C2 Nerve Root Preservation During Posterior Fixation for Instability Secondary to Congenital Craniovertebral Junction Anomalies: Feasibility Factors and Related Outcomes.

OBJECTIVE: Patients with instability because of congenital craniovertebral anomalies often have complex C1-C2 osseovascular anomalies. C2 nerve root sacrifice has been described to address such difficult anatomy during posterior C1-C2 fixation and has its own downsides. Its preservation as a recent alternative poses greater surgical challenge, and the considerations differ from other causes of craniovertebral junctional instability; the pertaining outcomes have been scarcely studied. The objective of this study was to prospectively determine the feasibility and outcomes related to C2 nerve root preservation in patients with congenital atlantoaxial dislocation (CAAD) after posterior C1-C2 fixation. METHODS: In this observational study, 63 patients (126 nerve roots) with CAAD after posterior fixation were prospectively assessed. Underlying osseovascular anomalies affecting the feasibility of C2 nerve root preservation, and C2 nerve-related dysfunction at 12 months follow-up were analyzed. RESULTS: The overall C2 nerve root preservation rate was 89.7%. Even in the presence of extreme joint obliquity/spondyloptosis and anomalous vertebral artery, it was feasible in about three fourths. After preservation, 28.3% patients developed new-onset C2 nerve root dysfunction: neuralgia in 2, dysesthesia in 6, and hypoesthesia/paresthesia in 9. The symptoms were not disabling in most patients. CONCLUSIONS: In most patients with CAAD, C2 nerve root preservation is feasible despite an aberrant bony and vascular anatomy. A few patients after nerve root preservation develop related symptoms that are conservatively manageable, with no significant adverse consequences. Given the controversy in the literature on C2 nerve sacrifice-related outcomes, we favor an attempt at C2 nerve root preservation.

Secondary anaerobic infection in a case of multidrug resistant tubercular paraspinal abscess: A rare presentation.

INTRODUCTION: Paraspinal abscesses are most commonly caused by Staphylococcus aureus and some Gram-negative bacteria. In developing countries, Mycobacterium tuberculosis (MTB) contributes to almost 50 % of cases. Even in proven cases of tubercular paraspinal abscesses, secondary infection of aerobic or anaerobic bacteria is possible and should be carefully evaluated for proper management. CASE REPORT: A type I diabetes mellitus patient presented with chronic backache and lower limb weakness and radiological investigations showed paraspinal collections suggestive of tuberculosis. The patient was then started on anti-tubercular drugs, she initially responded and then showed gradual deterioration in the form of increased pain, fever and pus discharge. Aerobic cultures of pus were sterile and anaerobic culture grew Peptoniphilus asaccharolyticus sensitive to metronidazole. Appropriate treatment had resulted in clinical improvement. CONCLUSION: Suspicion about co-infection with aerobic or anaerobic bacteria should be high even in proven cases of tubercular paraspinal abscess not improving despite proper anti-tubercular therapy.

Bilateral persistent 'second' intersegmental vertebral arteries: illustrated with a case.

Congenital craniovertebral junction deformities can be associated with an anomalous vertebral artery (VA). At times, the artery crosses the joint posteriorly (i.e., persistent first intersegmental artery) and is at risk during posterior approach. We report a new variant, wherein the bilateral VA coursed medially after exiting the C3 transverse foramina to lie beneath C2 pars interarticularis and enter the foramen magnum (without passing through C2 transverse foramen anywhere along its course). This is possibly a result of bilateral persistent second intersegmental arteries. It is pertinent to recognize this unusual variant to avoid VA injury, especially while inserting C2 pars/transarticular screw.