Technical note: Novel use of recombinant tissue plasminogen activator for the evacuation of an acute extensive spinal epidural haematoma in a patient with coagulopathy.

Spontaneous extensive spinal epidural haematoma poses a unique challenge for the neurosurgeon. Performing extensive laminectomies to remove all of the compressive haematoma can destabilise the patient's spinal column, which may require fixation. This is further complicated in patients with significant coagulopathy. We present a novel use of recombinant tissue plasminogen activator (rt-PA) in a patient with therapeutic coagulopathy, presenting with myelopathy secondary to an acute extensive spinal epidural haematoma. To the best of our knowledge, this is the first case of acute multilevel spinal epidural haematoma that has been successfully evacuated via single level laminectomy and topically applied rt-PA.

Should neurosurgeons continue to work in the absence of personal protective equipment during the COVID-19 era?

The COVID-19 pandemic has resulted in a widespread shortage of personal protective equipment (PPE). Many healthcare workers, including neurosurgeons, have expressed concern about how to safely and adequately perform their medical responsibilities in these challenging circumstances. One of these concerns revolves around the pressing question: should providers continue to work in the absence of adequate PPE? Although the first peak of the COVID-19 crisis seems to have subsided and supply of PPE has increased, concerns about insufficient PPE availability remain. Inconsistent supply, limited efficacy, and continued high demand for PPE, combined with the continued threat of a second COVID-19 wave, mean that the issues surrounding PPE availability remain unresolved, including a duty to work. This paper offers an ethical investigation of whether neurosurgeons should perform their professional responsibilities with limited availability of PPE. We evaluate ethical considerations and conflicting duties and thereby hope to facilitate providers in making a well-considered personal and moral decision about this challenging issue.

Bilateral laminotomy through a unilateral approach (minimally invasive) versus open laminectomy for lumbar spinal stenosis.

PURPOSE: To compare the outcomes of minimally invasive (MI) bilateral laminotomy via unilateral approach versus open laminectomy in the treatment of lumbar spinal stenosis (LSS). MATERIALS AND METHODS: In this prospective study, 62 patients were treated for LSS and were assigned to one of two groups over a 6-month period. Group A comprised 37 patients that underwent MI bilateral laminotomy. Group B comprised 25 patients that underwent open laminectomy. Follow-up duration was 3 years. The primary outcomes were the visual analogue scale (VAS) pain outcome score for back and leg, the Oswestry Disability Index (ODI) and complications. RESULTS: MI methods were superior in most primary outcomes compared to open laminectomy. VAS back pain outcome was reduced from close to 7 to 4 in both groups. VAS leg pain was reduced from 6.8 to 3.2 in MI group and from 8.7 to 3.5 in the open group (p > 0.05 between groups, p < 0.05 comparing pre- to post-operative back and leg pain). ODI improved from 56.5 to 13 and 58 to 24 in MI and open groups, respectively (p > 0.05 between groups, p < 0.05 comparing pre- to post-operative disability). Complication and revision rates were lower in the MI technique than open laminectomy (8 versus 56%, p < 0.05; 3 versus 12%, p > 0.05). Length of stay ranges were less in MI than open group (1-3 versus 7-30 days, p > 0.05). CONCLUSIONS: Bilateral laminotomy through a unilateral approach (minimally invasive) and open laminectomy are both effective in improving pain and disability in LSS. MI procedures have an advantage in shorter hospital stays, sparing of more bony structures and lower complication rates. MI unilateral decompression is at least as good as laminectomy in the treatment of LSS.

Ethical triage during the COVID-19 pandemic: a toolkit for neurosurgical resource allocation.

BACKGROUND: The COVID-19 pandemic confronts healthcare workers, including neurosurgeons, with difficult choices regarding which patients to treat. METHODS: In order to assist ethical triage, this article gives an overview of the main considerations and ethical principles relevant when allocating resources in times of scarcity. RESULTS: We discuss a framework employing four principles: prioritizing the worst off, maximizing benefits, treating patients equally, and promoting instrumental value. We furthermore discuss the role of age and comorbidity in triage and highlight some principles that may seem intuitive but should not form a basis for triage. CONCLUSIONS: This overview is presented on behalf of the European Association of Neurosurgical Societies and can be used as a toolkit for neurosurgeons faced with ethical dilemmas when triaging patients in times of scarcity.

Evaluation of an increased strut porosity silicate-substituted calcium phosphate, SiCaP EP, as a synthetic bone graft substitute in spinal fusion surgery: a prospective, open-label study.

PURPOSE: Silicate-substituted calcium phosphate-enhanced porosity (SiCaP EP, Inductigraft™, Altapore) is a synthetic bone graft material with enhanced strut porosity of 31-47%. SiCaP EP remains to be fully clinically evaluated in patients undergoing instrumented posterolateral fusion (PLF) surgery. We conducted a prospective, open-label, non-randomised, multicentre clinical study to evaluate efficacy of SiCaP EP as bone grafting material in PLF surgery with instrumentation for treatment of spinal disorders. METHODS: Patients with degenerative disc disease, spondylolisthesis or spinal stenosis underwent PLF surgery with SiCaP EP. The primary endpoint was evaluated in the per protocol population (N = 102) as solid fusion at postoperative month 12 assessed using computed tomography scans, with motion assessed using flexion-extension radiographs. Clinical outcomes included the Oswestry Disability Index, 36-item short-form health survey for quality-of-life, visual analog scale for pain scores and neurological assessments. Adverse events were recorded. RESULTS: Successful fusion was achieved in 59/89 (66.3%) patients at month 6, 88/102 patients (86.3%) at month 12 (primary endpoint) and 87/96 (90.6%) patients at month 24. Disability and pain reduced following surgery. Quality-of-life improved and neurological function was maintained postoperatively. Forty-three (33.3%) of the 129 patients who underwent surgery experienced adverse events; back pain was most frequent (n = 10); nine and 14 patients experienced serious adverse events judged related to device and procedure, respectively. CONCLUSIONS: Enhanced strut porosity SiCaP EP provided high (month 12: 86.3%) spinal fusion success rates in PLF surgery. Fusion success was associated with improved clinical outcomes in patients within 12 months, relative to baseline. CLINICALTRIALS. GOV IDENTIFIER: NCT01452022 These slides can be retrieved under Electronic Supplementary Material.

A randomised controlled trial of multimodal physiotherapy versus advice for recent onset, painful cervical radiculopathy - the PACeR trial protocol.

BACKGROUND: A research gap exists for optimal management of cervical radiculopathy in the first 12 weeks and short term natural history of the condition is somewhat unclear, although thought to be favourable. The primary aim of this assessor blinded, superiority, 2 parallel group randomised controlled trial is to investigate the effects of a 4 week physiotherapy programme (6-8 sessions) of manual therapy, exercise and upper limb neural unloading tape, compared to a control of weekly phone advice; on disability, pain and selected biopsychosocial measures, in acute and sub-acute cervical radiculopathy patients. A secondary aim is to identify whether any baseline variables, symptom duration or group allocation can predict outcome. METHODS: Participants are recruited from GP referrals in an urban setting, from a neurosurgery non-urgent waiting list and from self-referral through Facebook advertising. Eligible participants (n = 64) are diagnosed with radiculopathy based on a clinical prediction rule and must have symptoms of unilateral, single level, radiculopathy for between 2 and 12 weeks, without having yet received physiotherapy. Random 1:1 group allocation (using variable block sizes), allocation concealment, blinded assessment and intention to treat analysis are being employed. Treatment is provided by clinical specialist physiotherapists in primary and secondary care settings. Outcomes are measured at baseline, 4 (primary endpoint) and 12 weeks. Participants' report of pain, disability and their rating of recovery is also recorded by telephone interview at 6 months. Statistical analysis of between group differences will be performed with ANOVAs and MANOVAs, and multivariable regression analysis will be undertaken to explore predictor variables. Ethical approval for this study has been received from the Beaumont Hospital and Irish College of General Practitioners Research Ethics Committees. The trial is registered at ClinicalTrials.gov (NCT02449200). DISCUSSION: An internal pilot study to test retention and recruitment strategies led to trial expansion and this is now a multi centre trial involving 5 clinical sites. TRIAL REGISTRATION: NCT02449200 . Registered 20/05/15.

Gross total resection rates of grade II/III intramedullary ependymomas using the surgical strategy of en-bloc resection without intra-operative neurophysiological monitoring.

INTRODUCTION: Grade II and III intramedullary ependymomas [IME] are circumscribed with a plane of cleavage that should facilitate high gross total resection rates (GTR). Gross total resection of grade II/III IME is superior to subtotal resection (STR) and radiotherapy (RTx) for progression-free and overall survival. We sought to compare our GTR with other series that have utilised standard intraoperative monitoring techniques and we explored factors that may influence rates of resection. MATERIALS AND METHODS: Database search and retrospective chart and radiological review of all grade II or III spinal ependymomas over a 10-year period from the senior authors practice. Comprehensive PubMed search to identify similar series that identified histology, McCormick Function scores (MCC) preoperatively and post-operatively, surgical strategy and use of intraoperative monitoring. Standard statistical analysis was performed. RESULTS: Seventeen patients were identified: 16 grade II and one grade 3. GTR was 94.12%. Factors that correlated with a decline in MCC were longitudinal extension of the tumour (p = 0.0238) and presentation with motor signs and symptoms (p = 0.0223). There was no statistical difference between preoperative factors that influence post-operative outcomes in the current study when compared with other published series. There was no statistical difference between preoperative and postoperative MCC scores between our series and other published series. DISCUSSION: The current series with a GTR of 94.12% compares favourably with other published series with GTRs of 55.8-84% with no significant difference in functional outcomes. Series with low GTRs should examine their operative strategy or false-positive alarm rates which may lead to higher STRs. This series should be viewed as a unique opportunity to benchmark GTRs of circumscribed intramedullary tumours.

Three-dimensional gait analysis outcomes at 1 year following decompressive surgery for cervical spondylotic myelopathy.

PURPOSE: Gait impairment is an important feature of cervical sponydylotic myelopathy (CSM) as it can have a detrimental effect on function and quality of life. The aim of this study was to measure changes in gait in people with CSM following surgical decompression. METHODS: Thirteen participants with clinical and radiological evidence of CSM underwent three-dimensional gait analysis, using a full lower limb kinematic, kinetic and electromyography protocol, before and 12 months after decompressive surgery. RESULTS: No significant post-operative changes were detected in temporal-spatial or kinematic parameters. Kinetic data showed significant improvements in knee power absorption [mean improvement, 0.42 watts per kilogram (W/kg)], ankle plantarflexor moment (0.1 Nm/kg) and ankle power generation (0.55 W/kg). Electromyography showed a 4.7 % increase in tibialis anterior activation time. CONCLUSIONS: These findings indicate that improvement in locomotor function can be achieved after surgery. Future studies should explore the potential for further recovery of gait through targeted neuro-rehabilitation.

Flipping the mJOA: Clinical utility of the modified Japanese Orthopaedic Association score as a tool for detecting degenerative cervical myelopathy.

Introduction: People with Degenerative Cervical Myelopathy (DCM) often experience diagnostic delay. This could lead to poorer outcomes, including disability. Research question: Does the modified Japanese Orthopaedic Association scale (mJOA) have clinical utility as an early detection tool for possible DCM? Materials and methods: This is a prospective study of consecutive adult patients, referred to a National Neurosurgical Centre with a neck problem. Assessing clinicians undertook standard clinical examination and calculated the mJOA score. A consultant radiologist independently reported radiological findings, after which the assessing clinician determined the diagnosis. The sensitivity and specificity of mJOA for DCM at various cut-points was statistically analysed using Receiver Operating Characteristics (ROC) curves. Results: Of 201 patients (98 male, mean age 52.6 ± 13y) assessed over 13 months, 21 were diagnosed with DCM (prevalence 10.4%). Fifteen (71.4%) had a mJOA score classifying disease severity as mild, 4/21 (19%) had moderate disease and two (9.5%) had severe disease. A mJOA score ≤17 (cutpoint ≥1) showed sensitivity of 95% and specificity of 71% for the clinical diagnosis of DCM. mJOA score ≤16 (cutpoint ≥2) had sensitivity of 62% and specificity of 90%. The ROC area under the curve was 0.885 (95% confidence interval: 0.82 to 0.95). 87% of patients were correctly classified. Discussion and conclusion: mJOA score ≤16 is 90% specific for a subsequent diagnosis of DCM in people with neck problems and has potential to be used as an early detection tool. Further research is needed to replicate these findings and establish feasibility and acceptability in primary care.

Electromyographic characteristics of gait impairment in cervical spondylotic myelopathy.

AIM: Gait impairment in cervical spondylotic myelopathy (CSM) is characterised by a number of kinematic and kinetic abnormalities. Surface electromyography (EMG) can evaluate the contributions of individual muscles to a movement pattern and provide insight into the underlying impairments that characterise an abnormal gait. This study aimed to analyse EMG signals from major lower limb muscles in people with CSM and healthy controls during gait. METHODS: Sixteen people with radiologically confirmed CSM and 16 matched healthy controls participated in gait analysis. Surface EMG was recorded during walking from four lower limb muscles bilaterally. The timing of muscle activation, relative amplitudes of each burst of activity and baseline activation during gait, and the muscles' responses to lengthening as a measure of spasticity were compared using previously validated methods of EMG analysis. RESULTS: Compared to healthy controls, people with CSM had prolonged duration of activation of biceps femoris (12.5% longer) and tibialis anterior (12.4%), prolonged co-activation of rectus femoris and biceps femoris (5.14%), and impaired scaling of the amplitude of rectus femoris and biceps femoris. Muscle activation in response to lengthening was similar between groups. CONCLUSION: The results provide evidence for paresis as a contributory factor to gait impairment in CSM, indicated by impaired amplitude and the need for proximal co-activation to compensate for lack of distal power generation. Poor proprioception may have contributed to prolonged activation of tibialis anterior. Analysis of muscle responses to lengthening suggested that spasticity was not an important contributor. These findings have implications for the assessment and rehabilitation of gait impairment in CSM.

When does too little pressure become too much? A case of spontaneous intracranial hypotension presenting with acute loss of consciousness.

Background: We present a unique case of spontaneous intracranial hypotension (SIH) presenting with acute collapse and loss of consciousness. Case Description: The affected patient suffered an abrupt decline in level of consciousness several weeks after initial diagnosis. The patient was urgently transferred to a specialist neurosurgical unit. Imaging showed bilateral subdural fluid collections with significant associated local mass effect. The treating team faced a clinical conundrum with a lack of clarity as to whether this sudden deterioration was secondary to the local pressure effect on brainstem traction from reduced intracranial pressure. A decision was made to proceed with urgent burr-hole decompression of the bilateral subdural fluid collections. Conclusion: After a protracted, complex postoperative course, the patient recovered to full functional independence. To the author's knowledge, this is the first case in literature describing successful surgical management of SIH, with bilateral burr-hole evacuation to relieve the paradoxical mass effect of bilateral subdural fluid collections.

Gait impairment in cervical spondylotic myelopathy: comparison with age- and gender-matched healthy controls.

INTRODUCTION: Gait impairment is a primary symptom of cervical spondylotic myelopathy (CSM); however, little is known about specific kinetic and kinematic gait parameters. The objectives of the study were: (1) to compare gait patterns of people with untreated CSM to those of age- and gender-matched healthy controls; (2) to examine the effect of gait speed on kinematic and kinetic parameters. MATERIALS AND METHODS: Sixteen patients with CSM were recruited consecutively from a neurosurgery clinic, and 16 healthy controls, matched to age (± 5 years) and gender, were recruited for comparison. Patients and controls underwent three-dimensional gait analysis using a Vicon(®) motion analysis system, at self-selected speed over a 10-m track. Controls were also assessed at the speed of their CSM match. RESULTS: At self-selected speed, the CSM group walked significantly more slowly, with shorter stride lengths and longer double support duration. They showed significant decreases in several kinematic and kinetic parameters, including sagittal range of motion at the hip and knee, ankle plantarflexion, anteroposterior ground reaction force (GRF) at toe-off, power absorption at the knee in loading response and terminal stance, and power generation at the ankle. At matched speed, the CSM group showed significant decreases in knee flexion during swing, total sagittal knee range of motion, peak ankle plantarflexion and anteroposterior GRF. CONCLUSION AND IMPLICATIONS: The findings suggested that people with CSM have significant gait abnormalities that have not been previously reported. In particular, there are key differences in the motor strategies used in the terminal stance phase of gait that cannot be explained by speed alone.

An interesting case of primary spinal arachnoiditis.

Spinal arachnoiditis describes inflammation of the meninges, subarachnoid space and, in most cases, also involve the pial layer. The vast majority of cases described are secondary and are preceded by a known event, for example,. trauma, infections or irritative substances. Here, we present the case of primary spinal arachnoiditis. A 35-year-old lady was referred to the neurosurgical services in Dublin, Ireland with a 15-month history of progressive, right lower limb weakness. Magnetic resonance imaging revealed cystic distortion of the lumbar spinal canal extending up to the conus. Initially, an L2-L4 laminectomy was performed revealing thickened and adherent arachnoid with a large cyst in the spinal canal. Four months after initial operation, the patient represented with bilateral lower limb weakness and loss of detrusor function. Repeat magnetic resonance imaging was performed, which showed the development of a syrinx in the patient's thoracic spine. We then performed a T9-T10 laminectomy, midline myelotomy and insertion of a syringe-arachnoid shunt. Post-operative imaging showed resolution of the syrinx and a vast improvement in lower limb power. The patient also regained bladder control. In conclusion, spinal arachnoiditis is a clearly defined pathological and radiological entity with a highly variable clinical presentation. It is exceedingly difficult to treat as there is no recognised treatment currently, with most interventions aimed at symptomatic relief.

Ethico-legal regional differences in European neurosurgical practice: Part 1-pre-COVID-19 era.

Introduction: Professionalism entails expert knowledge, self-regulation, accountability, and professional ethics. These factors are influenced by culture, political observance, professional maturity, education, and occupation; ethical practices may thus vary between countries and affect how neurosurgery is practiced. Research question: This paper aims to conduct a survey that addresses whether ethico-legal practices differ in European countries and whether existing ethical guidelines have been implemented. Material and methods: A questionnaire survey was used to examine the ethico-legal situation in 29 European countries or regions. The reports were validated by representatives of each nation. Results: Existing guidelines had been implemented to a minimal extent. Major regional and national differences were found in attitudes toward life and death, prioritization, and issues related to professional conduct. Discussion and conclusion: The results of this survey reveal inadequacies and weaknesses of policies and resources, which should spark national discussions to improve the conditions that influence professional ethics. Unfortunately, only a minority of neurosurgeons know the neurosurgical ethics guidelines and apply them in their decision making. Our findings highlight the importance of values and professional ethics in decision making.

Neurotrauma admissions and COVID-19: a National Centre experience.

BACKGROUND: To investigate the impact of COVID-19 on trauma admissions to a National Neurosurgical Centre in Ireland. METHODS: Retrospective analysis of a prospectively maintained database of all trauma admissions to the National Neurosurgical Centre at Beaumont Hospital, Dublin, during the period March 1 to May 31, 2019 and 2020. Primary outcome was 30-day mortality rate. Secondary outcomes included time transfer time, time from admission to time of surgery, and intensive care unit (ICU) admissions. Patients under the age of 16 were excluded. RESULTS: A total of 32 and 39 patients were admitted to the National Neurosurgical Centre following trauma over the 3-month period in 2020 and 2019 respectively, giving a 17.9% reduction in admissions. The 30-day mortality rate increased from 7.7% in 2019 to 15.6% on 2020 (p = 0.45). Mean transfer time was 4 h 58 min in 2019 and 3 h 55 min in 2020 (0.22). Mean time from admission to time of surgery was 9 h 10 min in 2019 and 5 h 37 min in 2020 respectively (p = 0.35). In 2019, 20 patients (51.3%) were admitted to ICU. This increased to 23 patients (69.7%) in 2020 (p = 0.08). CONCLUSIONS: Traumatic brain injury 30-day mortality rates increased during the first COVID-19 lockdown period. Trauma admission rates to ICU remained unchanged despite an overall reduction in trauma admissions. Transfer time, time to surgery, and length of stay were impacted by COVID-19. Despite the challenges COVID-19 has posed, it is important to maintain a fully functioning neurosurgical and neurocritical care service during the pandemic.

Idiopathic intracranial hypertension: lumboperitoneal shunts versus ventriculoperitoneal shunts--case series and literature review.

OBJECTIVES: Idiopathic intracranial hypertension (IIH) is an uncommon but important cause of headache that can lead to visual loss. This study was undertaken to review our experience in the treatment of IIH by neuronavigation-assisted ventriculoperitoneal (VP) shunts with programmable valves as compared to lumboperitoneal (LP) shunts. METHODS: A retrospective chart review was conducted on 25 patients treated for IIH between 2001 and 2009. Age, sex, clinical presentation, methods of treatment and failure rates were recorded. RESULTS: Seventy-two per cent were treated initially with LP shunts. Failure rate was 11% in this group. Neuronavigation-assisted VP shunts were used to treat 28%. In this group, the failure rate was 14%. CONCLUSION: Our experience indicates that both LP shunts and VP shuts are effective in controlling all the clinical manifestations of IIH in the immediate postoperative period. Failure rates are slightly higher for VP shunts (14%) than LP shunts (11%). However, revision rates are higher with LP shunts (60%) than with VP shunts (30%).

The impact of COVID-19 on trauma referrals to a National Neurosurgical Centre.

BACKGROUND: To investigate the impact of COVID-19 on trauma referrals to a National Neurosurgical Centre during the first wave of COVID-19 in Ireland. METHODS: Retrospective analysis of a prospectively maintained database of all trauma referrals to the National Neurosurgical Centre at Beaumont Hospital, Dublin, during the period March 1-May 31, 2019 and 2020. Patient characteristics including age, sex, alcohol use, anticoagulant/antiplatelet use and initial Glasgow Coma Scale (GCS) were recorded. Patients were grouped based on trauma aetiology and diagnosis. RESULTS: There were 527 and 437 trauma referrals in 2019 and 2020 respectively. Overall, there was a 17.1% reduction in trauma referrals between 2019 and 2020. Traumatic brain injury, spinal injury and cranial fractures referrals reduced 25% (375 vs 283), 59% (32 vs 13) and 18% (39 vs 32) respectively from 2019 to 2020. Low-energy falls below 2 m was the most common mechanism of injury and accounted for 60 and 61% of referrals in 2019 and 2020. No reduction in road traffic collision (33 vs 34) and assault (40 vs 40) referrals were observed between years. CONCLUSIONS: COVID-19 has had a significant impact on both the volume and mechanism of trauma referrals to the National Neurosurgical Centre in Ireland, with falls below 2 m the most common mechanism of trauma referral across both years. The workload remains substantial and a fully resourced neurosurgical department is essential in any future COVID-19 waves.

Intermixed arteriovenous malformation and hemangioblastoma: case report and literature review.

We report the third presentation of an intermixed arteriovenous malformation and hemangioblastoma. The rare occurrence of the diagnostic histologic features of both a neoplasm and vascular malformation in a single lesion is more common in gliomas, as angioglioma, and is termed an 'intermixed' lesion. We review the literature concerning the developmental biology of each lesion, and potential interplay in the formation of an intermixed vascular neoplasm and vascular malformation. The roles of cellular origin, genetic susceptibility, favourable microenvironment, altered local gene expression and key regulatory pathways are reviewed. Our review supports angiography and genetic profiling in intermixed lesions to inform management strategies. Consideration should be given to multimodality therapeutic interventions as required, including microsurgical resection, stereotactic radiosurgery and further research to exploit emerging molecular targets.

Technical outcome of atlantoaxial transarticular screw fixation without supplementary posterior construct for rheumatoid arthritis.

BACKGROUND: transarticular screw (TAS) fixation without a supplementary posterior construct, even in rheumatoid arthritis (RA) patients, provides sufficient stability with acceptable clinical results. Here, we present our experience with 15 RA patients who underwent atlantoaxial (AA) TAS fixation without utilizing a supplementary posterior fusion. METHODS: To treat AA instability, all 15 RA patients underwent C1-C2 TAS fixation without a supplementary posterior construct. Patients were followed for at least 24 months. Pre- and postoperative sagittal measures of C1- C2, C2-C7, and C1-C7 angles, atlanto-dens interval (ADI), posterior atlanto-dens interval (PADI), and adjacent segment (i.e., C2-C3) anterior disc height (ADH) were retrospectively recorded from lateral X-ray imaging. The presence or absence of superior migration of the odontoid (SMO), cervical subaxial subluxation, C1-C2 bony fusion, screw pull-out, and screw breakage were also noted. RESULTS: There was little difference between the pre- and postoperative studies regarding angles measured. Following TAS fixation, the mean ADI shortened, and mean PADI lengthened. There was no difference in the mean measures of C2-C3 ADH. There was no evidence of SMO pre- or postoperatively. Two patients developed anterior subluxation at C5-C6; one of the two also developed anterior subluxation at C2-C3. All patients subsequently showed C1-C2 bony fusion without screw pull-out or breakage. CONCLUSION: In RA patients who have undergone C1-C2 TAS fixation, eliminating a supplementary posterior fusion resulted in adequate stability.

Spinal Cord Ependymoma - Surgical Management and Outcome.

BACKGROUND: Ependymoma is a common primary neoplasm of the spinal cord and filum terminale. Patients with spinal ependymoma usually experience gradual symptoms due to slow progression of the tumor; thus, early diagnosis can be challenging to make. OBJECTIVE: The objective of this study was to report 5 years' experience in treating spinal intramedullary ependymomas and to illustrate the advantage of aggressive complete resection whenever possible. PATIENTS AND METHODS: Retrospective medical notes of all patients with spinal ependymoma treated surgically over a 5-year period between January 2003 and January 2008 were recorded. Clinical presentation, spinal level, extent of resection, and complications were recorded. A prolonged follow-up was documented. RESULTS: There were 20 patients - 11 males, and nine females -included in this study. Their median age was 48 years (range 3-75 years). In 18 patients, total gross resection was achieved. Subtotal resection was only possible in one patient due to surgical difficulty. One patient underwent biopsy and referred for further surgery and subsequently had total resection. CONCLUSIONS: Radical total resection is achievable in spinal ependymomas, with minimal resultant morbidity.