Dorsal arachnoid web: A rare cause of syringomyelia and myelopathy.

Dorsal arachnoidal webs are condensations of arachnoidal tissue densely adherent to the pial surface of the posterior aspect of the dorsal spinal cord. Infrequently described in literature they disrupt the flow of CSF in the spinal subarachnoid space leading to syringomyelia and myelopathy. While there are several theories on their origin, the "scalpel sign" on magnetic resonance imaging is considered to be pathognomonic of this condition. An illustrative case of a 58 year old man with syringomyelia and dorsal cord indentation who presented with spastic paraparesis, gait instability, parasthesias and bilateral non radicular upper limb pain that resolved following excision of the web is described to highlight the importance of considering this diagnosis when cases of so called "idiopathic" syringomyelia are encountered.

A Dorsal Epidural Herniated Disc Fragment Initially Presenting as Guillain-Barré Syndrome.

Guillain-Barré syndrome (GBS) is a rare autoimmune disorder that presents with neurological symptoms that can mimic other conditions. This mimicry can hide other important neurological diagnoses. Here, we present a rare case of thoracic myelopathy secondary to a sequestered dorsal epidural herniated disc fragment that initially presented with the classic findings of GBS. A 58-year-old female presented with progressing bilateral lower extremity weakness, paresthesias, and absent bilateral lower extremity deep tendon reflexes. Lumbar magnetic resonance imaging (MRI) findings were disproportionate to presentation, and lumbar puncture fluid analysis revealed clear, colorless fluid with albuminocytological dissociation. The patient was diagnosed with GBS and treated with a short course of intravenous steroids followed by intravenous immunoglobulin. The patient later developed new-onset ulnar distribution paresthesias, lower extremity spasticity, constipation, and urinary retention that caused a decline in functional progress. Further investigation prompted evaluation with cervical and thoracic MRIs, which revealed a left dorsal epidural lesion at the T9-T10 level causing severe cord compression. The patient was definitively treated with a T9-T10 laminectomy and excision of the offending lesion. Pathology revealed collagenous tissue with fibroblastic proliferation, consistent with a sequestered fragment of the herniated intervertebral disc. The patient was further treated with both acute and subacute rehabilitation. She was eventually discharged home and was able to ambulate independently with a walker. Dependency on positive albuminocytological dissociation in cases of potential GBS can lead to errors in diagnostic accuracy and delay appropriate treatment. Clinicians should remain mindful that GBS is a diagnosis of exclusion and MRI of the entire spine should be considered when the diagnosis of GBS is uncertain.

Intraspinal periosteal chondroma in upper thoracic spine causing cord compression and myelopathy: A case report.

INTRODUCTION: Chondromas are slow-growing cartilage-forming benign tumors, rarely occurring in the spine. Generally, most spinal chondromas are asymptomatic; however, with slow progressive growth, these lesions may enlarge and expand and cause compressive neurological symptoms, resulting in radiculopathy or more commonly myelopathy due to direct neural compression. PRESENTATION OF CASE: A 15-year-old male adolescent presented to Emergency Department with history of fall (slippage) on concrete ground while playing three months back. On neurological examination, the motor power in bilateral upper limbs was 5/5 while it was 1/5 in both lower extremities. Some muscle wasting was noted in the lower limbs. The planter reflexes were upgoing; and the sensory loss was below T6 spinal level. CT scan of dorsolumbar spine demonstrated a well-defined high-density lesion in lateral aspect of spinal canal at T2-T3 vertebral level adjacent to left T2-T3 facet joint. MRI of dorsal spine revealed a 3 × 2 × 1 cm3-sized, well-defined, non-enhancing T1 low to isointense and T2/STIR heterogeneous hyperintense lesion with osseous and cartilaginous components in the left lateral aspect of spinal canal at T1-T3 level, causing compression and contralateral displacement of spinal cord. The patient was then subjected to posterior laminectomy, complete excision, followed by laminoplasty using minicranial plates and screws. Histopathology of the mass showed bony trabeculae with hematopoietic elements and attached lobules of hyaline cartilage, chondroid matrix and lobules of mature chondrocyte and myxoid changes. Postoperatively his power was improved slightly and he was able to stand up with some assistance. On six-month follow up, patient showed significant neurological improvement. He was able to walk independently with minimal assistance. He was able to control bowel and bladder functions. DISCUSSION: Chondromas occurring in the spine are rare, accounting for only about 3% of all chondromas. Spinal chondromas are commonly encountered in the thoracic spine as in our case. CONCLUSION: Complete en bloc surgical excision is generally recommended as the treatment of choice for cases with local and/or neurological symptoms.

Breast and dorsal spine relapse of granulocytic sarcoma after allogeneic stem cell transplantation for acute myelomonocytic leukemia: A case report.

BACKGROUND: Granulocytic sarcoma (GS) is a rare malignant tumor, and relapse is even rarer in the breast and dorsal spine following allogeneic hematopoietic stem cell transplantation. Currently, a standard treatment regimen is not available. CASE SUMMARY: A rare case of GS of the right breast and dorsal spine after complete remission of acute myelogenous leukemia is reported here. A 55-year-old female patient presented with a palpable, growing, painless lump as well as worsening dorsal compressive myelopathy. She had a history of acute myelomonocytic leukemia (AML M4) and achieved complete remission after chemotherapy following allogeneic hematopoietic stem cell transplantation. Imaging examinations showed the breast lump and C7-T1 epidural masses suspected of malignancy. Histologic results were compatible with GS in both the right breast and dorsal spine, which were considered extramedullary relapse of the AML treated 4 years earlier. CONCLUSION: A rare case of GS relapse following allogeneic hematopoietic stem cell transplantation and guidelines for treatment are discussed.

Concurrent Thoracic Spinal Intradural Extramedullary Epidermoid and Neurenteric Cyst in a Spinal Dysraphism Child.

INTRODUCTION: Intraspinal epidermoid cysts are congenital or acquired in origin; whereas intraspinal neurenteric cysts (NECs) are of congenital origin. Their individual association with spinal dysraphism and vertebral segmentation anomalies is very well known. CASE PRESENTATION: We hereby report a case of concurrent intradural extramedullary epidermoid and NEC at adjacent vertebral levels in a spinal dysraphism child, not reported in English Literature till now. CONCLUSION: Multiple spinal lesions related to any/all of the 3 germ layers can coexist at same or adjacent vertebral levels in the same patient and surgical planning shown to be done accordingly.

Functional outcome of surgically treated patients of ossified posterior longitudinal ligament of cervical and dorsal spine in Indian population - A single center retrospective analysis of 40 patients.

AIMS: The aim of the study was to retrospectively evaluate the neurological outcome in operated patients of ossified posterior longitudinal ligament (OPLL) of cervical and/or dorsal spine using modified Japanese orthopedic association (mJOA) score and find out the factors affecting the outcome. SETTINGS AND DESIGN: The study design was a retrospective study. MATERIALS AND METHODS: Forty operated patients of cervical and/or dorsal spine OPLL were included in the study. Neurological examination was conducted and analyzed using mJOA score pre- and postoperatively at 1, 6, and 12 months. Improvement in the mJOA score based on age, sex, type of OPLL, duration of symptoms, type of surgical procedure, and radiological parameters were calculated, analyzed, and compared with previous records of the patient. RESULTS: Significant improvement in mJOA scores with mean preoperative being 12.27 ± 1.95 with 1-year postoperative 13.85 ± 2.02 (P < 0.0001) noted. There is a significant difference in mean mJOA scores in posterior approach with instrumentation (P < 0.0001) as compared with laminoplasty group (P < 0.005). Patients with occupancy ratio <60% had better results (P < 0.0001) as compared to those with occupancy ratio of >60% (P = 0.003). Patients with duration of symptoms >1 year had poorer results compared to those of <1 year duration. Mean ossification kyphosis angle was 19.4° ± 5.73°. CONCLUSION: OPLL is a progressive disease which causes severe neurological deficit if left untreated. OPLL in a young patient with short duration of symptoms, low occupancy ratio, and low ossification kyphosis had better chances of neurological recovery. Type of OPLL and sex of patient do not affect the recovery. OPLL managed early and surgically has better results irrespective of anterior or posterior approach with significant improvement in mJOA score. Decompression with fusion has better results than decompression alone.

Hydatid Cyst of Dorsal Spine Masquerading as Tubercular Infection: A Case Report and Review of Literature.

Hydatid cyst disease of the spine is rare, and only a few are reported in the scientific literature. This infection is caused by the larvae of Echinococcus granulosus cestode. The presentation is usually late because the patient remains asymptomatic for a longer duration after the infection. The initial form of treatment is always surgical in a symptomatic patient for excision of the diseased tissue. A 35-year-old male presented in the outpatient department with a chief complaint of mid-back pain and intermittent history of fever following his back surgery for 4 years. The patient has taken presumptive treatment for tuberculosis before presenting it to us. Radiological investigations dictate the presence of hydatid cyst in the D4 vertebra. Intact cysts were excised with perioperative albendazole coverage. The patient was mobilized on postoperative day-1 with Taylor's brace, and the brace was continued for 6 weeks. The patient was followed up at regular intervals for 1 year, and no recurrence was found. Hydatid cyst disease in the spine is a rare disease but associated with high morbidity despite significant advances in diagnostic imaging techniques and surgical treatment. For a provisional diagnosis, magnetic resonance imaging is the investigation of choice. Surgical decompression is the main stray of treatment along with antihelminthic therapy. A close follow-up is required after the initial treatment to find the recurrence at the earliest.

Low Back Pain Among Weightlifting Adolescents and Young Adults.

Background Weightlifting is a common type of sports training that develops the strength and size of skeletal muscles. Low back pain (LBP) is one of its most common complaints. This sport has become prevalent among adolescents and young adults as they work to enhance their physique and body image. The aim of our study is to explore the nature and cause of LBP in weightlifting adolescents and young adults in an aim of extrapolating proper preventive measures. Methods Participants were patients who engaged in weightlifting sports and had presented to our clinic with nonspecific LBP. They were examined and asked to rate and localize their pain. Back positioning during weightlifting techniques along with other exercise habits was explored. Patients with congenital or systemic diseases and fractures were excluded from our study. Results A total of 93 patients presented with LBP (age range: 16-26 years), all of whom partook in weightlifting (N=93). Localized pain was found in 43 patients (46%). Pain radiating to the left side was found in 31 patients (33%), while pain radiating to the right was found in 19 patients (21%). LBP localized at the level of L4-L5 was found in 44 cases (47%), while that localized at L5-S1 was found in 43 cases (46%). Only six cases localized pain at the level of L3-L4 (7%). A total of 23 cases required surgery (25%), while others were managed conservatively. All the participants (100%) reported their pain to be initiated during or after weightlifting maneuvers. Psychological symptoms were found in 13 cases (19%). Factors that helped relieve the pain included surgery, swimming, and wearing a back brace. Conclusion Weightlifting is a sport that utilizes heavy weights to engage the muscles in the body, and consequently, predisposes athletes to LBP. Using excessive weights and performing improper techniques puts the back in a compromising position that may lead to injury. Medical and sports personnel should raise awareness on the biomechanical properties of the lumbar spine and the correct spine-protective posture during training to help prevent these injuries in the future.

Functional Outcome of Right-sided Thoracotomy for Tuberculosis of the Dorsal Spine.

INTRODUCTION: In pathologies of the spine involving dorsal vertebrae, it is a routine practice to go for left-sided thoracotomy. It is so because in this approach, we encounter the aorta before reaching the concerned dorsal vertebra which is easy to handle as compared to the inferior vena cava on the right-sided approach. This is because the aorta is a structure with thick muscular wall. However, there are conditions which demand right-sided thoracotomy for better outcome such as idiopathic scoliosis and dorsal spine tuberculosis (TB). The selection of side of thoracotomy should be done on case-to-case basis. STUDY DESIGN: This was a prospective study of 10-year duration. PURPOSE: The purpose of the study was to analyze whether it is more rational to do thoracotomy from the right side than left for dorsal spine TB. MATERIALS AND METHODS: The study was performed on 102 dorsal Koch patients with neurological deficit who required surgical decompression. Magnetic resonance imaging of those patients was analyzed. Seventy-two patients had predominant right-sided lesion. Left and central types of predominant results were in 19 and 11 patients, respectively. Among these 102 patients, 82 were operated with right-sided thoracotomy, whereas 20 were operated for left-sided thoracotomy. Preoperative and postoperative kyphosis angle (K angle), average surgical time, mean blood loss, and visual analog scale (VAS) score were calculated. The SPSS 17 software was used for the statistical analysis. RESULTS: Right thoracic approach turned out to be better approach than left in dorsal Koch spine. The average surgical time and mean blood loss were less in the right thoracotomy than left. Postoperative K angle and VAS were improved in the right thoracic approach as compared to left. CONCLUSION: Tubercular debris in the dorsal spine predominantly is on the right side, and right thoracotomy gives better results as there is better decompression of lesion.

Physiotherapist survey: Increasing thoracic spine movement within the management of chronic subacromial impingement syndrome.

AIMS: This study's primary aim is to address two questions. Firstly; what evidence exists regarding the inclusion of increasing thoracic movement within the management of subacromial impingement syndrome SIS?; and secondly, what proportion of Society of Musculoskeletal Medicine (SOMM) physiotherapists use this form of treatment within SIS management? METHODS: An online survey was conducted using a questionnaire incorporating a vignette describing a patient with chronic SIS. The SOMM physiotherapy members were sampled using convenience sampling. FINDINGS: This study has identified some evidence supporting increasing movement of the thoracic spine in the management of patients with SIS. No study or guideline protocols have been identified that advocate the use of this form of treatment, nor research identified that investigates physiotherapists' use of this form of treatment within SIS management. Of the 1340 physiotherapists surveyed, 52 responded of which 79% stated that they would use treatment aimed at increasing movement of the thoracic spine within SIS management. Chi Square analysis suggests no significant association between using this treatment and number of years experience (p value = 0.15) or courses attended (p = 0.62). CONCLUSIONS: Evidence suggests it is beneficial to include treatment to increase thoracic spine mobility within SIS management. This study highlights the need for the clinician to be aware of the role of the thoracic spine in relation to the biomechanics of the shoulder complex. Of the sample of SOMM physiotherapists obtained, the majority stated that they would use this form of treatment. Further research is recommended.

Symptomatic Thoracic Intramedullary Arachnoid Cyst: "A Rare Entity" Report of Two Cases with Short Review of Literature.

Spinal arachnoid cysts are uncommon benign lesions of spine axis and most commonly present as compressive myelopathy. Intramedullary arachnoid cyst is uncommonly seen, hence, not much discussed in literature. Due to rarity of this entity, many questions are yet to be answered and should be addressed properly, particularly related to etiopathogenesis, accustomed course, behavior, differential diagnosis, and the best treatment modality. We report the clinicopathological profile of thoracic intramedullary arachnoid cysts in two adult patients, and present a detailed review of available literature on the spinal intramedullary arachnoid cyst. Most of the literature concerning with intramedullary arachnoid cysts are in the form of case reports from pediatrics population. As far to the best of our knowledge, only a few cases excluding our two were found in both pediatrics and adult population.

Delayed Paraplegia in an Adult Patient With Spinal Cord Injury without Radiographic Abnormality of Dorsal Spine: A Lesson Learned.

Noncompressive myelopathy of lower dorsal spine secondary to trauma is a rare event. We report a case of delayed paraplegia in a patient with a history of road traffic accident. The X-ray of dorsolumbar spine did not show any abnormality. Magnetic resonance imaging of dorsolumbar spine was performed which showed the presence of central T2-weighted hyperintensities from D10-D11 to D12-L1 level. No associated bony injury was documented, and the integrity of the spinal canal was maintained. The patient was managed conservatively with bed rest, and steroids were given. However, the patient did not show any signs of improvement after 1 month of follow-up.

Piezoelectric Surgery for Dorsal Spine.

BACKGROUND: Laminoplasty and laminectomy are 2 common surgical procedures used in treating degenerative and neoplastic diseases of the spinal canal. Routinely used instruments, such as the Kerrison rongeur and high-speed drill, can result in potentially serious complications, such as dural injury and thermal and mechanical damage to neurovascular structures. We adopted piezoelectric bone surgery, which permits a selective cut of mineralized tissues, to perform posterior procedures on the thoracic spine, where the relationship between bone and the spinal cord is critical. The aim of this article was to evaluate the use of piezoelectric surgery for performing dorsal spine laminectomy and laminoplasty. METHODS: The Mectron piezosurgery device was developed for cutting bone with microvibrations that are created by the piezoelectric effect. This instrument allows a safe and precise bone cut, and it is characterized by no heat generation, thus avoiding thermal injury to bone and soft tissues. We used this device to perform 8 laminoplasties for tumors of the dorsal spine and 2 laminectomies for thoracic spinal stenosis in 10 patients. RESULTS: There were no procedure-related intraoperative complications, such as dural injury or damage to neural structures. CONCLUSIONS: The piezoelectric device showed excellent results in terms of safety and precise bone cutting properties when performing posterior surgical procedures in the dorsal spine, where thermal injury produced by the conventionally used drill may damage the spinal cord closer to bony elements.

A Rare Primary Dumbbell Lipoblastoma.

Lipomas and lipoblastomas are benign tumors of mesenchymal origin in contrast to liposarcoma that is a malignant tumor. Atypical lipomatous lesion arising from embryonal fat cells is termed as lipoblastoma. In the present case report 9-month-old male presented to us with painless, rapidly progressing mass over back, power was normal in all four limbs, fine needle aspiration cytology was suggestive of cellular tissue, magnetic resonance imaging suggestive of well-defined enhancing mass in paravertebral location, extending from D3 to D10 vertebrae with intraspinal extension, communicating through neural foramina at level of D7. Intraoperatively, it was dumbbell-shaped, looked like neurofiboma based on the gross findings and it was adherent to dorsal nerve root also. Single level laminectomy with complete surgical excision of lesion done with sacrifice of dorsal nerve root. Histopathology was suggestive of lipoblastoma. Postoperative recovery was uneventful.

Mature Cystic Teratoma of Dorsal Spinal Cord in Adult: An Unusual Lesion.

Teratomas are a type of multipotential cell tumor that contain a mixture of multiple germinal layers formed by normal organogenesis and reproductive tissues the incidence of intracranial teratomas is low, approximately 0.5-2.2% of all intracranial tumors. The occurrence of teratomas in the spine is extremely rare. Except for in the sacrococcygeal region, teratomas constitute <0.5% of all intraspinal tumors. According to the literature this is only 8th case of dorsal spinal mature cystic teratoma reported till date.

Transthoracic approach for ventrally situated paraspinal extradural hydatid cyst of the dorsal spine.

A 40-year-old female presented with back pain without any neurological deficits. Radiological investigations revealed a ventrally situated paraspinal lesion causing widening of the right D4 neural foramen. She underwent a right posterolateral thoracotomy and excision of the lesion in toto, which was reported as a hydatid cyst on histology. Ventrally situated paraspinal extradural hydatid cysts are rare. A Transthoracic surgical exposure offers a direct approach for complete excision of the lesion, minimizing the chances of rupture and spillage.

Primary dorsal spine primitive neuroectodermal tumor in an adult patient: Case report and literature review.

Primary spinal primitive neuroectodermal tumor (psPNET) is a rare entity with few cases reported in literature. We report a case of a 50-year-old female who presented to us with paraplegia and was diagnosed with extradural dorsal spine psPNET. The diagnosis was not suspected at presentation or on radiology but was established on histopathological examination. It is important to distinguish it from central nervous system primitive neuroectodermal tumors and from other spinal tumors since it follows a different clinical course and therapeutic outcome.

Transthoracic approach for lesions involving the anterior dorsal spine: A multidisciplinary approach with good outcomes.

INTRODUCTION: Anterior approach provides excellent visualization and access to the anterior thoracic spine. It may be used alone, in combination with a posterior midline approach or in a staged or sequential fashion. AIMS: To analyse our institutional experience in transthoracic approaches and to determine the safety and benefit of this approach in our patient series. MATERIALS AND METHODS: A total of 16 patients were operated for varying lesions of body of dorsal vertebra by the transthoracic approach. The study was for a period of 5 years from January 2011 to December 2015. Patients age ranged from 25 to 61 years with an average of 36.4 yrs. There were 7 males and 9 females. In our series 9 patients had Kochs spine, 4 patients were traumatic fracture spine and 3 had neoplastic lesion. Majority of patients had multiple symptoms with backache being present in all patients. RESULTS: There was one post operative mortality which was unrelated to surgery. One patient had post operative delayed kyphosis. Remaining patients improved in their symptoms following surgery. CONCLUSION: With careful coordination by thoracic surgeons, neurospinal surgeons and anaesthetists, the anterior spine approach for dorsal spine is safe and effective. Adequate preoperative evaluation should stratify the risk and institute measures to reduce it. Accurate surgical planning and careful surgical technique are the key to yield a good outcome and to reduce the risk of complications.

Dorsal spinal epidural psammomatous meningioma in an adult male.

Meningiomas are benign in nature and arise from the arachnoid cells. They are mostly situated in the intracranial compartment, whereas spinal meningiomas are rare. Approximately, in 10% of cases, an extradural component is seen but an exclusively extradural meningioma is quite uncommon. However, WHO Grade II (atypical) and Grade III (anaplastic) tumors can behave aggressively. We reported a case of purely extradural psammomatous meningioma in an adult male affecting the dorsal spine although uncommon meningiomas should be included in the differential diagnosis of extradural intraspinal masses.

Anterior versus posterior debridement fusion for single-level dorsal tuberculosis: the role of graft-type and level of fixation on determining the outcome.

PURPOSE: This study compared the clinical, radiological and functional outcome of anterior versus posterior approaches for single-level dorsal tuberculosis with analysis of effect of graft type and fixation level on the outcome. METHODS: Anterior group (AG): 43 cases (mean age: 49.5 years) fixed with Z-plate by anterior transthoracic-transpleural approach. Posterior group (PG): 49 cases (47.0 years) fixed with transpedicular-screws with unilateral facetectomy ± pediculectomy. Assessment was done using Frankel classification, blood-loss, operative-time, Kyphus-angle, correction loss, union and Oswestry disability index (ODI). RESULTS: Both groups had similar operative-time, blood-loss, time to union, follow-up, and hospital-stay. Kyphus-angle improved from 36.6 ± 8.4° to 7.5 ± 2.3° (AG) and from 38.5 ± 5.9° to 11.1 ± 3.6° (PG) and this was significant. Postoperative Kyphus-angles were significantly better than preoperative ones in both groups. The correction percentage was 79.2 % (AG) and 69.9 % (PG) and this was significant. ODI was 3.4 ± 4.1 (AG) and 3.0 ± 4.2 % (PG) and this was insignificant. Correction loss was .8 ± 1.2° (AG) and 1.9 ± 2.2° (PG) and this was significant. Union was faster with iliac graft but with lower correction degree and higher correction loss than rib-strut graft. All patients achieved union. All but three patients achieved full neurological recovery. Superficial infection occurred in three cases (PG:2; AG:1) lung parenchymal injury in two case (AG), and DVT in one case (AG). CONCLUSIONS: Both approaches give very good union and kyphosis correction rate that were maintained overtime. Anterior approach gives statistically better kyphosis correction and less correction-loss, but this is clinically insignificant. Besides, it is more risky and difficult. Strut-graft is essential in reconstruction and correction of kyphosis and vertebral height. LEVEL OF EVIDENCE: III therapeutic.