomy with diskectomy). Mean follow-ups were 4.1 years, 2.9 years, and 6.3 years. Good/ excellent results were approximately 80% in all three groups. The same results in each group raises questions about the complete origins of the symptoms in 20% of patients.

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Aim: To describe a single reference entry point technique for lumbar pedicle screw fixation in degenerative spine and to assess its accuracy in a retrospective case series. Materials and methods: We describe a simple technique for lumbar pedicle screw insertion which is based only on a single reference point, the superior half of transverse process. We retrospectively evaluated the computed tomography (CT) images for any pedicle wall violation with screw of all the patients who were treated by this technique who also had undergone a postoperative CT scan during the study period. A team of three evaluators of different experience and training, including one spine consultant, one spine fellow, and a musculoskeletal radiologist independently studied the CT pictures and pedicle wall violations graded using a previously described grading system, and the data were analyzed by simple percentages. Results: A total of 240 patients had undergone lumbar pedicle screw fixation with this new technique during the study period, of which 36 had underwent a CT scan. A total of 164 lumbar pedicle screws were assessed. Pedicle wall violations were recorded in 9.7, 8.5, and 12.2% of the screws respectively, by consultant spine surgeon, radiologist, and spine fellow. Most of the breaches were of grade I severity as per all the three observers. There were no grade IV breaches. Conclusion: The single reference point entry for pedicle screws in the lumbar spine described was as accurate as other well-established techniques with comparable pedicle malposition rates.

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Acute spontaneous spinal epidural hematoma (SSEH) is an extremely rare but a grave condition which if missed or diagnosed late can lead to serious life-debilitating neurological deficits. Numerous contributing factors are enlisted from idiopathic, trivial trauma to antiplatelet therapy. While aspirin is known to lower the risk of coronary artery disease and stroke, the risk of developing internal hemorrhages increases. Acute SSEH associated with aspirin is extremely rare. Emergency spinal decompression with evacuation of hematoma is the mainstay of treatment. We present a case of a 60-year-old male who presented to our hospital with sudden onset of backache followed by both lower limb paresis and inability to stand. The patient was on low-dose (75 mg) aspirin daily for ischemic heart disease. Emergency spinal decompression and hematoma evacuation was done due to worsening of neurological symptoms which led to improvement of symptoms.

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Introduction: To find the incidence of cervical injury in patients dying due to polytrauma observed during autopsy. Materials and methods: A total of 282 autopsies were studied. The cases included were those of polytrauma. The postmortem examination was done in these cases. Examination of Cervical Column was done from C1 to C7 and evidence of injury was noted and its incidence was found. Results: Spinal injuries were often secondary to head impacts, or to primary accelerations of the torso without head impact. At postmortem, cervical spine injuries were noted mostly at C5 to C6 level. The most common age group was 21 to 30 years and road traffic accident (RTA) was the most common mode of injury. Conclusion: We examined the cervical spine at autopsy and found significant results. Cervical spine injuries should always be suspected in polytrauma patients and cervical supportive care should be given right from the initial handling from site of injury till their transportation to emergency centers.

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Spinal epidermoid tumors are rare tumors, constituting about less than 1% of the spinal tumors. Most of them are intradural and extramedullary. We reported a case of a 27-year-old patient with an intradural intramedullary epidermoid cyst at the thoracolumbar region presenting with urinary incontinence and paraparesis along with kyphoscoliosis.

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