Context: Literature evaluating the efficacy and long-term clinico-radiological outcomes of anterior cervical discectomy and fusion (ACDF) and posterior fixation at C2–C3 for the treatment of unstable hangman's fractures is scanty. Aims: The aim of this study is to compare the efficacy, clinical-radiological outcomes, and complications of ACDF and posterior fixation techniques performed for unstable hangman's fractures. Settings and Design: The study design involves retrospective comparative study. Subjects and Methods: This study conducted from 2012 to 2018 included 21 patients with unstable hangman's fracture (Levine and Edwards Type II, IIa and III). All patients were divided into two groups based on the approach taken for fracture fixation (Group A-anterior approach and Group B-posterior approach). Peri-operative clinical, radiological parameters, postoperative complications, and outcomes were evaluated and compared in both the groups. Statistical Analysis Used: Chi-square test and Student's t-test were used. Results: The mean age was 39.8 ± 4.5 years in-group A and 41.3 ± 6.7 years in-group B. The male patients outnumbered the female patients and road traffic accident was the most common cause of unstable fractures. There were statistical significant differences in surgical time (P = 0.15), operative blood loss, pain-free status postsurgery, and hospital stay (P = 0.15) between two groups. No statistically significant differences noted in clinic-radiological outcomes in the form of visual analog scale and fusion rate at final follow-up between two groups at final follow-up. Conclusions: The unstable hangman's fractures can be effectively managed with both anterior and posterior approaches with comparable clinico-radiological outcome. A minimally invasive nature, earlier pain-free status, early mobilization with reduced hospitalization make the ACDF efficacious, particularly in cases with no medullary canal in C2 pedicles and traumatic C2–3 disc herniation with listhesis compressing the spinal cord.

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A 32-year-old male patient was operated for tethered cord associated with spinal lipoma. Further investigations showed the presence of basilar invagination, Chiari formation, and extensive syringomyelia. His neurological symptoms continued to worsen after the surgery, and over a 3-year period, he developed spastic quadriparesis and urinary retention and constipation. The patient was now treated by atlantoaxial fixation. Following the surgery, the patient improved in function in all four limbs and both the urinary and stool control. The presence of symptomatic Chiari formation in association with the tethered cord is a relatively rare clinical event. Surgical treatment of Chiari formation can result in a gratifying clinical recovery.

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Context: Multiple angles of the craniocervical junction (CCJ) are associated with pathological conditions and surgical outcomes, including the clivo-axial angle (CXA), clival slope (CS), and sagittal axis (XS). However, there are varying normative ranges reported and a paucity of data analyzing the effects of imaging modality, age, and gender on these angles. Setting and Design: A retrospective review of computed tomographic (CT) and magnetic resonance imaging (MRI) scans in fifty adults without CCJ pathology from 2014 to 2019. Methods: Age, gender, indication, and hours between scans were recorded. Two-blinded observers measured all angles. Analysis between angles from the same patient was performed using the Wilcoxon signed-rank test. Multivariable linear regression was used to test for associations between average angles and age or gender. Results: Average age and time between scans were 41.3 and 14.3 h, respectively, with 94% performed due to trauma. On CT, average CXA, CS, and XS were 162.1°, 118.4°, and 81.3°, respectively. On MRI, they were 159.8°, 117.2°, 85.3°, respectively. There were statistically significant differences between CXA and XS (P < 0.01) based on imaging modality. On CT, there was a significant increase in XS by 1.93°° and decrease in CS by 1.88°° and on MRI, there was a significant increase in CXA by 1.93°° and decrease in CS by 2.75°° corresponding with a 10-year advancement of age. Gender did not have an effect. Conclusion: There are significant differences in angular measurements of the CCJ between CT and MRI from the same patient, as well as changes in normative values based on age.

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Background: The aim of this article was to verify the utility of nasogastric (NG) tube in primary anterior cervical surgeries. Palpating and identifying the NG tube introduced during induction is one of the ways of preventing esophageal injuries during surgery. It may also be used as a conduit for postoperative feeding. However, the use of NG tube is not without complications. Esophageal perforation is one of them, with an incidence of 0.3%. Materials and Methods: A retrospective observational study was performed of patients who underwent a primary anterior cervical spine surgery from January 2007 to July 2017 by a single surgeon. The indications were degenerative, trauma, infection, and neoplasia. NG tube was avoided in all cases. The patients were followed for 6 months. Results: Our study included 356 patients (201 males and 155 females), with a mean age of 43.6 years (18–92 years) and a mean follow-up of 6 months. We had only one case of esophageal perforation (0.28%) attributed to a traumatic burst fracture. Conclusions: This study indicates that the use of a NG tube in primary anterior cervical spine surgery can be avoided. Comprehensive knowledge of anatomy and meticulous dissection may avoid the disastrous complication of esophageal rupture. This way the discomfort and complications associated with NG tube can be avoided.

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Objective: An alternative novel form of surgical treatment for patients having prolapsed or bulging intervertebral disc, with or without associated osteophyte, related lumbar radiculopathy by “only fixation” or internal orthosis and aiming for segmental arthrodesis is presented. Materials and Methods: During the period July 2014–October 2018, 44 patients presenting with symptoms of lumbar radiculopathy and diagnosed to have bulging, prolapsed or herniated lumbar intervertebral disc with or without associated osteophytes were treated by only spinal stabilization without resorting to any kind of bone, ligaments, osteophyte, or disc resection. Results: All patients had “immediate” postoperative relief from radicular symptoms. The Visual Analog Scale and the Oswestry Disability Index scores were used to assess the patient both before and after the surgical treatment. During the follow-up period that ranged from 10 to 60 months (average: 35 months), there was no recurrence of symptoms. Complete or significant resorption of the herniated disc was seen in 29 cases on follow-up radiological assessment. Conclusions: Spinal segmental fixation without any manipulation of the herniated disc or osteophyte and without any kind of bone or soft-tissue decompression is a safe, effective, and rational method of treatment of lumbar radiculopathy related to intervertebral disc herniation.

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We describe a comprehensive, multidisciplinary treatment approach for lumbar vertebral hemangiomas (VHs) with spinal stenosis and radiculopathy. A 59-year-old female presented with 1 year of pain predominantly in the lower back, with pain in the left buttock and proximal left anterior thigh as well and magnetic resonance imaging of the lumbar spine demonstrated lumbar scoliosis and an L3 vertebral lesion suspicious for hemangioma. A computed tomography guided biopsy was done, which supported the diagnosis. Definitive treatment entailed preoperative angiography and embolization, followed by L3 laminectomy, right L3 pedicle resection, partial L3 corpectomy, L3 vertebral cement augmentation, and L1 to L5 instrumented fusion. By 1-year postoperatively, the patient reported no radicular pain and only mild groin pain attributed to left hip degenerative joint disease. Radiographs 1-year postoperatively confirmed the stability of the instrumented posterior fusion and a magnetic resonance imaging with and without contrast confirmed no VH recurrence. A comprehensive and multidisciplinary approach for the treatment of VHs with neurological symptoms or signs is presented. This approach is recommended to maximize lesion removal, ensure biomechanical stability, and minimize recurrence.

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Objective: We evaluated surgical, clinical, and radiological outcomes of posterior occipitocervical fusion (OCF) using plate–rod–screw construct supplemented with allograft in cases of occipitocervical instability. Study Design: This was a retrospective analysis of prospective collected data. Methods: Data of 52 patients who underwent posterior OCF using plate–screw–rod construct supplemented with allograft at a single institute from 2009 to 2014 were analyzed. Demographics, clinical parameters (Visual Analog Score [VAS], ODI, and mJOA score), functional status (McCormick scale), radiological parameters – mean atlantodens interval, posterior occipitocervical angle, occipitocervical 2 angle, and surgical parameters (operative time, blood loss, hospital stay, and fusion) with complications were evaluated. Results: The mean age of the patients was 54.56 ± 16.21 years with male: female was 28:24. The mean operative time was 142.2 min (90–185 min) and mean blood loss was 250.8 ml. The mean duration of hospital stay was 6.7 days and mean follow-up period was 65.17 ± 5.39 months. There was significant improvement in clinical parameters (modified JOA score, VAS, and Oswestry Disability Index values) postoperatively. Forty patients showed recovery in neurological status at least in Grade 1 in McCormick scale with no neurological deterioration in any patient. Furthermore, radiological parameters at cervicomedullary junction got into acceptable range. Implant-related complications noted in 1 patient and 1 patient had vertebral artery injury. We had dural tear in 3 patients and infection in 2 patients. Fusion was achieved in 46 cases with mean time for fusion was 11.039 months. Conclusion: Patients with occipitocervical instability can successfully undergo posterior OCF using plate–screw–rod construct supplemented with allograft with high fusion rate, good clinical and functional outcomes, and low complication rate.

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Objectives: The aims of this study were to determine the incidence and main characteristics of associated intraspinal anomalies in patients with congenital scoliosis (CS) and to analyze the different factors that influence the curve progression. Design: This was a retrospective comparative study. Methods: This was a retrospective study of 128 patients with CS. Main Outcome Measurements: The incidence of the patients with intraspinal anomalies and their demographic, clinical, and radiological values was described. Results: Intraspinal anomalies were present in 13.3% of the patients. Among them, the most frequent anomaly was syringomyelia. The most frequent curve was the thoracic curve. The main deformity based on McMaster classification was formation failure. The curve progression during follow-up did not show significant differences between vertebral anomalies, syringomyelia, presence of thoracic anomalies, and gender (P > 0.05). Conclusions: Our study showed a lower percentage of spinal anomalies compared to other series. As other studies, the progression of the scoliosis curve in patients with spinal anomalies seems primarily to be determined by the type of vertebral malformation. Level of Evidence: Level II.

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Chondrosarcomas of the spine are rare tumors and represent <10% of all chondrosarcomas. In the spine, they may arise from vertebral bodies or posterior elements. They may occur in patients ranging from 13 to 78 years of age. Here, we present a case of a 25-year-old female who presented with complaints of lower backache, stiffness in both lower limbs, and tingling sensation in the right lower limb. On examination, both power and sensations were decreased below waist. Magnetic resonance imaging spine revealed an extradural lesion at D5 vertebral body level with severe cord compression. We received the mass in multiple fragments which were grayish-white and firm to hard in consistency. Microscopically, a chondroid tumor was seen with cells arranged in lobules in abundant myxoid matrix. The neoplastic chondrocytes were large in size and had bizarre hyperchromatic nuclei. Few binucleate and multinucleate forms were also seen along with occasional atypical mitoses. There was permeation and destruction of the host bone, and the tumor was seen invading the marrow spaces. Few foci showed high cellularity. No osteoid formation was seen by the tumor. The tumor was diagnosed as Chondrosarcoma – Grade II.

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Background: No study has evaluated the relationship between increasing BMI and severity/type of cervical spine injuries. Aims and Objectives: The objective of our study was to study the impact of body mass index (BMI) on severity of cervical spine fracture. Methods: We performed a retrospective cohort study of patients with traumatic cervical spine fractures at a level I trauma center over a 74-year period. CT scans of the cervical spine were blindly graded according to the AO Spine sub-axial cervical spine classification. The association between BMI and severity of cervical spine fracture was studied by multiple-variable logistic regression. Results: A total of 291 patients with an average BMI of 26.1 ± 5.4 kg/m² were studied. Higher BMI was not associated with more severe injury (OR 1.03, 95%, CI: 0.97–1.08). For rollover motor vehicle accident (MVA), the association was trending towards significance (OR 2.55, 95%, CI: 0.98-6.66, P = 0.06). Conclusions: Patients with higher BMI may be predisposed to more severe cervical spine fracture in rollover MVA, but not non-rollover MVA or falls.

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Study Design: This was a retrospective observational study. Aim: The aim of this study was to evaluate the effectiveness of applying the platelet-rich fibrin (PRF) with bone graft in accelerating the rate of lumbar interbody fusion. Settings and Design: This was a retrospective study measuring the outcome of posterior lumbar interbody fusion (PLIF) combined with PRF versus PLIF alone in the management of lytic spondylolisthesis. Subjects and Methods: Forty patients were treated with instrumented PLIF for low-grade lytic spondylolisthesis and divided into two equal groups: one with addition of PRF to the bone graft and the other without. The minimum follow-up was 2 years. Clinical outcome was measured by the Oswestry Disability Index (ODI) and Visual Analogue Pain Scale (VAS) at 3, 6, and 12 months postoperatively. Radiological outcome was measured by standing X-ray at 3, 6, 12, and 24 months and computed tomography at 6 and 12 months postoperatively. Results: ODI for the PRF group improved by 60% and 79% at 6 and 12 months, respectively, whereas for the non-PRF group, it improved by 55% and 70%. Radiological outcome showed fusion in 15 of 20 cases in the PRF group (75%) by the 6^th month and in 19 of 20 cases (95%) by 1 year and 100% at 2 years. In the control group, fusion was present in 12 of 20 cases (60%) by the 6^th month and in 13 of 20 cases in the PRF group (65%) by 1 year and 90% at 2 years (P < 0.05). Conclusions: These preliminary results show that PRF accelerates the rate of fusion in low-grade lytic spondylolisthesis in short-term follow-up.

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The fixation of type 2 odontoid fractures poses significant challenges in the elderly population due to coexistent osteoporosis and communition resulting in a high failure rate with conventional anterior screw fixation. Two elderly patients with unstable odontoid peg fractures and coexistent osteoporosis were treated with stentoplasty and anterior odontoid screw fixation. Additional anterior transarticular C1–2 screws were placed to address C1–2 instability. Both patients made an uneventful clinical recovery. One of the anterior C1–2 screws loosened due to the poor purchase in the osteoporotic bone in one patient. This did not affect the final outcome, and both the patients demonstrated maintained reduction and good alignment of odontoid peg after 2 years of follow-up. There was no intraoperative cement leak, pseudoarthrosis, or loss of reduction. Stentoplasty coupled with the anterior odontoid screw is a safe technique that can provide a biomechanically sound fixation of type 2 odontoid fractures in the presence of osteoporosis and significant communition.

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