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Background: Scheuermann's disease is regarded as the most common cause of structural hyperkyphosis within adolescents without any proper treatment. It may lead to progressive deformity and back pain which influences patient's quality of life during adolescence and adulthood. Treatment approach to Scheuermann's kyphosis has not been clearly defined due to its different definitions and obscure natural history. The goal of treatment is not only to prevent progression but also to obtain permanent correction. Bracing, especially Milwaukee brace and physiotherapy are two of the common nonoperative treatment modalities. Hence, the present study intended to evaluate the effectiveness of Milwaukee brace on progression control as well as correction of Scheuermann's kyphosis. Materials and Methods: In a retrospective, observational study, all the patients diagnosed with Scheuermann's kyphosis were reviewed in 2003–2013, who were treated by Milwaukee brace at a single center. There was a minimum of 2-year follow-up after completion of bracing, during which clinical and radiological parameters were identified and recorded. Results: The mean angle of kyphosis in these patients at the presentation was 63.24 ± 9.96 and at the end of this study was 36.5° ± 13.4° (P < 0.001). Moreover, mean improved angle in those patients with <75° of kyphosis was 25.26° ± 7.78° and in those with 75° or more than 75° of kyphosis was 26.77° ± 19.76° (P < 0.001). Conclusion: Conservative treatment with Milwaukee brace and physiotherapy was effective in our hand for halting kyphosis progression in 97.5% of Scheuermann's kyphosis, which could be advised for cases up to 90° of kyphosis before skeletal maturity. As a result, a trial of brace treatment could be recommended in patients with severe kyphosis (up to 90°) which can open a new insight in conservative treatment of Scheuermann's kyphosis.

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Patients with spinal epidural abscesses (SEAs) may have a variable presentation. Such an infection has a typical appearance on magnetic resonance imaging (MRI) and enhances with gadolinium. We present a case that was a diagnostic challenge where pre- and intra-operative findings resulted in conflicting impressions. The mimicker was a spinal angiolipoma (SAL). The authors then provide a thorough review of this rare spinal neoplasm. A 55-year-old man presented with back pain, paresis, paresthesia, and urinary retention. MRI was indicative of a longitudinal epidural thoracic mass with a signal homogeneous to nearby fat, curvilinear vessels, and lack of enhancement. Although at emergent surgery, the lesion was found to contain abundant purulent material. Microbiology was positive for methicillin-resistant Staphylococcus aureus and consistent with SEA without evidence of neoplasia. While the imaging features were suggestive of an angiolipoma, the findings at surgery made SEA more likely, which were validated histopathologically. The diagnosis of SEA is often clear-cut, and the literature has reported only a few instances in which it masqueraded as another process such as lymphoma or myelitis. The case highlights SEA masquerading as an angiolipoma, and further demonstrates to clinicians that obtaining tissue diagnosis plays a crucial role diagnostically and therapeutically. SALs, on the other hand, are slow-growing tumors that can be infiltrating or noninfiltrating. They typically present with chronic symptoms and T1-MRI shows an inhomogeneous picture. Complete surgical excision is standard of care and patients tend to do well afterward.

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Hydatid disease or hydatidosis is the most widespread zoonosis caused by Echinococcus granulosus. Liver and lungs are the most common sites. Bone involvement is rare and reported in 0.5%–4% with spinal involvement reported in 50% of these cases. We present a case of spinal hydatidosis in a 35-year-old male presenting with lower extremity weakness and numbness. Magnetic resonance imaging (MRI) of the spine showed multiple cystic lesions at the T9–T11 level with involvement of the paraspinal muscles. The lesion was seen intraspinal, intradural, intramedullary, and epidural. Radiological impression was aneurysmal bone cyst. The patient underwent laminectomy, and the excised cysts showed characteristic features of hydatid cyst (HC) on histopathology. The patient was started on antihelminthic therapy postoperatively. MRI is a diagnostic modality for HC, but the unusual location and absence of characteristic features can cause diagnostic difficulty. A high index of suspicion should be kept in patients residing in endemic areas and presenting with unusual cystic lesion of spine.

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Study Design: We introduce a simple free hand technique with great ease of application, without angles, measures or degrees, and without any fluoroscopic guidance. It is a safe and reproducible technique. We present our preliminary experience with the use this technique, with inimitable simplicity. Purpose: The primary aim of the procedure was to achieve adequate screw trajectory in an apparent challenging ease which is reproducible with a good outcome. Overview of Literature: Lateral mass screw fixation is used for posterior subaxial cervical fixation. It was described by Louis and Magerl, then by Anderson, An, and Ebraheim et al. Each one described the procedure with a unique screw entrance point and trajectory. Technical Note: This study is a prospective case study of 45 patients who underwent subaxial cervical lateral mass screw fixation. The screws were inserted using a free hand method. The described free hand technique was found to minimize the morbidity associated with other techniques without compromising the quality of fixation. Conclusions: Surgical experiences with this technique found it equally safe, rapid, easy, and reproducible.

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Aim: This study aimed to describe the application of minimally invasive surgery (MIS) in separation surgery combined with postoperative stereotactic body radiation therapy (SBRT) in patients with symptomatic metastatic epidural spinal disease. Methods: Three techniques are described: (1) MIS posterior separation surgery alone, (2) MIS posterolateral separation surgery with percutaneous pedicle screw placement, and (3) MIS lateral corpectomy with percutaneous pedicle screw placement. Seven representative cases are presented in which the above techniques were applied and after which postoperative SBRT was performed. Results: The seven representative patients (3 male, 4 female) had a mean age of 54 years (range, 46–62 years). Two patients had a primary diagnosis of cholangiocarcinoma and in one patient each a diagnosis of breast, renal, lung adenocarcinoma, melanoma, and urothelial squamous cell carcinoma as their primary tumor. All patients had additional multiorgan disease apart from the metastatic spine involvement. Three patients underwent operations in the lumbar spine, two in the thoracic spine, and one in each of the thoraco-lumbar and lumbo-sacral spine. The average operating time was 149 ± 60.3 min (range, 90–240 min). The mean estimated blood loss was 188.8 cc. The mean length of stay in the hospital was 4 days (range, 3–7 days). There were no surgical complications. All patients received postoperative SBRT (typically 24 Gy in 3 fractions) at a mean of 43.2 days after surgery (range, 30–83). Conclusions: Early reports such as this suggest that MIS techniques can be successfully and safely applied in accomplishing “separation surgery” with adjuvant SBRT in the management of metastatic spinal disease. The potential advantages conferred by MIS techniques such as shortened hospital stay, decreased blood loss, reduced perioperative complications, and earlier initiation of adjuvant radiation are highly desirable in the treatment of this challenging patient population.

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Objective: Shifting national healthcare trends place increased emphasis on patient-centered care and value-based outcomes, and thus, patient-reported outcome instruments (PROIs) are often used. We sought to characterize the trends in PROI use over the past decade with regard to thoracolumbar degenerative spine disease and spinal deformity in major neurosurgical journals. Methods: Articles were screened for PROI use through a PubMed search among five major neurosurgical journals from 2006 to 2016. Articles focusing on adult thoracolumbar deformity and degenerative disease were selected with stringent criteria to further characterize PROI use. Results: A total of 29 different PROIs were used among 102 articles identified from 2006 to 2016 using our search strategy. Journal of Neurosurgery: Spine contained the most articles utilizing PROIs with 35.3% of all articles meeting search criteria. The most frequently used PROIs were Oswestry Disability Index, visual analog scale, and the European Quality of Life Five-dimension questionnaire used in 79.4%, 59.8%, and 29.4% of articles, respectively. Linear regression identified a significant increase in the number of articles employing PROIs from 2006 to 2016 (Y = 1.85, R² = 0.77, P < 0.01). The total number of PROIs per article was relatively stagnant over time and did not significantly change (Y = 0.03, R² = 0.05, P = 0.51). Conclusions: PROI use as an outcome tool in the adult thoracolumbar disease literature has increased during the past decade, which may be an indicative of PROI use to define patient expectations. This may also represent a trend toward PROI use as a surrogate measure of value-based care.

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Segmental spinal dysgenesis is a rare and challenging entity especially when associated with occult dysraphism. Experience with a female patient followed during a period of 10 years spanning from 5 to 15 years of age is reported. During that period the girl underwent three spinal operations consisting in one decompression and spinal cord untethering, one posterior instrumented fusion and a spinal cord re-untethering. Clinical and radiological features are discussed and considerations on optimization of management strategies are made.

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Prostate carcinoma presenting as symptomatic metastases to atlantoaxial spine is extremely rare. Spastic quadriparesis due to pathological fracture of odontoid as the only initial manifestation without symptoms of primary malignancy is rarer still. We report a 64-year-old male who presented with progressive spastic quadriparesis along with urinary retention of 3 weeks duration. Computed tomography and magnetic resonance imaging cervical spine and craniovertebral junction showed type III pathological fracture of odontoid with anterior translation of C1 with spinal cord compression. Biopsy from an enlarged prostate showed adenocarcinoma of prostate. The patient was managed conservatively from neurological aspect as he refused for any surgical intervention.

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Background: Cervical radiculopathy is the common clinical entity, often caused by “wear and tear” changes that occur in the spine. In the younger population, cervical radiculopathy is a result of a disc herniation or an acute injury causing foraminal impingement of an exiting nerve, whereas in the older individuals, it is due to foraminal narrowing from osteophyte formation, decreased disc height, and degenerative changes of the uncovertebral joints anteriorly and of the facet joints posteriorly. In most (75%–90%), cervical radiculopathy responds well to conservative treatment, whereas the remaining patients, who fail to achieve acceptable recovery with conservative modalities, alone need surgical decompression of the nerve root. Surgical interventions can be categorized into anterior and posterior approaches to the spine. Our study is focused on the surgical outcome of anterior discectomy with fusion versus posterior cervical discectomy with foraminotomy for cervical monoradiculopathy. Materials and Methods: Ours is a retrospective study including patients of one level unilateral posterolateral cervical disc prolapse with radiculopathy operated in Department of Neurosurgery, Bangalore Medical College and Research Institute between 2012 and June 2016. The hospital records, imagings, operation notes, and follow-up records were reviewed and analyzed. One hundred and fourteen patients of cervical monoradiculopathy were investigated and operated, 76 operated by anterior cervical discectomy with fusion (ACDF), and 38 operated by posterior cervical laminoforaminotomy (PCL). Results: The average operation time in 76 patients of ACDF group was 178 min and in 38 patients of PCL group was 72 min. Sixty-nine (91%) patients of ACDF and 38 (100%) patients of PCL had symptomatic relief but statistically (P > 0.5) was not significant. Three patients in ACDF group had hoarseness of voice due to recurrent laryngeal nerve palsy and there were no fresh permanent neurological deficits in any patients of PCL group over a follow-up period of 36 months. The average postoperative hospital stay was 5 days in ACDF group and 3 days in PCL group. The average intraoperative blood loss was <50 ml in ACDF group and 650 ml in PCL group. The need of analgesic for pain arising from bone graft site in ACDF group was comparable with operative site pain in PCL group. Conclusions: PCL is a simple approach, yields gratifying results, and is a promising alternative in selected cases of cervical monoradiculopathy due to disc prolapse.

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Study Design: This was an interventional human cadaver study and radiological study. Objectives: Atlas instrumentation is frequently involved in fusion procedures involving the craniocervical junction area. Identification of the entry point at the center of atlas lateral mass (ALM) is challenging because of its rounded posterior surface and the surrounding venous plexus. This report examines using the medial edge of atlas posterior arch (MEC1) as a fixed and reliable anatomic reference to guide the entry point of ALM screws. Methods: Fifty, normal, cervical spine computed tomography studies were reviewed. ALM screw trajectories were planned at one point along MEC1 and another point 2 mm lateral to MEC1. Free-hand ALM instrumentation was performed in ten fresh human cadavers using the 2 mm entry point, with a sagittal trajectory parallel to atlas inferior arch (IAC1); three-dimensional imaging was then performed to confirm instrumentation accuracy. Results: The average ALM diameter was 12.35 mm. Inserting a screw using the entry point 2 mm lateral to MEC1 was closer to ALM midpoint than using the entry point along MEC1 (P < 0.0001). Twenty ALM screws were successfully inserted in the ten cadavers. No encroachments into the spinal canal or foramen transversarium occurred. However, two screws were superiorly directed and violated the occipitocervical joint; they were not parallel to IAC1. Conclusion: MEC1 provides a fixed and reliable landmark for ALM instrumentation. An entry point 2 mm point lateral to MEC1 is close to ALM midpoint. IAC1 also provides a guide for the sagittal trajectory. Attention to anatomic landmarks may help reduce complications associated with atlas instrumentation but should be verified in future clinical studies.

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Two unlike metals near one another can break down as they move toward electrochemical equilibrium resulting in galvanic corrosion. We describe a case of electrochemical corrosion resulting in pseudarthrosis, followed by instrumentation failure leading to subarachnoid hemorrhage. A 53-year-old female with a history of cervical instability and two separate prior cervical fusion surgery with sublaminar cables presented with new onset severe neck pain. Restricted range of motion in her neck and bilateral Hoffman's was noted. X-ray of her cervical spine was negative. A noncontrast CT scan of her head and neck showed subarachnoid hemorrhage in the prepontine and cervicomedullary cisterns. Neurosurgical intervention involved removal of prior stainless steel and titanium cables, repair of cerebrospinal fluid leak, and nonsegmental C1–C3 instrumented fusion. She tolerated the surgery well and followed up without complication. Galvanic corrosion of the Brook's fusion secondary to current flow between dissimilar metal alloys resulted in catastrophic instrumentation failure and subarachnoid hemorrhage.

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The authors present the case of a patient that demonstrates resolution of delayed onset hypoglossal nerve palsy (HNP) subsequent to occipital condyle fracture following a motor vehicle accident. Decompression of the hypoglossal nerve and craniocervical fixation led to satisfactory long-term (>5 years) outcome. There is a scarcity of literature in recognizing HNPs following trauma and a lack of pathophysiological understanding to both a delayed presentation and to resolution versus persistence. This is the first report demonstrating long-term resolution of hypoglossal nerve injury following trauma to the craniocervical junction.

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Background: Spinal cord compression is a known cause of spinal cord injury. The purpose of this study is to measure pressure response during graded spinal cord compression. This information will be important in evaluating the amount of canal compromise that can be tolerated before risking neurological injury secondary to cord compression. To date, there is no published study that has evaluated pressure response to graded canal compromise in the thoracic and lumbar spine. Materials and Methods: A comparative biomechanical investigation using an in vitro burst fracture model of graded spinal canal compromise was performed. Four porcine spines, sectioned into four thoracics and four lumbar segments, were harvested from 30 kg pigs. Graded spinal canal compromise (0.75 mm/30 s) was achieved using a modified 12.7 mm dynamic hip screw. The real-time ventral epidural pressure was measured at each 0.75 mm of canal compromise. Results: A significant increase in spinal cord pressure was recorded during graded spinal cord compression (P < 0.0001), and there were no statistical differences between the increase in pressure measured in the thoracic and lumbar spinal segments (P = 0.83). The pressure to degree of canal compromise curve exhibited an initial rapid rise in pressure followed by incrementally smaller increases in pressure as canal compromise increased. Conclusions: Spinal cord pressure increased with any degree of canal compromise, the most important rise occurring with initial compression. Future studies will evaluate the usefulness of laminectomy in vivo to completely restore ventral epidural pressure in the thoracic and lumbar spine.

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Objective: To determine the entry for the dorsal pedicular screw in relation to the notch present at the junction of base of the lateral margin of superior articular process with superior border of transverse process in dorsal spine. The advantage of this technique is a constant and easily identifiable entry point which does not involve partial resection of the inferior facet, thus maintaining stability and maintaining the well defined transverse and sagittal screw angles and decreasing the incidence of medial and inferior pedicle violation. Materials and Methods: The study was carried out using ten cadavers (four male and six female). Spinal column was dissected completely from cadavers. Before the experiment, normal anatomy was confirmed on all cadavers excluding cases of spinal deformity. Dissection was done by the spine surgeons taking care to preserve all the bony landmarks near the entry point. This study was carried out bilaterally on pedicles between the first and twelfth thoracic (T) vertebrae. Results: The relation of the superior articular notch and transverse process to the thoracic spine pedicles was studied. It was found that superior third of the pedicle was related to the superior articular notch and the transverse process in the first five thoracic vertebrae. The relation of these structures to the pedicle of the sixth thoracic vertebra was somewhat equally distributed between the superior and middle third of the pedicle. From the 7^th to 12^th thoracic vertebrae the superior articular process and transverse process were related to the middle third of the pedicle in almost all the cases. It is important to note that the inferior 1/3^rd of the pedicle was not related to these landmarks at any of the levels. Conclusion: We conclude that the ideal pedicle entry point described here should be considered by surgeons during thoracic pedicle screw instrumentation. The notch at the base of the superior articular process will always remain constant and therefore an important anatomical landmark in guiding the screw toward the entry of the pedicle.

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