Neck pain is a diffuse problem with a high incidence and often leads to the more or less appropriate prescription of imaging studies of the cervical spine. In general, this is represented by a magnetic resonance imaging (MRI) scan. Frequently such studies reveal no other significant findings apart from a loss of cervical lordosis either under the form of a simple straightening of the spine or even an inversion of the normal curvature into a kyphosis. Faced with this entity, the clinician is put in front of a series of questions: to which extent such a finding plays a role in the patient's symptoms? If it does what is the role of conservative or even invasive treatment? What are the implications for surgery either for decompressive procedures or corrective procedures? To shed some light on these questions, the authors present a narrative review of the most relevant literature on the topic. Papers examined span from the initial epidemiologic reports out of the pre-MRI and computerized tomography era up to the most recent discussions on cervical sagittal alignment and its implications both for the surgical and nonsurgical patient. In this process, it becomes increasingly clear that we are still far from making any definite statements.

Objective: The authors evaluate the significance of atlantoaxial instability in the management of idiopathic syringomyelia. Background: We recently observed that atlantoaxial dislocation can be present even when the atlantodental interval was within normal range. Atlantoaxial instability can be identified on the basis of facetal mal-alignment or even by direct observation of status of joint during surgery. Our observations are discussed in nine patients where we identified and treated atlantoaxial instability in cases that would otherwise be considered as having “idiopathic” syrinx. Materials and Methods: The authors report experience with nine cases that were diagnosed to have “idiopathic” syrinx. The main bulk of the syrinx was located in the cervico-dorsal spinal region in all cases. One patient had been treated earlier by syringo-subarachnoid shunt surgery and one patient had undergone foramen magnum decompression. Results: On radiological evaluation, eight patients had posterior atlantoaxial facetal (Type B) dislocation. In one patient there was no facetal mal-alignment and was labeled to have axial or central (Type C) facetal instability. All patients were treated by atlantoaxial fixation. All patients improved symptomatically in the immediate postoperative period and the improvement was progressive and sustained on follow-up. In one case, the size of syrinx reduced in the immediate postoperative imaging. In the period of follow-up (range 6–42 months - average 19 months), reduction in the size of syrinx was demonstrated on imaging in three cases. Conclusions: The positive clinical outcome suggests that atlantoaxial instability may be the defining phenomenon in development of previously considered “idiopathic” syringomyelia.

Background: Craniovertebral junction is a complex anatomical location posing unique challenges to the surgical management of its pathologies. We aimed to identify the fifty most-cited articles that are dedicated to this field. Methods: A keyword search using the Thomson Reuters Web of Knowledge was conducted to identify articles relevant to the field of craniovertebral junction surgery. The articles were reviewed based on title, abstract, and methods, if necessary, and then ranked based on the total number of citations to identify the fifty most-cited articles. Characteristics of the articles were determined and analyzed. Results: The earliest top-cited article was published in 1948. When stratified by decade, 1990s was the most productive with 16 articles. The most-cited article was by Anderson and Dalonzo on a classification of odontoid fractures. By citation rate, the most-cited article was by Herms and Melcher who described Goel's technique of atlantoaxial fixation using C1 lateral mass screws and C2 pedicle screws with rod fixation. Atlantoaxial fixation was the most common topic. The United States, Barrow Neurological Institute, and VH Sonntag were the most represented country, institute, and author, respectively. The significant majority of articles were designed as case series providing level IV evidence. Conclusion: Using citation analysis, we have provided a list of the most-cited articles representing important contributions of various authors from many institutions across the world to the field of craniovertebral junction surgery.

Context: Sudden death from subarachnoid hemorrhage (SAH) is not uncommon. Aims: The goal of this study is to elucidate the effect of the cervical spinal roots and the related dorsal root ganglions (DRGs) on cardiorespiratory arrest following SAH. Settings and Design: This was an experimental study conducted on rabbits. Materials and Methods: This study was conducted on 22 rabbits which were randomly divided into three groups: control (n = 5), physiologic serum saline (SS; n = 6), SAH groups (n = 11). Experimental SAH was performed. Seven of 11 rabbits with SAH died within the first 2 weeks. After 20 days, other animals were sacrificed. The anterior spinal arteries, arteriae nervorum of cervical nerve roots (C6–C8), DRGs, and lungs were histopathologically examined and estimated stereologically. Statistical Analysis Used: Statistical analysis was performed using the PASW Statistics 18.0 for Windows (SPSS Inc., Chicago, Illinois, USA). Intergroup differences were assessed using a one-way ANOVA. The statistical significance was set at P < 0.05. Results: In the SAH group, histopathologically, severe anterior spinal artery (ASA) and arteriae nervorum vasospasm, axonal and neuronal degeneration, and neuronal apoptosis were observed. Vasospasm of ASA did not occur in the SS and control groups. There was a statistically significant increase in the degenerated neuron density in the SAH group as compared to the control and SS groups (P < 0.05). Cardiorespiratory disturbances, arrest, and lung edema more commonly developed in animals in the SAH group. Conclusion: We noticed interestingly that C6–C8 DRG degenerations were secondary to the vasospasm of ASA, following SAH. Cardiorespiratory disturbances or arrest can be explained with these mechanisms.

Background: Diagnostic yields for spondylodiscitis from CT guided biopsy is low. In the recent years, minimally invasive surgery (MIS) has shown to have a low morbidity and faster recovery. For spinal infections, MIS surgery may offer an opportunity for early pain control while obtaining a higher diagnostic yield than CT-guided biopsies. The aim of this study was to review our patients who underwent MIS surgery for spinal infection and report outcomes. Methods: A retrospective review of seven patients who underwent MIS decompression and/or discectomy in the setting of discitis, osteomyelitis, spondylodiscitis, and/or an epidural abscess was identified. Patient data including symptoms, visual analog score (VAS), surgical approach, antibiotic regimen, and postoperative outcomes were obtained. Results: Of the 7 patients, 5 patients had lumbar infections and two had thoracic infections. All seven patients improved in VAS immediately after surgery and at discharge. The average VAS improved by 4.4 ± 1.9 points. An organism was obtained in 6 of the 7 (85%) patients by the operative cultures. All patients made an excellent clinical recovery without the need for further spine surgery. All patients who received postoperative imaging on follow-up showed complete resolution or dramatically improved magnetic resonance imaging changes. The follow-up ranged from 2 to 9 months. Conclusions: MIS surgery provides an opportunity for early pain relief in patients with discitis, osteomyelitis, spondylodiscitis, and/or epidural abscess by directly addressing the primary cause of pain. MIS surgery for discitis provides a higher diagnostic yield to direct antibiotic treatment. MIS surgery results in good long-term recovery.

Background: Many patients suffer from radiculopathy and low back pain due to lumbar disc hernia. Transforaminal percutaneous endoscopic discectomy (TPED) is a minimally invasive method that accesses the disc pathology through the intervertebral foramen. Health-related quality of life (HRQoL) has been previously assessed for this method. However, a possible effect of the level of operation on the postoperative progress of HRQoL remains undefined. Purpose: The purpose of this study was to evaluate the impact of the level of operation on HRQoL, following TPED. Patients and Methods: A total of 76 patients diagnosed with lumbar disc hernia were enrolled in the study. According to the level of operation, they were divided into three groups: Group A (21 patients) for L3–L4, Group B (40 patients) for L4–L5, and Group C (15 patients) for L5–S1 intervertebral level. All patients underwent TPED. Their HRQoL was evaluated by the short-form-36 (SF-36) health survey questionnaire before the operation and at 6 weeks, 3, 6, and 12 months postsurgery. The progress of SF-36 was analyzed in relation to the operated level. Results: All aspects of SF-36 showed statistical significant improvement, at every given time interval (P ≤ 0.05) in the total of patients and in each group separately. Group A had a significantly higher increase in physical functioning (PF) score at 3 and 12 months postsurgery (P = 0.046 and P = 0.056, respectively). On the other hand, Group B had a significant lower increase in mental health (MH) score at 6 months (P = 0.009) postoperatively. Conclusion: Our study concludes that the level of operation in patients who undergo TPED for lumbar disc herniation affects the HRQoL 1 year after surgery, with Group A having a significantly greater improvement of PF in comparison with Groups B and C.

Objective: This study aims to improve the understanding of the anatomic variations along the thoracic and lumbar spine encountered during an all-posterior vertebrectomy, and reconstruction procedure. This information will help improve our understanding of human spine anatomy and will allow better planning for a vertebral body replacement (VBR) through either a transpedicular or costotransversectomy approach. Summary of Background Data: The major challenge to a total posterior approach vertebrectomy and VBR in the thoracolumbar spine lies in the preservation of important neural structures. Methods: This was a retrospective analysis. Hundred normal magnetic resonance imaging (MRI) spinal studies (T1–L5) on sagittal T2-weighted MRI images were studied to quantify: (1) mid-sagittal vertebral body (VB) dimensions (anterior, midline, and posterior VB height), (2) midline VB and associated intervertebral discs height, (3) mean distance between adjacent spinal nerve roots (DNN) and mean distance between the inferior endplate of the superior vertebrae to its respective spinal nerve root (DNE), and (4) posterior approach expansion ratio (PAER). Results: (1) The mean anterior VB height gradually increased craniocaudally from T1 to L5. The mean midline and posterior VB height showed a similar pattern up to L2. Mean posterior VB height was larger than the mean anterior VB height from T1 to L2, consistent with anterior wedging, and then measured less than the mean anterior VB height, indicating posterior wedging. (2) Midline VB and intervertebral disc height gradually increased from T1 to L4. (3) DNN and DNE were similar, whereby they gradually increased from T1 to L3. (5) Mean PAER varied between 1.69 (T12) and 2.27 (L5) depending on anatomic level. Conclusions: The dimensions of the thoracic and lumbar vertebrae and discs vary greatly. Thus, any attempt at carrying out a VBR from a posterior approach should take into account the specifications at each spinal level.

Object: Atlantoaxial instability with irreducible odontoid process is one of the challenges in spine surgery. These lesions are commonly treated through anterior transoral approach which is followed by posterior atlantoaxial fusion. However, there are still many limitations, especially cerebrospinal fluid fistula with subsequent life-threatening infection, difficulty in cases with limited opening of mouth due to temporomandibular arthritis or anomalies of naso-oropharynx. Türe et al. used the extreme lateral transatlas approach for the removal of odontoid. In this study, we applied the transatlas approach but through posterior midline incision aiming to evaluate its safety and feasibility. Methods: In four silicon injected, formalin-fixed cadaver heads, posterior removal of the odontoid was done through the familiar midline incision and subperiosteal muscle separation and elevation of muscles as on unit followed by microscopic exposure and mobilization of the vertebral artery after opening of the foramen transversarium of atlas followed by drilling of lateral mass and odontoidectomy. Occipitocervical stabilization was done between the occiput and C2, C3 (C1 lateral mass screw can be added in the contralateral side for better stabilization). Results: Unilateral excision of the lateral mass of atlas after mobilization of the vertebral artery provided safe and excellent exposure of the odontoid process in the four cadaver heads without injury to vertebral artery or retraction of the dura. Conclusion: Posterior removal of the odontoid can be done safely through wide and sterile operative field, and occipitocervical fixation performed at the same sitting without need for another operation and hence avoids the risk of cord injury from repositioning.

Background: Transverse (type II) odontoid process fracture is among the most commonly encountered cervical spine fractures. Nonsurgical management through external immobilization is occasionally preferred to surgical management but is criticized for its higher rates of failure and lower patient satisfaction. Our aim is to analyze patient-reported outcomes in patients who underwent nonsurgical treatment for type II odontoid fractures. Methods: We identified patients >18-year-old who underwent external immobilization as a treatment for isolated type II odontoid fracture between 2007 and 2012. We collected demographic parameters, clinical presentation, mode of injury, imaging studies and modality and duration of treatment (soft collar, halo-vest, or both). Patients were contacted by telephone to participate in a 15-min survey addressing their recovery including their subjective rate of return to preinjury level of functioning. Results: Fifteen patients met the inclusion/exclusion criteria and participated in our survey. Patients were followed up for an average of 19 months after injury. Overall mean age was 61 years. Injury followed a mechanical fall or a road traffic accident in 11 and 4 cases, respectively. External immobilization was achieved by halo vest only in nine patients, soft collar only in two patients (13%), and through a sequential combination in the remaining 4 (27%). This was deployed for a mean of 7.8 months. Radiological studies at the last follow-up showed bony healing (27%), fibrous nonunion (60%), and persistent instability (13%). Patients reported gradual recovery of function throughout the 1^st year after injury with levels above 70% of preinjury functioning achieved by 13% of patients at 6 months, 33% at 9 months, and 47% at 12 months. Overall satisfaction with nonsurgical management was 68%. Conclusion: In selected patients with type II odontoid fractures, external immobilization represents a good option with acceptable course of recovery.

Disc fragments are well known to migrate to superior, inferior, or lateral sites in the anterior epidural space, posterior epidural migrated lumbar disc fragments is an extremely rare disorder, 61 cases have been reported to date. However, there were no cases with perforated ligamentum flavum (LF). We report a different case with perforation of ligamentum ligamentum by disc fragment. To the best of our knowledge, this is the first report of perforation LF by a posterior epidural migrated sequester disc.

Traumatic high-grade spondylolisthesis in subaxial cervical spine is frequently associated with acute spinal cord injury and quadriparesis. There have been rare cases where such pathology demonstrates minimal to no neurological deficits. Assessment of the underlying biomechanics may provide insight into the mechanism of injury and associated neurological preservation. Patient 1 is a 63-year-old female presenting after a motor vehicle collision with significant right arm pain without neurological deficits. Imaging demonstrated C7/T1 spondyloptosis, associated with a locked facet on the left at C6/7 and a locked facet on the right at C7/T1, with a fracture of the left C7 pedicle and right C7 lamina. Patient 2 is a 60-year-old male presenting after a bicycle collision with transient bilateral upper extremity paresthesias without neurological deficits. Imaging demonstrated C7/T1 spondyloptosis, with fractures of bilateral C7 pedicles, C7/T1 facets, and C7 lamina. Patient 3 is a 36-year-old male presenting after a motor vehicle collision with diffuse tingling sensation throughout all extremities. His neurological examination was nonfocal. Imaging demonstrated a grade 4 spondylolithesis at C7/T1, associated with bilateral C7/T1 locked facets. From literature, most cases were noted to be dislocations resulting from fractures of the posterior elements. A minority of cases has been found to involve facet dislocations without fractures. Further biomechanical studies are needed to understand the underlying mechanisms.

Solitary fibrous tumor (SFT) usually originates from the pleura because of abnormal proliferation of fibroblast cells. It is extremely rare for the tumor to originate from the spine. Here, we report the second case of malignant SFT of thoracic spine with distant metastases in a 35-years-old female.