Cervical Spine Fracture with Extreme Dislocation in a Patient with Ankylosing Spondylitis: A Case Report and Systematic Review of the Literature.

Background: Ankylosing spondylitis (AS) is a seronegative arthropathy which results in pathological ossification of the ligaments, disc, endplates and apophyseal structures. Cervical spinal fractures are more common in patients with ankylosing spondylitis than in patients without ankylosing spondylitis due to coexistent osteoporosis and kyphotic alignment of the spine. The risk of fracture-dislocation and associated spinal cord injury is also more in these patients. Management of cervical spine fractures in patients with ankylosing spondylitis is more challenging. Case Description: We report a 56-year-old male patient who presented to our emergency department following a road traffic accident. He had ASIA B spinal cord injury at C7 level. CT scan revealed a C6-7 fracture-dislocation with features suggestive of AS. The fracture involved all the three columns and extended through C7 body anteriorly and through the C6-7 disc posteriorly. The treating team was not aware that he had AS, and thus, precautions related to his head position were not taken. He underwent reduction of the fracture-dislocation and 360° fixation. Conclusions: The management of cervical spine fractures in patients with ankylosing spondylitis is challenging. They need long segment fixation in their preoperative spinal alignment. Proper preoperative planning can result in good outcome.

Mission impossible: chemotherapy in the intensive care for pineal region germ cell tumor.

Pineal region tumors are rare and a heterogenous group of primary central nervous system tumors which are primarily classified as germ cell tumors and non-germ cell tumors. Chemotherapy and radiotherapy as the primary treatment modalities have been reported to result in good outcomes. We discuss the case of a young girl who presented to our emergency department in an unconscious state and had a large lesion in the posterior third ventricular region, but without any associated hydrocephalus which could explain her stuporous state. Given the rapid decline in her sensorium, we were faced with the difficult choice between surgical decompression of the tumor and a trial of rescue chemotherapy following histopathological confirmation through biopsy. She underwent an open biopsy followed by chemotherapy in a neurosurgical intensive care unit despite her poor Karnofsky performance score. She improved after chemotherapy and her tumor decreased in size significantly over time. We highlight the role of chemotherapy administered in the neurosurgical ICU to an unconscious patient with a large chemoresponsive tumor leading to rapid shrinkage of the lesion and gradual improvement in the sensorium of the patient.

Comparison of outcomes of surgery for intracranial meningioma in elderly and young patients - A systematic review and meta-analysis.

OBJECTIVE: The proportion of elderly patients with intracranial meningiomas is increasing as the life expectancy has improved. Increasing age is classically believed to be associated with higher perioperative morbidity and mortality in neurosurgical patients. METHODS: We performed a systematic literature search in 'PUBMED' and 'EMBASE' databases and reviewed all the studies comparing outcomes of surgery between young and elderly patients with intracranial meningiomas (IM). Data related to 3-month mortality rates, length of hospital stay and complications, preoperative status and comorbidity, meningioma size, location, histology, peritumoral edema, and grade of excision were extracted and analyzed. RESULTS: Thirteen retrospective studies fulfilled the eligibility criteria out of the 893 reviewed articles. Pooled analysis showed that the 3-month mortality rate (4.65% versus 1.42%) and length of stay (10d versus 6.8d) for elderly patients were significantly higher as compared to the young population. The rates of cardio-respiratory complications (16.3% v/s 8.3%), intracranial hemorrhage (10.2% v/s 4.2%) and new-onset neurologic deficit (20.7% v/s 10.1%) were also significantly high in the elderly group as compared to the young patients. Moreover, a higher prevalence of associated comorbidities and poor performance score was noted in the elderly patients of IM. CONCLUSIONS: The overall mortality rate and rates of perioperative complications (cardio-respiratory, neurologic, intracranial hemorrhage) after surgery in elderly patients with IM patients are higher as compared to young patients and should be kept in mind when formulating treatment strategy for IM in this patient population.

Giant Sporadic Unilateral Vestibular Schwannoma in Child: Can It Get Bigger Than This?

Vestibular schwannomas (VSs) are rare in children and, when present, are usually part of neurofibromatosis 2 and bilateral. Sporadic unilateral VSs in the pediatric age group itself are rare in medical literature and giant sporadic unilateral pediatric VSs (>4 cm) are extremely rare. Herein, we describe the largest reported case of giant sporadic left-sided VS in a 10-year-old boy.