The phenomenon of vertebral body drift in neurofibromatosis and its implications for surgical safety.

OBJECTIVE: To report on the phenomenon of body drift in neurofibromatosis scoliosis and discuss its implication on surgical safety. MATERIALS AND METHODS: Ten dystrophic neurofibromatosis scoliosis (NF) and ten adolescent idiopathic scoliosis (AIS) were studied by radiographs, CT, and MRI. The curve characteristics and a detailed analysis of the morphology of the apical and three adjacent vertebral segments above and below were done. The coronal alignment and the presence of a drift of the vertebral body in relationship to the lamina were carefully studied in both groups and compared. RESULTS: The mean cobb angle in the NF group was 77.6°, and 63.7° in the AIS group. All the studied vertebra in the NF group had extensive pedicle changes, which were more severe at the apical and periapical regions. Body drift was noted in 29 vertebral segments, with 9/10 of apical segments showing a significant drift. The body drift was associated with significant pedicle dystrophic changes and was independent of the curve magnitude. In comparison, in AIS, no body drift was noted despite a larger deformity and more severe vertebral rotation. CONCLUSION: The 'body drift' phenomenon was unique to neurofibromatosis scoliosis and was secondary to severe pedicle morphology changes. This was present even in curves less than 60° and could result in cord injury while instrumenting the concave pedicle. Therefore, a thorough preoperative assessment and planning by a 3D CT are mandatory.

A Rare Case of Contiguous Three-level Lumbar Burst Fractures-treated with Combined Posterior Stabilization and Anterior Fusion.

INTRODUCTION: Burst fractures occur frequently in high energy trauma and are commonly associated with falls from height and road traffic accidents. While multiple burst fractures are not uncommon in thoracic spine, three or more contiguous level burst fractures are a relative rarity especially, in lumbar spine. The treatment of multilevel burst fractures must be individualized, and each fracture should be treated according to its inherent stability. To the best of our knowledge, this is the only case of such injury reported in English literature. CASE REPORT: A 17-year-old girl who sustained contiguous three-level lumbar burst fractures with neurological compromise following alleged history of fall from height. Radiographs/computed tomography scan revealed burst fractures of L2, L3, and L4 vertebrae with retropulsion of bony fragments at all the levels. Patient underwent minimally invasive posterior stabilization and anterior Hemi-corpectomy of L2, L4, and fusion. The patient recovered completely from neurological deficits by the end of 6 months. CONCLUSION: Multiple contiguous burst fractures in the lumbar spine are a rare entity. To the best of our knowledge, this is the only case of such injury reported in English literature. The treatment requires a thorough assessment of the fracture pattern and often requires a combination of surgical approaches. Each fracture merits treatment based on individual characteristics of fracture patterns and the amount of canal compromise at each level.

Management of Neglected Odontoid Fracture in the Ankylosed Spine: A Case Report and Technical Note.

INTRODUCTION: While odontoid fractures frequently lead to non-union in elderly population, they are relatively rare in the younger age group. We present our management of a rare case of neglected odontoid fracture in an ankylosed spine of a young female. CASE REPORT: A 28-year-old female presented to our emergency department with neck deformity after a history of fall 1 year back. She presented with clinical symptoms and signs of cervical myelopathy. Diagnostic imaging confirmed ankylosis of the cervical spine with a non-union of the odontoid fracture with atlantoaxial instability and kyphosis. She was treated with anterior release of the odontoid through a standard Smith-Robinson approach, anatomical reduction, and posterior occipitocervical stabilization and fusion. CONCLUSION: Non-union with a malpsitioned odontoid fracture in an ankylosed spine can be addressed by an anterior release and reduction with posterior fusion with good functional outcome.

Primary Ewing's sarcoma of the C2 vertebra with progressive quadriparesis: Report of a rare case and review of the literature.

BACKGROUND: Ewing's sarcoma is a malignant primitive neuroectodermal tumor (PNET) of childhood and adolescence. Primary Ewing's sarcoma of the spine is uncommon, and even more rarely involves the C2 vertebra. CASE DESCRIPTION: A 14-year-old patient was admitted with a history of chronic neck pain, which exacerbated after playing contact sports 3 weeks before presentation. On initial examination, he had pain radiating into the left upper extremity plus spasticity in all the four limbs. The cervical X-rays revealed a mixed sclerotic-lytic lesion involving the C2 vertebral body. The CT bony and soft-tissue windows documented predominant left-sided tumor invasion of the posterior elements, pedicles, and body of C2 along with extension into the spinal canal resulting in severe cord compression with peritumoral soft-tissue edema. The angiogram revealed a patent left vertebral artery entirely surrounded/encased by tumor. The PET-CT scan demonstrated no other spinal or systemic lesions. Due to his rapid neurological deterioration, the patient underwent an emergent biopsy of the tumor with posterior decompression and occipitocervical stabilization. The biopsy demonstrated a PNET (e.g., positive CD 99 MIC2 marker for Ewing's sarcoma). Following subsequent chemotherapy and radiation, the patient rapidly improved over a period of 3 months. CONCLUSION: Primary Ewing's sarcoma involving the C2 vertebra is exceedingly rare and warrants surgical decompression with pathological confirmation to provide additional multi-modal/multi-disciplinary adjunctive radiation/chemotherapy.

Preschool Child with Displaced Odontoid Synchondrosis Fracture Treated by Surgical Management Showing Excellent Remodeling.

INTRODUCTION: Cervical spine injuries in the children are unusual, and an incidence rate of 1.5-3% of all the spinal fractures has been reported. The cartilaginous end plate between the dens and the body of the axis usually ossifies at the age of 5-7 years. This anatomical characteristic has been attributed to odontoid synchondrosis fractures in young children. However, odontoid process fractures are rare in children and only few cases have been reported in literature. CASE REPORT: We report a case of a displaced odontoid synchondrosis fracture in a 2-year-old girl with anterior subluxation of C1 over C2 vertebra. This was treated with a posterior atlantoaxial fusion using sublaminar wiring. Immediate post-operative radiography showed partial reduction of the displaced odontoid fragment on C2 body with residual step deformity with angulation at the fracture site. Follow-up at 1 year showed excellent remodeling. CONCLUSION: Synchondrosis fractures of the odontoid are rare and usually found in children under 7 years of age. Most of these patients can be treated by external immobilization alone. However, in small children with significant displacement and angulation, posterior C1-C2 fusion is a better option providing more stability. Furthermore, one can expect significant remodeling of the fracture within this population.

Osteoporotic Vertebral Compression Fracture and Single Balloon Extrapedicular Kyphoplasty: Findings and Technical Considerations.

OBJECTIVE: To evaluate the functional and radiological outcome of balloon kyphoplasty and to endorse the unilateral single balloon extrapedicular kyphoplasty as practically more feasible and safer method in comparison to the conventional methods. METHODS: Totally, 81 patients were presented to our center with osteoporotic vertebral compression fracture. Among these, 59 patients (61 vertebrae) were enrolled with stable wedge osteoporotic compression fracture. Pre-operatively percentage of vertebral height loss and kyphotic angle were calculated and single balloon extrapedicular kyphoplasty was performed in all cases. RESULTS: Postoperatively, anterior vertebral height improved to 79.61% of normal subjects. In our study, the mean segmental kyphosis correction following balloon kyphoplasty was 14.27°. Overall incidence of cement leak in our study was 15.25%. CONCLUSION: Although we encountered the few difficulties, but this technique holds the safety and feasibility measures. Furthermore, it is effective in restoring anterior vertebral height, alignment and angle of kyphosis.

Langerhans Cell Histiocytosis in the Adult Lumbar Spine - A Case Report and Literature Review.

INTRODUCTION: Langerhans cell histiocytosis (LCH) in spine is a benign disorder that mainly affects children and is rare in adults. The treatment of LCH in adults is still controversial. The literature is drought with reports regarding management of LCH in adults with pathological fracture. We report a case of LCH at L5 vertebra in an adult patient treated with posterior stabilization, decompression, and anterior corpectomy and reconstruction. CASE PRESENTATION: A 30-year-old manual laborer working in Middle East, presented to us with severe pain in the lower back (VAS-8) with the right lower limb radiculopathy for 6 months. Radiological investigations revealed to have a solitary osteolytic lesion with pathological fracture at L5 vertebral body. MRI showed hyperintense lesion in T2 sagittal images and hypointense in T1 sagittal images in L5 vertebral body. PET scan showed metabolically active lesion involving L5 vertebra body and right ischium. CT-guided biopsy from L5 vertebral body was performed, but was inconclusive. The patient underwent surgical management in the form of posterior stabilization L4-S1 and transpedicular biopsy. The sample was sent for frozen section and confirmed the presence of neoplasia but did not provide sufficient information about the nature of pathology. Intraoperatively, the decision was made to do anterior excision biopsy, corpectomy, and reconstruction with titanium mesh cage filled with cement. The precise diagnosis of LCH was established on histopathological examination and confirmed with immunohistochemistry positivity for CD1a and S100. The patient had immediate relief of his back pain and radicular pain. He was able to resume his daily activities at 1 month after the surgery. At 2-year follow-up patient was asymptomatic and no local recurrence was noticed. CONCLUSION: Surgical excisionfor LCH in adults should be considered in patients with refractory low back pain with pathological fracture, neurological deficits, or spinal instability.

Outcome Evaluation of Modified Uninstrumented Open-door Cervical Laminoplasty for Ossified Posterior Longitudinal Ligament with Cervical Myelopathy.

STUDY DESIGN: This was a retrospective study. PURPOSE: To evaluate the short term outcomes of a novel self-developed technique of performing uninstrumented open-door cervical laminoplasty (ODCL) in patients with cervical myelopathy secondary to ossified posterior longitudinal ligament (OPLL). REVIEW OF LITERATURE: Published literature on cervical laminoplasties largely focuses on the outcomes of instrumented variants. MATERIALS AND METHODS: Retrospective data were collected from 54 patients who underwent uninstrumented ODCL for cervical OPLL at a single institution from January 2010 to February 2017. The preoperative and postoperative modified Japanese Orthopaedic Association score (mJOA) and Nurick grading were documented. Cervical lordotic angle at C2-C7 and range of motion (ROM) were obtained from the preoperative and postoperative lateral cervical radiographs in neutral and flexion extension views, respectively. Descriptive and analytical statistics were generated by SAS 9.4 University Edition (SAS Institute, Cary. North Carolina, USA). RESULTS: The average age was 58.6 ± 7.8 years. The average time of presentation from the onset of symptoms was 7.6 ± 3 months. Of the 54 patients who were included in the study, majority (48.14%) had segmental type of OPLL while C3-C6 was the most commonly operated level (66.67%). The mean operating time was 115 ± 31 min with a mean blood loss of 165.9 ± 75 ml. There was a significant improvement in the mJOA scores (9.2 ± 1.1-13.7 ± 0.9, P < 0.0001) and Nurick grading (3.4 ± 0.8-1.6 ± 0.5, P < 0.0001) at 24-month followup. Preoperative C2-C7 angle had an average decrease of 4.5° at 24-month followup (19.3 ± 7.2-14.8 ± 8.8, P < 0.0001). There was a mean reduction of 4.3° ± 3.78° noted in the C2-C7 ROM between the preoperative and final followup. CONCLUSION: Uninstrumented ODCL is an easily reproducible and economical alternative to the standard instrumented laminoplasty with equivalent short term outcomes. This technique is a valuable option in the treatment of cervical OPLL, especially in regions with scarce resources.

Rare Case of Bilateral Pure Facet Joint Dislocation of Upper Lumbar Spine without Facet Fracture: A Case Report.

INTRODUCTION: Bilateral facetal dislocation without facet fracture, although common in cervical spine, is a very rare entity in lumbar spine with <15 cases reported so far. Such injuries are very unstable involving all the three columns. Neurological insult and visceral affection are commonly associated with bilateral facetal dislocation. CASE REPORT: A 22-year-old gentleman presented with ASIA Aparaplegia following road traffic accident. Radiographs/computed tomography scan revealed pure facetal dislocation L1-L2 with no evidence of facet fracture. The patient also had liver laceration. The patient underwent open instrumented reduction along with left-sidedtransforaminal removal of damaged disc and inter body fusion. The patient improved significantly to ASIA C neurological status at 6-month follow-up. CONCLUSION: Pure facetal dislocation, although rarely seen in lumbar region, is a very unstable injury. Prompt recognition and early intervention facilitate nursing care and neurological recovery. Recognition of associated injuries is also important.

Outcomes of Unstable Subaxial Cervical Spine Fractures Managed by Posteroanterior Stabilization and Fusion.

STUDY DESIGN: Retrospective study. PURPOSE: To evaluate clinical and radiological outcomes of unstable subaxial cervical spine injuries managed by both posterior tension band column stabilization and anterior decompression, stabilization, and fusion. OVERVIEW OF LITERATURE: Unstable subaxial cervical spine injuries often involve disruption of the anterior column and posterior tension band osteoligamentous complex. Such injuries need immediate surgical intervention. Different methods of reduction and surgical approaches have been published in the literature, with lack of consensus on a uniform or standardized method. Controversy still exists regarding stabilization of unstable cervical fractures by anterior or posterior approach alone or combined approaches. METHODS: We retrospectively evaluated 24 patients with post-traumatic unstable subaxial cervical spine injuries with their preoperative clinical details, X-ray, computed tomography, and magnetic resonance imaging of the cervical spine for fracture classification based on the mechanism of injury with status of disc herniation and posterior tension band disruption. All patients were managed by immediate reduction, posterior and anterior stabilization, and fusion in a single session of anesthesia. Data of all patients were analyzed with respect to pre- and postoperative neurological status based on American Spinal Injury Association grading, Visual Analog Scale score, the observation of bony fusion, and implant failure at 1, 3, 6, and 12 months. Data were analyzed using paired t-test. RESULTS: All patients had solid fusion at the desired level with considerable neurological improvement at the 1-year follow-up. CONCLUSIONS: In unstable cervical injuries, stabilization of disrupted posterior tension band increases the stability of anterior plating and fusion. This method of immediate reduction and circumferential stabilization is rapid, safe, and effective and has a low rate of complications.