Context: Spinal paragangliomas are rare neuroendocrine tumors of the extra-adrenal paraganglionic system. Aims: This study describes the clinicopathological features of eight cases of spinal paraganglioma and highlights the significance of important morphological features and immunohistochemistry in the diagnosis of paraganglioma at this unusual site. Material and Methods: All the cases of primary spinal paragangliomas diagnosed during the last six years (2008-2013) in the Department of Pathology at our hospital were reviewed. Results: There were six males and two females. The mean age at diagnosis was 50.4 years. All patients presented with low back pain. All tumors were located in the cauda equina or conus medullaris region. Magnetic Resonance Imaging and intraoperative appearance were that of a vascular, well-circumscribed intradural, extramedullary tumor suggestive of either schwannoma or ependymoma. All the patients underwent gross total resection of the tumor. Histopathology in five of the cases showed 'ependymoma-like histology' while only three cases had a predominant classic 'zellballen' pattern. Two cases had prominent 'gangliocytic differentiation'. In the five cases with 'ependymoma-like histology', the diagnosis was confirmed on Immunohistochemistry (IHC). Conclusions: Even though relatively rare, paraganglioma should be considered in the differential diagnosis of spinal tumors and due to their clinical, radiological and histopathological similarity to schwannoma and ependymoma, the diagnosis should be based on close examination of the clinical, radiological and pathological findings.

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Syringomyelia resulting from arachnoiditis secondary to aneurysmal subarachnoid hemorrhage (SAH) is an extremely rare clinical entity with few cases reported in the literature. The presentation, management, and pathogenesis of syringomyelia in this setting is poorly understood. We describe the presentation, radiology, management, and outcomes in two patients with syringomyelia resulting from arachnoiditis secondary to aneurysmal SAH and review the literature on this rare condition. Case number 1 was treated successfully with syrinx-subarachnoid shunt after extensive lysis of adhesions. Case number 2 was treated with syringoperitoneal shunt. Both patients had radiographic decreased syrinx size postoperatively. These patients add to the small literature on syringomyelia occurring secondary to SAH-associated arachnoiditis. The radiographic outcomes demonstrate that in the appropriately selected patient, syrinx-subarachnoid or syringoperitoneal shunting are viable options.

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Background: Traditionally, conservative treatment of thoracolumbar (TL) burst fractures without neurologic deficit has encompassed the application of an extension brace. However, their effectiveness on maintaining the alignment, preventing posttraumatic deformities, and improving back pain, disability and quality of life is doubtful. Objective: The objective was to identify and summarize the evidence from randomized controlled trials (RCTs) to determine whether bracing patients who suffer TL fractures adds benefices to the conservative manage without bracing. Materials and Methods: Seven databases were searched for relevant RCTs that compared the clinical and radiological outcomes of orthosis versus no-orthosis for TL burst fractures managed conservatively. Primary outcomes were: (1) Loss of kyphotic angle; (2) failure of conservative management requiring subsequent surgery; and (3) disability and pain outcomes. Secondary outcomes were defined by health-related quality of life and in-hospital stay. Results: Based on predefined inclusion criteria, only two eligible high-quality RCTs with a total of 119 patients were included. No significant difference was identified between the two groups regarding loss of kyphotic angle, pain outcome, or in-hospital stay. The pooled data showed higher scores in physical and mental domains of the Short-Form Health Survey 36 in the group treated without orthosis. Conclusion and Recommendation: The current evidence suggests that orthosis could not be necessary when TL burst fractures without neurologic deficit are treated conservatively. However, due to limitations related with number and size of the included studies, more RCTs with high quality are desirable for making recommendations with more certainty.

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Aim: Quantitative anatomy of the facets of the sub-axial cervical spine was performed. The purpose of the evaluation was to determine the feasibility of insertion of Goel inter-facetal articular spacers in the sub-axial cervical spine. Only few studies detailing the morphometry of the facets are available in the literature. Materials and Methods: Ten cervical vertebrae from C3 to C7 with a total of 20 facets were evaluated by the author. The anatomic parameters studied were the height, width, thickness, shape, orientation, and inclination of each of the superior and inferior facets. The alterations in a number of intervertebral segmental distances were measured before and after spacer insertion. The distance of the inferior facet from the foramen tranversarium, spinal canal, and neural foramina was measured to assess safety of spacer insertion with respect to the vertebral artery and neural structures. Results: The height, width and thickness of the superior facets from C3 to C7 ranged from 6 to 12 mm, 8 to 12 mm, and 2.5 to 6 mm, respectively. The inferior facets had an average height of 10.5 mm, average width of 11.2 mm and average thickness of 3.5 mm. The inclination of the superior facets with respect to the transverse plane ranged from 22° to 45° and that of the inferior facets ranged from 29° to 53°. The distance of the anterior margin of the inferior facet from the posterior border of the foramen transversium ranged from 5 to 7 mm. This distance was maximum at C3 level, then decreased at C4 and remained constant from C5 to C7. Conclusion: This anatomic evaluation aided in understanding the morphology of the cervical facets and the suitability of the cervical facetal articular cavity for insertion of spacers.

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Objective: Nearside impact collisions presenting with lateral mass fractures of atlanto-axial vertebrae contralateral to the impact site represents a rare fracture pattern that does not correlate with previously described injury mechanism. We describe our clinical experience with such fractures and propose a novel description of biomechanical forces involved in this unique injury pattern. The findings serve to alert clinicians to potentially serious consequences of associated unrecognized and untreated vertebral artery injury. Material and Methods : In addition to describing our clinical experience with three of these fractures, a review of Crash Injury Research and Engineering Network (CIREN) database was conducted to further characterize such fractures. A descriptive analysis of three recent lateral mass fractures of the atlanto-axial segment is coupled with a review of the CIREN database. A total of 4047 collisions were screened for unilateral fractures of atlas or axis. Information was screened for side of impact and data regarding impact velocity, occupant injuries and use of restraints. Results: Following screening of unilateral fractures of atlas and axis for direct side impacts, 41 fractures were identified. Cross referencing these cases for occurrence contralateral to side of impact identified four such fractures. Including our recent clinical experience, seven injuries were identified: Five C1 and two C2 fractures. Velocity ranged from 14 to 43 km/h. Two associated vertebral artery injuries were identified. Conclusions: Complexity of the atlanto-axial complex is responsible for a sequence of events that define load application in side impacts. This study demonstrates the vulnerability of vertebral artery to injury under unique translational forces and supports the use or routine screening for vascular injury. Diminished sensitivity of plain radiography in identifying these injuries suggests that computerized tomography should be used in all patients wherein a similar pattern of injury is suspected.

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Context: Surgery for the rheumatoid cervical spine has been shown to stabilize the unstable spine; arrest/improve the progression of neurological deficit, help neck pain, and possibly decelerate the degenerative disease process. Operative intervention for the rheumatoid spine has significantly changed over the last 30 years. Aims: The purpose of this study was to review all cases of cervical rheumatoid spine requiring surgical intervention in a single unit over the last 30 years. Materials and Methods: A prospectively-maintained spine database was retrospectively searched for all cases of rheumatoid spine, leading to a review of indications, imaging, Ranawat and Myelopathy Disability Index measures, surgical morbidity, and survival curve analysis. Results: A total of 224 cases were identified between 1981 and 2011. Dividing the data into three time-epochs, there has been a significant increase in the ratio of segment-saving Goel-Harms C1-C2: Occipitocervical fixation (OCF) surgery and survival has increased between 1981 and 2011 from 30% to 51%. Patients undergoing C1-C2 fixation were comparatively less myelopathic and in a better Ranawat class preoperatively, but postoperative outcome measures were well-preserved with favorable mortality rates over mean 39.6 months of follow-up. However, 11% of cases required OCF at mean 28 months post-C1-C2 fixation, largely due to instrumentation failure (80%). Conclusion: We present the largest series of surgically managed rheumatoid spines, revealing comparative data on OCF and C1-C2 fixation. Although survival has improved over the last 30 years, there have been changes in medical, surgical and perioperative management over that period of time too confounding the interpretation; however, the analysis presented suggests that rheumatoid patients presenting early in the disease process may benefit from C1 to C2 fixation, albeit with a proportion requiring OCF at a later time.

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Study Design and Objective: The author reports experience with treatment of degenerative lumbar canal stenosis that involved fixation-arthrodesis of the affected spinal segment using "double insurance" transarticular screws for each joint. No direct bone, ligament or disc resection is done for decompression of the spinal dural tube or root canal. Methods and Summary of Background Data: During the period March 2011-September 2011, seven patients having lumbar canal stenosis were treated with a modification of transarticular method of screw fixation that involved insertion of two or "double insurance" screws at each articular joint. The operation involved section of the spinous process at its base, opening up of the facet joint, denuding of articular cartilage, insertion of intra-articular bone graft and insertion of two transarticular screws at each facet joint. The fixation was done in four levels in two patients, at three levels in four patients and at two levels in one patient. Oswestry disability index and visual analog scale were used to clinically assess the patients before and after the surgery and at follow-up. Results: During the average period of follow-up of 26.9 months (range 24-30 months), there was varying degree of recovery of symptoms. The procedure resulted in firm stabilization and fixation of the spinal segment and provided a ground for arthrodesis. During the period of follow-up, one patient underwent re-exploration and decompressive laminectomy as she continued to have significant pain symptom. Conclusions: Vertical instability and telescoping, listhesis or overriding of the facets on physical activity seems to be the defining phenomenon in the pathogenesis of lumbar canal stenosis. The clinical outcome in our patients suggest that fixation of the spinal segment can be a rationale form of treatment. "Double insurance" transarticular method of treatment is a simple, safe, and effective method of spinal stabilization.

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Anterior thoracic spinal instrumentation has traditionally been supported by a posterior thoracic construct spanning from at least two levels above to two levels below; however, instrumentation at a single-level above and below may be adequate to support such a construct. We report two cases of transthoracic corpectomy with short-segment posterior fixation with success in long-term stabilization. Two patients with thoracic vertebral malignancy resulting in spinal deformity and spinal cord compression underwent transthoracic corpectomy with placement of an expandable cage proceeded by posterior fixation one level above and one level below. Using the Cobb angle, the degree of kyphosis was measured at 3, 6, and 12 months postoperatively. Long-term spinal stabilization was achieved in both patients. There was no significant increase in kyphosis and no evidence of hardware failure in either patient during the follow-up period. Transthoracic corpectomy with supplementary posterior fixation one level above and below may be adequate to stabilize the spine.

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Imaging with positron emission tomography (PET) and ⁶⁸ Ga-DOTA peptides is a promising method in intracranial meningiomas. Especially in recurrent meningioma discrimination between scar tissue and recurrent tumor tissue in magnetic resonance imaging (MRI) is often difficult. We report the first case of ⁶⁸ Ga-DOTATATE-PET/computed tomography (PET/CT) imaging in recurrent spinal meningioma. A 64-year-old Caucasian female patient was referred to our department with the second recurrence of thoracic meningothelial meningioma. In MRI, it remained unclear if the multiple enhancements seen represented scar tissue or vital tumor. We offered ⁶⁸ Ga-DOTATATE-PET/CT imaging in order to evaluate the best strategy. ⁶⁸ Ga-DOTATATE-PET/CT imaging revealed strong tracer uptake in parts of the lesions. The pattern did distinctly differ from MRI enhancement. Multiple biopsies were performed in the PET-positive and PET-negative regions. Histological results confirmed the prediction of ⁶⁸ Ga-DOTATATE-PET with vital tumor in PET-positive regions and scar tissue in PET-negative regions. Differentiating scar tissue from tumor can be challenging in recurrent spinal meningioma with MRI alone. In the presented case, ⁶⁸ Ga-DOTATATE-PET imaging was able to differentiate noninvasively between tumor and scar.

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The primary objective was to report this rare case and discuss the probable mechanism of thyroid storm following anterior cervical spine surgery for Kochs cervical spine.

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