Venous pathology targeted surgical management in Hirayama disease: A comprehensive case series of nine cases exploring this potential etiology.

Objective: Hirayama disease is a rare cause of cervical myelopathy predominantly affecting young individuals. The disease is classically characterized by muscle atrophy in the distal upper limbs. While various etiopathogenesis such as dural sac dysplasia, nerve root dysplasia, structural abnormalities of the spinal ligament, and venous dysplasia have been proposed, this study explores the potential role of venous pathology and surgical management on the basis of it. Methodology: This is a prospective descriptive case series of nine cases. The diagnosis was made based on the Huashan diagnostic criteria which includes clinical manifestation, imaging, and electrophysiology. In cases where magnetic resonance imaging (MRI) failed to demonstrate engorged veins, a computed tomography (CT) venogram of the cervical spine was used as an imaging tool. All patients underwent cervical laminectomy and coagulation of the posterior epidural venous plexus with or without laminoplasty. All the patients were followed up regularly; clinical improvement and neck disability index were assessed. Results: All nine patients were male and exhibited classical clinical features, electrophysiological abnormalities, and MRI findings except, in one patient where a CT venogram helped in establishing the diagnosis as the MRI was inconclusive. Postoperatively, all patients had neurological improvement and stabilization of the disease. All patients who underwent CT venogram and cervical spine X-ray in neutral and dynamic position demonstrated no recurrence of engorged venous plexus or significant instability except one patient developing kyphosis. One patient experiencing symptoms in the other limb underwent a second surgery. Conclusion: This comprehensive case series strongly supports venous pathology as a potential etiology of Hirayama disease. Surgical management with laminectomy and venous coagulation with or without expansile laminoplasty has delivered consistent improvement in neurological outcomes and long-term disease stabilization without the restriction of movements and lesser complications. However, further research is warranted to elucidate the mechanism underlying cervical venous dilatation.

Role of magnetic resonance imaging and 18-fluorodeoxyglucose positron emission tomography-computed tomography in identifying pain generators in patients with chronic low back pain.

Objective: Low back pain (LBP) is a major cause of pain and disability. Identification of the pathology accurately or the pain generators is sometimes difficult with the conventional modalities such as magnetic resonance imaging (MRI), computed tomography (CT), or X-ray. Nuclear medicine investigations such as single-photon emission CT (SPECT/CT) or 18-fluorodeoxyglucose positron emission tomography-CT (18-FDG PET-CT) have emerged as an adjuvant tool in these cases. In this study, we evaluated and analyzed the role of 18-FDG PET-CT in identifying active pain generators and the outcomes of interventions based on that compared to MRI. Methodology: This study included all patients who fell under inclusion criteria presented with chronic LBP with or without radiculopathy. History and clinical examination were done as well as Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) scores were calculated. All the patients underwent MRI lumbosacral spine with sacroiliac (SI) joint and 18-FDG PET-CT whole spine. Patients in whom PET-CT was positive and active pain generator was identified were managed for the specific level or pain generator responsible by appropriate modalities, i.e. surgery, interfacetal injections, transforaminal epidural injections, and SI joint injections. Patients in whom PET-CT was negative were managed according to the pain generator identified on the basis of MRI and clinical correlation. Patients were told to follow-up after 1 week and 1 month, and subsequent improvement was evaluated on the basis of VAS after 1 week and 1 month and ODI score after 1 month. Results: A total of 20 patients were included in the study, with a mean age of 41.9 ± 13.53 years. Twelve patients had multiple level pathology without the indication of significant pain generator and eight patients' symptoms did not correlate with the MRI findings. 18-FDG PET-CT was done in all patients. 10% (2/20) patients were identified with active pain generators on PET-CT which were not identified on MRI. Eleven out of twenty patients underwent intervention in the form of surgery or pain injections. The mean VAS and ODI score in the patients intervened on the basis of 18-FDG PET-CT improved by 70.59% and 50%, respectively, whereas in patients who underwent intervention on the basis of MRI had improvement in mean VAS and ODI score by 58.57% and 30.81%, respectively after 1 month. Conclusion: Inflammation and associated degenerative process in the spine is a continuous process and affects multiple levels and might not be easily picked up on MRI or other conventional modalities. Thus, 18-FDG PET-CT is useful in identifying these active inflammatory processes and thereby helping in the localization of active pain generators. Treating these active pain generators has a better outcome in patients after intervention in terms of better pain relief and quality of life and also reduces the levels being treated.

MITLIF Operative Nuances- Step by Step.

BACKGROUND: : MITLIF is popular among minimally invasive lumbar interbody fusion procedures. The common indications of MITLIF are Grade I and selected cases of Grade II spondylolisthesis, Failed Back Surgery Syndrome, spondylodiscitis and deformity correction. OBJECTIVE: : To describe the technical nuances of MITLIF along with an operative video of a case of L4-L5 Grade I Spondylolisthesis. SURGICAL PROCEDURE: : Two incisions of 2.5 cm length are made on either side, at the level to be operated and further access is created by muscle splitting. Screws, rods and cage(s) are placed through this corridor under fluoroscopic guidance. RESULTS: : This procedure has the advantages of minimal blood loss, less muscular trauma, retention of intact posterior ligamentous anatomy, shorter hospital stay, lesser CSF leak and infection rates when compared to the open approaches. CONCLUSIONS: MITLIF has emerged as the standard procedure replacing open approaches. Mastery of this approach is strongly recommended to spine surgeons.

Minimally invasive transforaminal lumbar interbody fusion: Technical tips, learning curve, short-term clinical outcome, and brief review.

BACKGROUND: Current trends in spine surgeries have shifted to minimally invasive procedures. Minimally invasive approaches are getting more popular for lumbar interbody fusion procedures. OBJECTIVES: The objective of the study was to report technical modifications, learning curve, and short-term clinical results in minimally invasive transforaminal interbody fusion (MITLIF). MATERIALS AND METHODS: All MITLIF cases performed from 2018 July to March 2020 were included. First three authors were operating surgeons. Visual analog scores (VAS) scoring for pain, Macnab criteria, and Oswestry disability index (ODI) were used for outcome assessment. Operating time, radiation exposure, and complications were assessed separately in a group of 20 as per time sequence in series to assess the learning curve. RESULTS: A total of 61 patients were included. Various indications included spondylolisthesis, failed back surgery, calcified lumbar disc, and spondylodiscitis. Mean age was 47.08 ± 12.06. Intraoperative blood loss was 97.04 ± 25.58. Mean operating time and number of C-arm shots were 190.75 ± 37.11 and 159.3 ± 74.54, respectively, in initial 20 cases which however reduced in later operated cases. Significant improvement in VAS and ODI scores was observed at follow-up of 6.34 ± 4.67 months. Three cases needed surgical revision in the initial 20 cases, and there were no revision surgeries in later operated cases. CONCLUSION: MITLIF could be done in failed back surgery cases, spondylodiscitis, and deformity corrections in addition to spondylolisthesis. It has advantages of less injury to soft tissues, maintaining the posterior tension band, decrease in blood loss and hospital stays, and early mobilization. However, it has longer learning curve and takes minimum 20 cases for the surgeon to acquire reasonable experience and confidence.

A Brief Review of Ventriculoatrial and Ventriculopleural Shunts.

INTRODUCTION: Alternate approaches such as ventriculoatrial (VA) or ventriculopleural (VPL) procedures still have a place in the surgical armamentarium for patients with recurrent ventriculoperitoneal (VP) shunt failures related to defective absorption, infections, or frequent malfunctions. METHODS: We reviewed the literature and our experience with these techniques, and offered suggestions for safely performing these operations. Historical perspectives were also included to facilitate an improved understanding of the technical developments. RESULTS: Our findings and the available medical literature suggest VA and VPL options are safe and effective alternatives for managing the complex patient with hydrocephalus. Potential issues and complications were discussed along the technical advances for a safer operation. CONCLUSION: The VA and VPL options should be considered for patients with recurrent VP shunt issues. They are safe and effective options for managing complex hydrocephalus patients.

A Rare Case of Sphenoid Encephalocoele Presenting with Fifth Cranial Nerve Involvement.

A 14-year-old girl presented with chronic headache, recurrent episodes of vomiting, fever, and two episodes of generalized tonic clonic seizure in the past 2 months. Neuroimaging revealed herniation of the brain along with the dura through a defect in the left greater wing of the sphenoid. Left pterional craniotomy was carried out. Herniation of the dural sac along with its contents through the bony defect in the greater sphenoid wing was identified lateral to the V2 nerve passing through the foramen rotundum. The dural defect was repaired. Bony defect was covered with a circular titanium plate. The patient did not have cerebrospinal fluid rhinorrhea postoperatively. At 6-month follow-up, she was asymptomatic.