Correction of pediatric cervical kyphosis: our experience and systematic-literature review.

BACKGROUND: Pediatric cervical kyphosis is a distinct entity with diverse etiology (congenital, syndromic, traumatic, metabolic or neoplastic). Surgical correction in pediatric population is challenging due to their growing spine and low blood volume. PURPOSE: To analyse their presentation, surgical techniques and outcome of pediatric cervical kyphosis and systematically review the pertinent literature. DESIGN: Retrospective study. PATIENT SAMPLE: 16 patients aged ≤ 18 years who underwent correction for cervical kyphosis between 2009 and 2021. OUTCOME MEASURES: Nurick's grading, mJOA score and Global cobb's angle. METHODS: Clinical parameters (Nurick grading and mJOA score) were noted from database on admission and on follow-up at 6 months. Radiological parameters of assessment included Global Cobb's angle. The C2-C7 Cobb angle was the angle of C2 vertebra lower end plate and C7 vertebra lower end plate. For C1-2 kyphosis, anterior border of C1 and anterior border of C2 angle was taken. Radiographic parameters were studied on CT and radiographs of cervical spine to assess for stability, the degree of deformity correction and fusion status at 6 months follow-up. RESULTS: 16 patients with mean age of 14.2 ± 3 years (9 syndromic, 4 post-traumatic, 2 metabolic and 1 post-laminectomy). All underwent surgical correction, 6 underwent Antero-posterior spinal fusion, 6 underwent Posterior spinal fusion and 4 underwent Anterior spinal fusion. There was significant clinical improvement postoperatively with-Nurick grade (pre vs. post: 2.8 vs. 1.8, p = 0.004), mJOA score (pre vs. post: 11.3 vs. 14, p = 0.003). There was significant deformity correction of Cobb's angle from 40.7 ± 26.5° to 14.9 ± 10° (p = 0.001). Early complications included intraoperative hemodynamic instability (3) and wound complication (1). Mean follow-up was 76.9 ± 59.3 months. CONCLUSION: Pediatric cervical kyphosis is a debilitating condition which are managed surgically. Approach has to be individualized to the pathology and good results can be achieved. Patients should be screened for syndromic association and followed-up regularly.

Determination of Availability of Safety Margin for Placement of C3-C6 Pedicle Screw on CT Angiography.

BACKGROUND: Cervical pedicle screws (CPS) in the subaxial cervical spine (C3-C6) are faced with high incidence of perforating the lateral pedicular cortex endangering the vertebral artery (VA). The present study analyzes the pedicle width (PW) from C3 to C6 and defines the relation of VA with regard to pedicle and transverse foramen (TF) to determine the safety margin in cases of lateral pedicular breach. METHODS: Computed tomography angiograms of 500 patients were retrospectively studied to identify the pedicle width (PW), VA area, TF area, and the lateral pedicle to vertebral artery distance (LPVA). Occupancy ratio (OR; the percentage area of transverse foramen occupied by VA) and safety margin (SM; permissible displacement of VA in TF), along with LPVA were considered to be protective parameters against VA injury if lateral pedicle breach happens. RESULTS: PW was 4.7 mm at C3, 4.83 mm at C4, 5.26 mm at C5 and 5.41 mm at C6. Mean LPVA at different levels was between 0.97 mm and 1.15 mm, OR was around 20% at all levels, and mean SM was between 2.34 mm and 2.92 at various levels. Sex differences were statistically significant for PW but not for LPVA, SM, or OR. CONCLUSIONS: This study gives us an idea about the various parameters in placement of cervical pedicle screw in subaxial cervical spine and the probable reasons there are few vertebral artery injuries despite high incidence of cervical pedicle breach. LPVA, safety margin, and OR may explain why even very significant CPS misplacement does not lead to vascular injury or neurologic deficit.

Traumatic Lateral Spondyloptosis: Case Series.

OBJECTIVE: To apprise readers about this rare but severest form of traumatic spine injury and its surgical management. BACKGROUND: Complete fracture dislocation and subluxation (>100%) of 1 vertebral body in the coronal or sagittal plane with respect to the adjacent vertebra is defined as spondyloptosis. In coronal spondyloptosis the subluxated vertebral bodies lie beside each other, and the condition is lateraloptosis. Patients with lateraloptosis present unique surgical challenges because reduction and achieving realignment of spinal column require meticulous planning and execution. METHODS: A retrospective analysis of patients admitted with lateraloptosis over a 4-year period (2013-2016) was done. Lateraloptosis was defined on computed tomography as complete subluxation of the spinal column with more than 50% of adjacent vertebral bodies lying directly lateral to each other. RESULTS: Five men, ranging from 18 to 50 years (mean, 35.2 years) old were included in the study. Three patients had thoracic spine lateraloptosis, and in 2 the injury was at the thoracolumbar junction. All patients underwent single-stage posterior surgical reduction and fixation. Intraoperatively, cord transection was seen in 3 patients, and dural tear with cerebrospinal fluid leak was seen in 1 patient. The mean follow-up period was 14 months (range, 1-36 months), during which 1 patient died of complications arising from bedsores. All patients remained at American Spinal Injury Association grade A neurologically. CONCLUSION: Lateraloptosis is difficult to treat, and the aim of surgery is to stabilize the spine. Rehabilitation remains the most crucial factor, but the scarcity of proper rehabilitation centers results in high mortality and morbidity.

Medial sphenoid wing meningiomas: Experience with microsurgical resection over 5 years and a review of literature.

BACKGROUND: Medial sphenoid wing meningiomas are medially located tumors on the sphenoid wing with attachment over the anterior clinoid process. They represent a distinct entity. These medial sphenoid wing meningiomas present a more difficult problem for the neurosurgeons because in a majority of cases, they involve the anterior visual pathways and arteries of the anterior circulation and may invade the cavernous sinus (CS). Higher morbidity, mortality and recurrence rates have been observed in these tumors compared with meningiomas in other locations. The rate of recurrence for medial sphenoid wing meningiomas is reported as being one of the highest amongst intracranial meningiomas. MATERIAL AND METHODS: The authors retrospectively analyzed 78 consecutive patients with the diagnosis of medial sphenoid wing meningioma who were operated in our department from January 2008 to December 2012. RESULTS: These patients, having a meningioma of the medial sphenoid ridge, were divided into two types depending on the involvement of CS. Diplopia, internal carotid artery encasement, and postoperative visual deterioration were more common in Type 2 tumors. Similarly, extent of resection and postoperative morbidity were greater in Type 2 patients. CONCLUSIONS: CS invasion confers an added risk to the surgical morbidity and outcomes. However, with proper surgical techniques, optimum outcomes can be achieved and overall surgical results at our center are found to be comparable to that of the current literature.