Usefulness of 3D CT/MRI Fusion Imaging for the Evaluation of Lumbar Disc Herniation and Kambin's Triangle.

Study design: Prospective study. Objective: The aim of this study is to visualize the morphology of a lumbar herniated disc and Kambin's triangle in three dimensions (3D) based on preoperative CT/MRI fusion images. Methods: CT/MRI fusion images of 23 patients (10 males and 13 females; mean age 58.2 years) were used to evaluate Kambin's triangle, which is created between the superior articular process (SAP), exiting nerve root (ENR), inferiorly by the superior endplate of the lower lumbar vertebra and dural canal medially at 60 degree and 45 degree endoscopic approach angles. The percentage of the safe usage of transforaminal endoscopic approach was evaluated to utilize a 5 mm dilater without partial facet resection in the fusion image. The 3D lumbar nerve root sleeve angulation (3DNRA), which is the angle between the axis of the thecal sac and the nerve root sleeve, was calculated. The herniated discs were also visualized in the CT/MRI fusion image. Results: The 3DNRA became smaller from L2 to S1. The L2 3DNRA was statistically larger than those of the other root, and the S1 3DNRA was significantly smaller than the others (p < 0.05). (L2, 41.0°; L3, 35.6°; L4, 36.4°; L5, 33.9°; and S1, 23.2°). The SAP-ENR distance at 60° was greatest at L4/5 (5.9 mm). Possible needle passages at 60° to each disc level were 89.1% at L2/3, 87.0% at L3/4 and 84.8% at L4/5. However, the safe 5 mm dilater passage at 60° without bony resection to each disc level were 8.7% at L2/3, 28.3% at L3/4 and 37.0% at L4/5. The 60° corridor at L2/3 was the narrowest (p < 0.01). All herniated discs were visualized in the fusion image and the root compression site was clearly demonstrated especially with foraminal/extraforaminal herniations. Conclusion: The 3D lumbar CT/MRI fusion image enabled a combined nerve-bony assessment of Kambin's triangle and herniated disc. A fully endoscopic 5 mm dilater may retract the exiting nerve root in more than 60% of total cases. This new imaging technique could prove to be very useful for the safety of endoscopic lumbar disc surgery.

O-arm Navigation-Guided Surgical Resection and Posterior Fixation for a Large Sacral Schwannoma.

Sacral schwannoma is a rare tumor with relatively few symptoms; it thus tends to be large at diagnosis and is challenging to treat surgically. We present the case of a 12-year-old girl with a large sacral schwannoma that was successfully surgically resected using O-arm navigation in a two-stage operation. First, we performed tumor resection from the posterior aspect with assisted O-arm navigation. One week later, resection from the anterior aspect was conducted with posterior spinopelvic fixation and fibula graft. We performed partial resection of the tumor from the anterior and posterior aspects as much as possible. O-arm navigation contributed to precise and safe tumor resection and implant insertion.

C-Arm-Free Circumferential Minimally Invasive Surgery for Adult Spinal Deformity: Technical Note.

BACKGROUND: Circumferential minimally invasive surgery (cMIS), as a technique for reducing the complications of adult spinal deformity surgery, is receiving considerable attention. Conventional cMIS is performed using intraoperative fluoroscopy. In this work, we describe a new cMIS technique without using C-arm fluoroscopy for correcting adult spinal deformities. CASE DESCRIPTION: A 70-year-old woman with symptomatic adult spinal deformity was referred to our hospital. The patient's daily life has been affected by severe low back pain for more than 4 years. The surgery was performed without C-arm fluoroscopy. The percutaneous pedicle screws and intervertebral cages were inserted only under navigation guidance. The patient was successfully treated with surgery, and her low back pain was well controlled. Her clinical outcomes were as follows: Oswestry Disability Index improved from 64% to 14% and the low back pain visual analog scale score improved from 75 mm to 24 mm at 1 year of final follow-up. CONCLUSIONS: C-arm-free cMIS for adult spinal deformity is a useful technique that reduces percutaneous screw and cage misplacement. With this new technique, the surgeons and the operation room staff can avoid the risk of an adverse event of intraoperative radiation.

Isolated Intramedullary Spinal Cysticercosis: A Case Report with Review of Literature of a Rare Presentation.

A number of parasitic infections can involve the central nervous system of which neurocysticercosis (NCC) is the most common one in developing countries. Most often the brain is involved, spine and spinal cord involvement is very rare and intramedullary involvement is rarer still. Here, we report a 30-year-old male patient, with intramedullary NCC of dorsal spinal cord.

Reoperation in Spinal Dysraphism: Does it Help in Reversing the Neurological Deficits?

AIMS: After initial primary repair by inexperienced hands for the spectrum of pathological conditions in spinal dysraphism (SD), a few percentage of patients present with recurrent symptoms and worsening neurological status especially when primarily pathology is not identified and dealt properly. When the primary intradural tethering element is left untouched, worsening of symptoms is common. In this retrospective study, we tried to analyze the symptomatology, functional outcome at 1-2 months after the second surgery and associated complications. SUBJECTS AND METHODS: All patients underwent second surgery at author's institution. Pre and post-operative data were evaluated using Necker -Enfants Malades (NEM) neurological and modified Hoffer ambulatory scale. RESULTS: The main presenting complaints were bladder incontinence and limb weakness. Preoperative mean scores for motor and bladder were 3.56 and 2.78 out of 5, 2.67 out of 4, and 2.11 out of 3 for bowel and sensory function, respectively. Postoperative mean score for motor, sensory, bladder, and bowel function revealed good neurological improvement. Statistically neurological improvement in bladder and bowel function was significant. More than 60% of patients had normal ambulation at follow-up. CONCLUSIONS: Patients presenting with recurrent symptoms in an operated case of SD need to be investigated, cause of recurrence has to be identified, and if needed repeat surgery is recommended at the earliest. Long-standing neurological deficits can potentially improve, especially bladder and bowel function which gives a good quality of life to the patients. Furthermore, we want to stress the fact that since it is an intradural pathology, these cases should be operated by experienced neurosurgeons, and this fact should be made aware among referring doctors.

Subclinical respiratory dysfunction in chronic cervical cord compression: a pulmonary function test correlation.

OBJECTIVE Respiratory abnormalities are well documented in acute spinal cord injury; however, the literature available for respiratory dysfunction in chronic compressive myelopathy (CCM) is limited. Respiratory dysfunction in CCM is often subtle and subclinical. The authors studied the pattern of respiratory dysfunction in patients with chronic cord compression by using spirometry, and the clinical and surgical implications of this dysfunction. In this study they also attempted to address the postoperative respiratory function in these patients. METHODS A prospective study was done in 30 patients in whom cervical CCM due to either cervical spondylosis or ossification of the posterior longitudinal ligament (OPLL) was diagnosed. Thirty age-matched healthy volunteers were recruited as controls. None of the patients included in the study had any symptoms or signs of respiratory dysfunction. After clinical and radiological diagnosis, all patients underwent pulmonary function tests (PFTs) performed using a standardized Spirometry Kit Micro before and after surgery. The data were analyzed using Statistical Software SPSS version 13.0. Comparison between the 2 groups was done using the Student t-test. The Pearson correlation coefficient was used for PFT results and Nurick classification scores. A p value < 0.05 was considered significant. RESULTS Cervical spondylotic myelopathy (prolapsed intervertebral disc) was the predominant cause of compression (n = 21, 70%) followed by OPLL (n = 9, 30%). The average patient age was 45.06 years. Degenerative cervical spine disease has a relatively younger onset in the Indian population. The majority of the patients (n = 28, 93.3%) had compression at or above the C-5 level. Ten patients (33.3%) underwent an anterior approach and discectomy, 11 patients (36.7%) underwent decompressive laminectomy, and the remaining 9 underwent either corpectomy with fusion or laminoplasty. The mean preoperative forced vital capacity (FVC) (65%) of the patients was significantly lower than that of the controls (88%) (p < 0.001). The mean postoperative FVC (73.7%) in the patients showed significant improvement compared with the preoperative values (p = 0.003). The mean postoperative FVC was still significantly lower than the control value (p = 0.002). The mean preoperative forced expiratory volume in 1 second (FEV1) (72%) of the patients was significantly lower than that of the controls (96%) (p < 0.001). The mean postoperative FEV1 (75.3%) in the cases showed no significant improvement compared with the preoperative values (p = 0.212). The mean postoperative FEV1 was still significantly lower than the control value (p < 0.001). The mean postoperative FEV1/FVC was not significantly different from the control value (p = 0.204). The mean postoperative peak expiratory flow rate was significantly lower than the control value (p = 0.01). The mean postoperative maximal voluntary ventilation was still significantly lower than the control value (p < 0.001). On correlating the FVC and Nurick scores using the Pearson correlation coefficient, a negative correlation was found. CONCLUSIONS There is subclinical respiratory dysfunction and significant impairment of various lung capacities in patients with CCM. The FVC showed significant improvement postoperatively. Respiratory function needs to be evaluated and monitored to avoid potential respiratory complications.

Primary intracranial malignant melanoma: A rare casewith review of literature.

We present a rare case of the primary intracranial melanoma in the right parafalcine frontal region in a 65-year-old male. Computed tomography and magnetic resonance imaging showed a Space occupying lesion in the right parafalcine frontal region with necrosis, vasogenic edema and mass effect. A rather well-defined, dark brown-black tumor was totally removed and histologically diagnosed as malignant melanoma. The patient improved after surgery. In our case, no systemic melanomas were found in close clinical examinations, there was a single nodular tumor attached to the leptomeninges and a favorable outcome was obtained by surgical treatment alone. Primary central nervous system melanomas have rarely been reported, and this case is reported for its rarity.

Acute spinal subdural hematoma after vigorous back massage: a case report and review of literature.

STUDY DESIGN: A case report and review of literature. OBJECTIVE: We report on a patient with traumatic spinal subdural hematoma after vigorous back massage while on vacation. SUMMARY OF BACKGROUND DATA: Traumatic spinal subdural hematoma is extremely rare, and to our knowledge, this is the first case reported after violent back massage. We emphasize a high index of suspicion for early recognition and treatment for a good neurological recovery. METHODS: A 41-year-old male was brought to our hospital with severe back pain, motor and sensory impairments of the bilateral lower extremities, and urinary dysfunction after vigorous back massage. Magnetic resonance images revealed an acute spinal subdural hematoma in the thoracolumbar region. After careful monitoring of his neurological status, the patient was successfully managed with conservative treatment. RESULTS: After 2 weeks of hospitalization, complete motor power recovery was achieved with only minor sensory deficit. At a follow-up of more than 12 months, the patient has no residual neurological deficits. CONCLUSION: Spinal subdural hematoma secondary to physical trauma is quite rare. This case brings new information that traumatic spinal subdural hematoma can be caused by violent massage. LEVEL OF EVIDENCE: N/A.

Frontal intraparenchymal Schwannoma--case report and review of literature.

Intracranial intraparenchymal Schwannomas are very rare. Twenty-eight cases of frontal intraparenchymal Schwannomas have been reported so far. These generally present with seizures, raised intracranial pressure, nasal stuffiness and epistaxis. We present a patient with frontal intraparenchymal Schwannoma who underwent frontal craniotomy and excision. At follow-up the patient is seizure free and is relieved of his symptoms.