Philosophies And Surgical Techniques on Os Odontoideum Treatment with Literature Review.

Introduction: Os-odontoideum is a rare condition described radiographically and clinically as a congenital anomaly of the second cervical vertebra (axis). It is a smooth, independent ossicle of variable size and shape separated from the base of a shortened odontoid process by an obvious gap, with no osseous connection to the body of C2. Materials and Methods: This study reviewed the literature on OO to evaluate its etiology, clinical presentations, differential diagnosis, imaging modalities, and outcomes in the management of asymptomatic and symptomatic cases of Os Odontoideum. Key articles from PubMed, EMBASE, Google Scholar, and Cochrane were searched. Discussion: Considering etiology, the traumatic hypothesis is favoured over the congenital hypothesis as per recent literature on OO. Clinical presentation varies from asymptomatic to mild neck pain to severe myelopathy and neurodeficit. Various C1-C2 instrumentation and fusion techniques like wiring, trans articular screw and laminar screws have been described with success rates. Conclusion: Os odontoideum is a rare condition with limited existing literature. Considering the significant risks involved if conservative management opts, like severe neuro deficit to sudden death on trivial trauma and the recent improvement of imaging tools helping to understand the pathology of the disease, surgery can be indicated even in an incidentally detected os odontoideum. However, a case-by-case approach can be considered for stable asymptomatic patients depending on factors such as age, activity level, comorbidities, syndromic association, and radiographic findings.

The insert and revolve technique: a novel approach for inserting cages during unilateral biportal endoscopic assisted fusion surgery for effective spinal alignment restoration.

STUDY DESIGN: Retrospective study. PURPOSE: This study aimed to propose a method of performing unilateral biportal endoscopy (UBE)-assisted interbody cage insertion for fusion using the "insert and revolve" technique and analyze the clinico-radiological outcomes. OVERVIEW OF LITERATURE: UBE-assisted lumbar interbody fusion (ULIF) is a rapidly evolving technique combining the advantages of minimally invasive technique with ease of learning. The limited size of cages was a result of the narrow insertion channel. We propose a technique in which large extreme lateral interbody fusion cages can be inserted through the same opening. METHODS: This study included 104 patients who underwent ULIF using the "insert and revolve technique" between July 2019 and September 2022. The patients were followed up for at least 12 months postoperatively. The clinical outcomes were assessed using the Visual Analog Scale (VAS) for leg pain and back pain, Oswestry Disability Index (ODI), and modified McNab's criteria. Changes in segmental lordosis (SL), intervertebral disc height (IVDH), segmental coronal alignment (SCA), cage subsidence, and fusion grade were evaluated at 6- and 12-month follow-up. RESULTS: The VAS scores for leg and back pain and ODI score showed significant improvement. Based on the Macnab's criteria, 97 patients showed excellent outcomes and seven demonstrated good outcomes at 12 months. The mean IVDH increased from 6.3±2 to 10±2.1 mm immediately after surgery and 10±1.1 mm at 6 months. SL improved from 9.3°±11.5° to 17.78°±8.1°, while SCA improved from 7.7°±2.1° to 3.4°±1.2° at 1 year. Moreover, 92 and 11 patients showed grade 1 and 2 fusion, respectively, according to the Bridwell grading at 1 year. CONCLUSIONS: The "insert and revolve technique" facilitates the successful insertion of large cages, contributing to the restoration of disc height and coronal and sagittal spinal correction with favorable fusion rates.

Unilateral Biportal Endoscopy for L5-S1 Extraforaminal Stenosis (Far Out Syndrome) - Technical Note with Literature Review.

Introduction: Extraforaminal stenosis in L5-S1, or far-out syndrome (FOS), is defined as L5 nerve compression by the transverse process (TP) of the L5 and the ala of the sacrum and disc bulging with/without osteophytes and/or the thickened lumbosacral and extraforaminal ligament. This study aims to describe the unilateral biportal endoscopic decompression technique of the extraforaminal stenosis at L5-S1 or far out syndrome and evaluate its clinical results with a literature review. Case Report: A 44-year-old male presented with severe right sharp shooting pain in the buttock, thigh, leg, foot, and/or toes with numbness in the foot and toes (Visual Analog Scale [VAS] 8/10) for six months with an Oswestry disability index (ODI) score of 70%. Her pain aggravated when bending forward and performing daily routine activities. He also complained of exaggeration of pain in daily regular activities. On physical examination, power in the right lower limbs was 5/5 as per the Medical Research Council (MRC) grading, and deep tendon reflexes were normal. Pre-operative X-ray and CT scan showed no instability or calcified disc osteophyte, and magnetic resonance imaging showed extraforaminal stenosis due to disc herniation at L5-S1 in Figure 1. We performed UBE-L5-S1extraforaminal discectomy surgery to resolve his symptoms. The operative time was 68 min; blood loss was 30 mL. After surgery, the patient was followed up at one week, six weeks, three months, six months, 12 months, and two years. The pain and tingling sensation in the legs improved at the 1-week follow-up, with a VAS score of 0/10 and an ODI score of 10% at the 2-year follow-up. Patient satisfaction was surveyed using Macnab's criteria at the final follow-up visit of 2 years and was found to be excellent. Post-operative imaging showed a good extraforaminal decompression at L5-S. Conclusion: Unilateral biportal endoscopy technique has brought a paradigm shift in the treatment of spinal pathologies and has served as another treatment option for the past two decades. The UBE decompression technique for extraforaminal stenosis at L5-S1 has the advantages of minimally invasive spine surgery; it is a safe and effective treatment option for treating extraforaminal stenosis at L5-S1.

Philosophies And Surgical Techniques for Ewing's Sarcoma of Spine with Review of Literature.

Introduction: Ewing sarcoma (ES) is a malignant and aggressive bony tumor affecting the most common age group of 5-20 years. It constitutes 10%-15% of all bone sarcomas and is the second most common primary malignant bone tumor after osteosarcoma. It usually presents with pain, which is typically constant and progressive in nature. The primary source of pain is due to the instability of the spine to support the weight of the body, the vertebral body's expanding cortices due to the growing mass, compression of nerve roots due to tumour mass, pathologic fractures, spinal cord compression, and invasion of tissue by the tumour mass. Methods: We reviewed the literature on Ewing's Sarcoma of the spine to evaluate its etiology, clinical presentations, differential diagnosis, imaging modalities and management with chemotherapy, radiotherapy, and surgical management. PubMed, EMBASE, Google Scholar and Cochrane key articles were searched. Keywords like 'Ewing's Sarcoma,' 'Spine,' 'etiology,' 'treatment,' 'surgical management,' and 'en bloc resection' were used. Discussion: The current management of Ewing's sarcoma of the spine usually involves three primary modalities: combination chemotherapy, surgery and/or radiotherapy. Recent improvements in combination chemotherapy (vincristine, doxorubicin, cyclophosphamide +/- Ifosfamide and etoposide) are among the most significant factors for improving survival. Also, recent advancements in radiotherapy, instrumentation, and fusion techniques in surgical management have been demonstrated to improve local disease control and overall survival. Conclusion: Primary Ewing sarcoma of the spine is a rare condition affecting the most common age group of 5-20 years, accounting for 1-3 cases/million/year. About 5 % of cases have spine involvement. Recent improvements in combination chemotherapy have improved the overall survival rates. Enbloc resection and/or radiotherapy have improved local control of the disease.

Pedicle screw accuracy placed with assistance of machine vision technology in patients with neuromuscular scoliosis.

INTRODUCTION: Pedicle screws are the primary method of vertebral fixation in scoliosis surgery, but there are lingering concerns over potential malposition. The rates of pedicle screw malposition in pediatric spine surgery vary from 10% to 21%. Malpositioned screws can lead to potentially catastrophic neurological, vascular, and visceral complications. Pedicle screw positioning in patients with neuromuscular scoliosis is challenging due to a combination of large curves, complex pelvic anatomy, and osteopenia. This study aimed to determine the rate of pedicle screw malposition, associated complications, and subsequent revision from screws placed with the assistance of machine vision navigation technology in patients with neuromuscular scoliosis undergoing posterior instrumentation and fusion. METHOD: A retrospective analysis of the records of patients with neuromuscular scoliosis who underwent thoracolumbar pedicle screw insertion with the assistance of machine-vision image guidance navigation was performed. Screws were inserted by either a staff surgeon, orthopaedic fellow, or orthopaedic resident. Post-operative ultra-low dose CT scans were used to assess pedicle screw accuracy. The Gertzbein classification was used to grade any pedicle breaches (grade 0, no breach; grade 1, <2 mm; grade 2, 2-4 mm; grade 3, >4 mm). A screw was deemed accurate if no breach was identified (grade 0). RESULTS: 25 patients were included in the analysis, with a mean age of 13.6 years (range 11 to 18 years; 13/25 (52.0%) were female. The average pre-operative supine Cobb angle was 90.0 degrees (48-120 degrees). A total of 687 screws from 25 patients were analyzed (402 thoracic, 241 lumbosacral, 44 S2 alar-iliac (S2AI) screws). Surgical trainees (fellows and orthopaedic residents) inserted 46.6% (320/687) of screws with 98.8% (4/320) accuracy. The overall accuracy of pedicle screw insertion was 98.0% (Grade 0, no breach). All 13 breaches that occurred in the thoracic and lumbar screws were Grade 1. Of the 44 S2AI screws placed, one screw had a Grade 3 breach (2.3%) noted on intra-operative radiographs following rod placement and correction. This screw was subsequently revised. None of the breaches resulted in neuromonitoring changes, vessel, or visceral injuries. CONCLUSION: Machine vision navigation technology combined with careful free-hand pedicle screw insertion techniques demonstrated high levels of pedicle screw insertion accuracy, even in patients with challenging anatomy.

Use of Navigable Ablation Decompression Treatment (L-DISQ) for Contained Cervical Disc Herniation - Technical Note and Literature Review.

Introduction: A new navigable percutaneous disc decompressor (L'DISQ-C, U&I Co., Uijeongbu, Korea), introduced in 2012, is designed to allow direct access to herniated disc material. The L'DISQ device can be curved by rotating a control wheel, directed into disc herniation treats, and decompresses contained herniated discs with minimal collateral thermal damage. This study reports the case of contained central disc herniation in a 34-year-old male with a 2-year follow-up successfully treated with navigable ablation decompression treatment (L-DISQ). Case Report: A 34-year-old man presented to the outpatient department with a 6-month history of neck pain and bilateral upper limb radiation. His neck pain had increased progressively. At the time of presentation, his neck pain visual analog scale score was 7/10, and his neck disability index score was 30. The magnetic resonance images showed a single fluid-containing lesion with a hyperintense zone at the C4-5 levels with central disc herniation. The patient was successfully treated with the navigable ablation decompression treatment (L-DISQ) procedure. Conclusion: The navigable ablation decompression treatment (L-DISQ) is a valuable technique in treating contained cervical disc herniation with rapid pain relief and improvements in functional outcomes without any significant injury to surrounding structures. It is safe, precise, and effective in the treatment of symptomatic cervical disc herniations. Large, randomized, and multicenter trials are needed to explore the potential of the same technique further.

Use of monopolar cautery in patient with a vagal nerve stimulator during neuromuscular scoliosis surgery.

It is a historic and common practice while performing spine surgery on patients with a VNS has been to have the patient's neurologist turn off the VNS generator in the pre-operative anesthetic care unit and to use bipolar rather than monopolar electrocautery. Here we report a case of a 16-year-old male patient with cerebral palsy and refractory epilepsy managed with an implanted VNS who had scoliosis surgery (and subsequent hip surgery) conducted with the use of monopolar cautery. Although VNS manufacturer guidelines suggest that monopolar cautery should be avoided, perioperative care providers should consider its selective use in high-risk instances (with greater risks of morbidity and mortality due to blood loss which outweigh the risk of surgical re-insertion of a VNS) such as cardiac or major orthopedic surgery. Considering the number of patients with VNS devices presenting for major orthopedic surgery is increasing, it is important to have an approach and strategy for perioperative management of VNS devices.

Unilateral Biportal Endoscopic Approach for Symptomatic Adjacent Segment Disease: Case Report and Technical Note.

Introduction: Recently, lumbar degenerative disease has been treated using unilateral biportal endoscopic (UBE) lumbar interbody fusion. However, the use of the UBE approach for symptomatic ASD following lumbar interbody fusion surgery isn't illustrated widely in the literature. This case report and technical note describe the use of the UBE approach for symptomatic ASD. Case Report: A 72-year-old female who underwent conventional fusion surgery elsewhere twelve years ago at the L5-S1 level presented with severe back pain (VAS 8/10) and radicular pain in both legs (left > right) (left VAS 7/10, right VAS 7/10) for 1 year with an ODI score of 70%. Preoperative X-ray and MRI showed dynamic instability with spondylolisthesis at L4-5. We performed an upper-level extension using UBE FES techniques to resolve ASD. The operative time was 132 minutes, blood loss was 40 ml. After surgery, the patient was followed up at 1 week, 6 weeks, 3 months, 6 months, 12 months, and 2 years. The pain and tingling sensation in the legs got better at the 1-week follow-up itself with a VAS score of 0/10 and an ODI score of 10% at the 2-year follow-up. Patient satisfaction was surveyed using Odom's criteria at each follow-up visit (at 1 week, 6 weeks,3 months, 6 months, and 2 years) and found to be excellent. Postoperative imaging showed a good reduction and canal decompression at L4-5. Conclusion: The UBE fusion extension technique for ASD is a safe, less invasive, and effective treatment option for lumbar interbody fusion extension and posterior pedicle screw revision with less morbidity and early recovery.

The Past, Present, and Future of Unilateral Biportal Endoscopy with a Technical Note on Novel Endoscopic Visualization Pedicle Screw Insertion Technique and UBE-transforaminal Lumbar Interbody Fusion Technique with Literature Review.

Introduction: Over the past two decades, unilateral biportal endoscopy (UBE) has brought a new paradigm shift in the surgical treatment of spinal disorders with its innovative technique. This study aims to review the development of the UBE technique with a technical note on the novel endoscopic visualization pedicle screw (EVPS) insertion technique and UBE-transforaminal lumbar interbody fusion technique (UBE-TLIF). Case Report: A 66-year-old female presented with severe back pain (Visual Analog Scale [VAS] 8/10) and radicular pain in both legs (left > right) (left VAS 7/10 and right VAS 7/10) for one year with an Oswestry disability index (ODI) score of 70%. Her pain aggravated when bending forward and performing daily routine activities. She also complained of severe intermittent neurological claudication at a distance of <50 m. On physical examination, power in the lower limbs was 5/5 as per the Medical Research Council grading, and deep tendon reflexes were normal. She had a known case of diabetes mellitus and hypertension and was on treatment with oral medications. Pre-operative X-ray and magnetic resonance imaging showed dynamic instability with spondylolisthesis at L4-5. We performed UBE-TLIF with the EVPS insertion technique to resolve her symptoms. The operative time was 122 min; blood loss was 40 mL. After surgery, the patient was followed up at one week, six weeks, three months, six months, 12 months, and two years. The pain and tingling sensation in the legs improved at the 1-week follow-up, with a VAS score of 0/10 and an ODI score of 10% at the 2-year follow-up. Patient satisfaction was surveyed using Macnab's criteria at the final follow-up visit of 2 years and was found to be excellent. Post-operative imaging showed a good reduction and canal decompression at L4-5. Conclusion: The novel EVPS insertion technique and UBE-TLIF have the advantages of minimally invasive spine surgery; they are a safe and effective treatment option for treating lumbar spine pathologies.

Recurrent solitary bone plasmacytoma: A case report.

BACKGROUND: Plasmacytoma is an hematological malignancy that originates in bone. It may involve a single skeletal location. Notably, these lesions can progress to involve multiple segments in 50% of cases, at which point they are classified as having multiple myeloma (MM). CASE DESCRIPTION: One year ago, this patient had undergone a D6 laminectomy and biopsy for plasmacytoma. Now at age 73, she newly presented with the onset of a progressive paraparesis of 4 weeks' duration. On examination, she had 3/5 strength in both lower extremities accompanied by diffuse hyperreflexia, and bilateral Babinski signs. She underwent a D5-D7 decompression, D6 corpectomy with anterior mesh cage reconstruction, and a D3-D9 posterior fusion. CONCLUSION: Patients originally treated for plasmacytoma present 50% of the time with the new onset of neurological symptoms and signs due to the subsequent evolution of MM. As these lesions may be refractory to radiation and/or chemotherapy, surgery is often warranted.

A Stepwise Posterolateral Approach for Computed Tomography Guided C2 (Axis) Transpedicular Biopsy: A Technical Note.

Introduction: Minimally invasive percutaneous CT-guided biopsies of the spine are well established. Although, technical difficulties with CT-guided percutaneous intervention of the C2 body present due to the smaller size of the vertebral elements and potential injury of the critical adjacent structures such as Carotid arteries laterally, vertebral artery, and cervical nerve posterolaterally, pharynx and larynx anteriorly, and spinal cord in the cervical spinal canal. Routinely transoral approach is used for the percutaneous intervention of the C2 body. Literature on the posterolateral approach for biopsies of the C2 vertebral body is sparse as compared to other approaches. This case report presents a case of adenocarcinoma diagnosed with CT-guided percutaneous biopsy of the C2 body using a posterolateral approach under local anesthesia. Case Report: A 70-year-old female presented to our outpatient clinic with complaints of progressively increasing neck pain with a visual analog score (VAS) 7/10. Neck pain was radiating to the base of the occiput and aggravated by neck movements. On clinical examination, there was axial tenderness at the base of the skull and the upper part of the cervical spine. Neurological examinations of sensory and power in all the limbs were normal. Systemic examination and laboratory parameters did not reveal any abnormality. X-rays and MRI revealed a fracture of the odontoid process with marrow edema with differentials of metastasis. PET scan revealed left lung lesion likely to be primary lesion and lesion in C2 vertebral body as likely metastasis. A minimally invasive percutaneous CT-guided posterolateral approach for biopsy proved moderately differentiated adenocarcinoma from the lung with metastasis to C2 vertebrae. The patient was started on an appropriate Chemotherapy regimen as per the Immunohistochemistry (IHC) and Genomic studies with adjuvant radiotherapy. Conclusion: Understanding the detailed anatomy prior to CT guided minimally invasive percutaneous C2 biopsy procedure helps in increasing its safety, precision, and high yield. Stepwise approach to the procedure aids in getting repeatable and high-yielding results especially in a technically challenging area such as C2 vertebrae.

Extremely rare case of retropharyngeal space benign plexiform schwannoma - Excised through Smith- Robinson Approach.

BACKGROUND: Approximately 25-45% of schwannomas are typically slow-growing, encapsulated, and noninvasive tumors that occur in the head-and-neck region where they rarely involve the retropharyngeal space. Here, we report deep-seated benign plexiform schwannoma located in the retropharyngeal C2-C5 region excised utilizing the Smith-Robinson approach. CASE DESCRIPTION: A 30-year-old male presented with dysphagia and impaired phonation attributed to an MR documented C2-C5 retropharyngeal schwannomas. On examination, the lesion was soft, deep seated, and extended more toward the right side of the neck. Utilizing a right-sided Smith-Robinson's approach, it was successfully removed. The histopathology confirmed the diagnosis of a plexiform schwannoma. CONCLUSION: Retropharyngeal benign plexiform schwannomas are rare causes of dysphagia/impaired phonation in the cervical spine. MR studies best document the size and extent of these tumors which may be readily resected utilizing a Smith-Robinson approach.