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   Table of Contents - Current issue
Coverpage
July-December 2021
Volume 4 | Issue 2
Page Nos. 147-265

Online since Friday, July 16, 2021

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EDITORIAL  

Indexing of journal: Impact or relevance p. 147
Manish Chadha, Anil K Jain
DOI:10.4103/ISJ.ISJ_62_21  
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ORIGINAL ARTICLES Top

Association of developmental lumbar spinal canal stenosis and stunting p. 149
Jamlick Micheni Muthuuri
DOI:10.4103/isj.isj_20_20  
Objective: To determine a possible relationship between developmental lumbar spinal canal stenosis (DLSS) and stunting. Background: Stunting is due to failure of longitudinal length with shortened long bones. Stunted individuals have failure of growth of long bones implying a possibility of involvement of short and flat bones. The hypothesis in this study is that DLSS is part of a generalized skeletal dysplasia. Materials and Methods: This is a cross-sectional study (CSA) of 400 patients looking at the association of DLSS with stunting. The study compares the size of the spinal canal in individuals with stunting and those without stunting. Stunting was defined according to the WHO/UNICEF criteria of −2SD of the median height of the same population. The participants were divided into two types: those who were deemed stunted and those who were not. DLSS was similarly defined as −2SD of the relevant measured parameter. The study included skeletally mature patients between 18 and 60 years. All syndromic individuals, those with spine tumors and previous spine surgery, were excluded. Results: Four hundred individuals were sampled from a pool of 597 participants. One hundred and eight or 27% were stunted. The stunted individuals had statistically significantly shallow canal depths or anteroposterior diameters (11.2 ± 2.0 mm vs. 14.6 ± 2.6 mm, t(398) = −11.1, P < 0.001), and narrower canal widths (transverse diameters) (14.6 ± 3.3 mm vs. 18.8 ± 4.5 mm, t(398) = −8.1, P < 0.001) and smaller CSAs (134.0 ± 49.4 mm vs. 220.2 ± 82.0, t(398) = −9.4, P < 0.001) when compared to individuals with normal heights. Odds ratio was 10. Conclusions: Stunted individuals have smaller lumbar spinal canals when compared to nonstunted individuals. It can be concluded that developmental lumbar spinal canal stenosis is part of a generalized skeletal dysplasia.
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Clinical and surgical outcomes of enneking stage III aneurysmal bone cysts of the spine p. 155
Sanjeev Kumar Pandey, Edmond Jonathan Gandham, Krishna Prabhu
DOI:10.4103/isj.isj_29_20  
Objective: To study the clinicoradiological characteristics and surgical outcomes in patients with aggressive aneurysmal bone cyst (ABC) of spine. Materials and Methods: In this retrospective study, data was collected from patients with aggressive ABC of spine managed between January 2007 and December 2016. Clinical findings, radiological, and histological characteristics were studied. Follow-up was done either in the outpatient clinic or through a telephonic interview. Results: Seven patients (mean age, 15.6 years, range, 6–23 years) diagnosed with Enneking stage III aneurysmal bone cyst of the spine were included in the study. Local pain with restriction of movement was the most common presenting complaint (100%). Four patients presented with myelopathy. Thoracic spine was the most common site of involvement (43%). Of the patients, 71% had involvement of all three columns. All patients underwent surgical management; gross total resection in four patients (57%) and subtotal in three patients (43%). Of the seven patients, six required instrumented fusion. None of the patients developed any perioperative complication except for one patient who developed transient hip flexion worsening. Two patients received conformal radiation therapy (RT) postoperatively. The follow-up ranged from 40 months to 108 months (mean follow-up was 4.5 years). There were no recurrences. At last follow-up, all patients were alive and had significant improvement. Conclusions: ABC of the spine is found predominantly in the pediatric population. Intralesional en bloc resection with instrumented stabilization provides effective and fast relief from pain, early mobility, good surgical, and long-term outcomes. Conformal RT following a planned subtotal excision prevents the progression of the disease.
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In-vivo clinical validation of perpendicular to superior articular process as thoracic pedicle trajectory: A retrospective case series of 60 pediatric scoliosis p. 163
Aziz Ahmad, Chadi Ali, Oliver Stokes
DOI:10.4103/ISJ.ISJ_57_20  
Study Design: This is a retrospective case series study. Objective: Thoracic pedicle screw insertion can be technically challenging because of narrow pedicles. Placement of thoracic pedicle screws in pediatric scoliosis and adult deformity surgeries, due to three-dimensional rotation of vertebrae, is even more challenging because the usual landmarks are less evident, and the sagittal trajectory is more difficult to correctly orientate due to the vertebral rotation. We describe a variation of freehand technique to guide sagittal trajectory of thoracic pedicle screw. Materials and Methods: The inferior articular process of cranially adjacent vertebrae is osteotomized using a Capener Gouge to expose the superior articular process (SAP) of the thoracic vertebrae to be instrumented. An O’Connell dissector is then placed flush on the SAP. The main shaft of the dissector is at right angle to the base plate; pedicle finder is placed parallel to the shaft and follows the same sagittal trajectory as the shaft. Results: A total of 390 pedicle screws were identified in a consecutive series of 60 scoliosis patients inserted using this technique. Only one screw was revised for lateral breach. There was no intra-operative complication or neurological sequelae in any of our patients. Conclusion: Freehand pedicle screw placement remains a very common technique, used particularly by pediatric scoliosis surgeons. One of the drawbacks of previous reports of the freehand technique is that the sagittal trajectory is not clearly defined. Our technique fills this gap, and this series demonstrates that the technique produces a reliable and consistent result.
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Return to work after surgical treatment for cervical spondylotic myelopathy p. 170
Arun John Paul, Rohit Amritanand, Kenny S David, Venkatesh Krishnan
DOI:10.4103/ISJ.ISJ_18_21  
Purpose: The purpose of the study was to determine the rate and predictors of return to work (RTW) after surgery for cervical spondylotic myelopathy (CSM). Overview of Literature: RTW is arguably the most important outcome following spine surgery from a patient’s perspective. But, to the best of our knowledge, there have been no reports in the English literature describing RTW among patients undergoing surgery for moderate-to-severe CSM. Materials and Methods: We included adult patients with CSM with Nurick grade ≥ 3 who underwent surgery. They were divided into two groups: those who returned to work within 6 months (group 1) and those who did not (group 2) and their outcomes were analyzed. Results: A total of 34 patients were included in the study. Baseline characteristics were comparable between the groups. Only 18 (52.9%) patients returned to work by 6 months. The nature of work had a statistically significant association with RTW by 6 months (P = 0.005) with failure to RTW specifically seen in manual laborers. Age, body mass index, symptom duration, pre-operative absenteeism, smoking, diabetes mellitus, number of levels operated, surgical approach, and post-operative complications did not have significant association with RTW. Better functional outcomes were seen in patients who returned to work as calculated using Nurick grade (P = 0.000) and modified Japanese Orthopedic Association score (P = 0.001). All the patients who returned to work and 75% of the patients who did not RTW were satisfied with the outcome of surgery (P = 0.039). Conclusion: In spite of functional improvement, CSM was associated with poor RTW with manual laborers being the most vulnerable group. This study will help surgeons modulate patient expectations as well as provide a platform for counseling them.
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Paradoxical reactions in spinal tuberculosis: A case series p. 176
Gautam R Zaveri, Nitin P Jaiswal
DOI:10.4103/ISJ.ISJ_77_20  
Introduction: Clinical or radiological worsening of pre-existing tubercular lesions or appearance of new lesions in patients who have shown initial improvement following antitubercular chemotherapy (ATT) is termed as a paradoxical reaction (PR). The appearance of these lesions after spine surgery raises the possibilities of drug resistance, treatment failure, and surgical site infection. This retrospective case series aims to describe the presentation of PRs in spinal tuberculosis (TB), identify risk factors, and propose a treatment plan for PRs within the spine. Materials and Methods: Nine patients (2 males and 7 females; mean age 31.2 years), who underwent posterior transpedicular decompression and instrumented fusion for spinal TB, presented 4–7 weeks later with a soft, large swelling at the surgical site. In one patient, the swelling had burst through the skin resulting in a discharging wound. Two patients had screw pullout with local kyphosis. All patients had been started on ATT only after index surgery and had experienced improvement in constitutional symptoms, pain, and neurology. Magnetic resonance imaging showed large fluid collection at the surgical site without any new bony lesions. Results: All patients underwent surgical debridement with two patients requiring revision instrumentation. Examination of tissue and fluid revealed caseating granulomas and mycobacteria. Continuation of the same ATT led to uneventful healing. Conclusion: PRs in patients with spinal TB presented with a cold abscess at the surgical site between 4 and 7 weeks after starting ATT. Surgical drainage with debridement and continuation of ATT without changes to the regimen led to uneventful healing in all patients. Young age, female sex, thoracic lesions, and patients virgin to ATT prior to surgery were risk factors.
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Efficacy of posterior cervical laminectomy for multilevel cervical ossification of posterior longitudinal ligament p. 181
Sanjeev Asati, Vishal G Kundnani, Shrikant S Sagane, Sanyam Jain, Saijyot Raut
DOI:10.4103/ISJ.ISJ_84_20  
Study Design: This study design includes retrospective study of prospectively collected data. Introduction: The purpose is to determine the efficacy of posterior cervical laminectomy for multilevel cervical ossified posterior longitudinal ligament (OPLL). Laminectomy has been a preferred surgical treatment for multilevel cervical OPLL since a long time. Because of the risk associated with progressive kyphosis, the trend is shifted from laminectomy alone to laminoplasty and laminectomy with fusion. The data regarding the efficacy of laminectomy alone in terms of clinical and radiological parameters in multilevel cervical OPLL are scanty. Materials and Methods: We reviewed 82 patients with multilevel cervical OPLL who underwent posterior cervical laminectomy from January 2008 to December 2014. Patients with age ≥45 years, C2–C7 Cobb’s angle ≥ 10º, compression at ≥3 levels, and a minimum of 5 years of follow-up were included in the study. Demographics, pre and postoperative clinical parameters (visual analog scale (VAS), Nurick’s grading, and modified Japanese orthopedic association (mJOA) score), radiological parameters (C2–C7 Cobb’s angle, C2–C7 sagittal vertical axis (SVA)), perioperative parameters, complications, and recovery rate were evaluated. Results: The mean age of the patients was 56.4 (46–72) with M: F of 52:30. The mean blood loss and mean operative time were 93.9 mL and 96.6 min, respectively. There was significant improvement (P < 0.05) in VAS (3.6 ± 1.4 to 1.8 ± 0.8), Nurick’s grading (3.2 ± 0.9 to 1.9 ± 0.6), and mJOA score (8.4 ± 1.4 to 13.8 ± 1.9). C2–C7 Cobb’s angle increased from ‒14.4 ± 1.7º preoperatively to ‒8.2 ± 1.5º postoperatively and C2–C7 SVA from 18.4 ± 12.5 to 29.8 ± 15.8. Intraoperatively four patients had a dural tear. Three patients showed neurological deterioration postoperatively and three had unilateral C5 palsy which improved within a period of 6 months. 18.3% had an excellent outcome, 40.3% had good, 34.1% had fair, and 7.3% of the patients had a poor outcome. Conclusion: Multilevel cervical laminectomy is an effective surgical procedure in properly selected patients with multilevel OPLL. The outcomes are satisfactory in terms of radiological and clinical parameters. The risk of postlaminectomy kyphosis is not too high, and we found no correlation of kyphosis with clinical affection.
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Cervical and thoracolumbar radiological sagittal parameters in asymptomatic Indian population p. 188
Yogesh Kishorkant Pithwa, Sanjeev Sankar Chandran, Vishnu Vardhan Rudravaram
DOI:10.4103/ISJ.ISJ_92_20  
Introduction: There is a dearth of normative data for radiological sagittal parameters of asymptomatic Indians. The present study aimed to address this lacuna. Materials and Methods: Sagittal radiological parameters were studied in asymptomatic volunteers: seven lumbopelvic, i.e., pelvic index (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), cranial LL (crLL), caudal LL (caLL), PI-LL; three thoracic and thoracolumbar, i.e., thoracolumbar alignment (TL), thoracic kyphosis (TK), T1 slope (TS0); five cervical, i.e., cervical sagittal vertical axis (cSVA), cervical lordosis (CL), TS-CL, C2 slope (CS), C2 T1 pelvic angle (CTPA); and lastly, five global parameters: SVA, T9 spinopelvic inclination (T9SPI), T1 spinopelvic inclination (T1SPI), T1 pelvic angle (TPA), C2 pelvic angle (CPA) were studied. Results: Volunteers (n = 125) aged 41.49±12.93 years were included. Mean PI, PT, SS, LL, crLL, caLL, PI-LL, TL, TK, TS, cSVA, CL, TS-CL, CS, CTPA, SVA, T9SPI, T1SPI, TPA, and CPA were 47.23±8.04°, 13.4±6.61°, 33.68±4.59°, −56.19±7.83°, −22.71±9.82°, −45.02±10.07°, −7.83±9.4°, 9.99±11.17°, 22±7.33°, 4.88±7.64°, 34.77±12.2 mm, −6.36±10.99°, −0.5±10.02°, 2.56±9.53°, 3.54±1.04°, −36.49±23.4 mm, −10.89±2.75°, −7.88±2.17°, 5.52±6.82°, and 10.72±6.69°, respectively. As per Roussouly’s classification, the distribution for types I, II, III, and IV was 32 (25.6%), 41 (32.8%), 45 (36%), and 7 (5.6%), respectively. LL correlated significantly with PI, SS, and TK. TS had significant correlation with CL and TS-CL. cSVA significantly correlated with CL. PI-LL significantly correlated with TS-CL. CS significantly correlated with cSVA and TS-CL. TS-CL significantly correlated with cSVA. TPA correlated significantly with PT, SVA, PI, and PI-LL. CTPA correlated significantly with CL, cSVA, TK, and TS-CL. Males had significantly different SVA (−35.3 mm), TK (22.4°), TS (6.2°), TPA (6.35°), cSVA (37.1 mm), and CTPA (3.95°) when compared with females (−58.4 mm, 17.2°, −0.15°, 0.3°, 24.95 mm, and 2.85°, respectively) (P = 0.008, 0.003, 0.002, 0.003, 0.002, and 0.0005, respectively). Conclusion: Normative data for sagittal profile in Indian volunteers, enunciated in this study, can be used to guide decisions in surgery.
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Early experiences in the management of traumatic spinal injuries at a level 1 trauma center in India during the COVID-19 pandemic p. 198
Kamran M Farooque, Tushar R Nayak, Burhan S Siamwala, Aayush Aryal
DOI:10.4103/ISJ.ISJ_9_21  
Context: Overwhelmed by COVID-19 patients requiring urgent medical attention and intensive care beds, majority of our medical resources are allocated for the management of the current pandemic. Other urgent cases requiring surgical attention also need to be optimally addressed. Aims: The aim of this article is to report the early results and organizational protocol in the management of traumatic spinal fractures at a level-1 trauma center during the current pandemic. Settings and Design: This is a retrospective study of patients with vertebral fractures operated by a single surgeon between April and October 2020. All patients were tested for the SARS-CoV-2 virus, and the tests were repeated every 72 h. We modified our institutional protocol to aid the early management of emergency traumatic spine cases during this pandemic. Descriptive analysis of data collected from hospital records was carried out using Statistical Package for Social Sciences, Virginia, USA, Version 20. Results: A total of 44 patients were operated. Burst fracture was the most common fracture with a fall from height being the most common mechanism of injury. Two patients tested positive for the novel corona virus. There were no complications and none of the healthcare staff involved in the patient care or patients reported symptoms of COVID-19 during a 30-day follow‐up period. Conclusion: Surgical treatment of patients with vertebral fractures, with strict adherence to personal protective measures and local guidelines, did not increase the risk of contracting SARS‐CoV2 to either healthcare workers or patients during the lockdown period.
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CASE REPORTS Top

Brown tumor causing thoracic compressive myelopathy: A case report and review of literature p. 203
Manoj Kumar Ramachandraiah, Thomas Joseph Kishen
DOI:10.4103/isj.isj_48_20  
Brown tumors are nonneoplastic bony lesions resulting from primary, secondary or tertiary hyperparathyroidism. Primary hyperparathyroidism is caused by parathyroid adenomas or parathyroid hyperplasia while chronic renal failure is a common cause of secondary hyperparathyroidism. Elevated parathyroid hormone levels cause increased osteoclastic activity, bone resorption and reactive fibroblastic proliferation leading to the formation of Brown tumor. Although Brown tumors are more commonly seen in the maxilla and mandible, it can occur in the long, flat bones or any bone. It is less commonly seen in the spine. In this report, we discuss the presentation, management, difficulties with histopathological diagnosis, and follow-up of a Brown tumor in a 55-year-old gentleman undergoing renal dialysis who presented with thoracic compressive myelopathy. Our patient underwent a T4 laminectomy, tumor debulking, and T2–T6 instrumented posterior fusion. Based on histopathological examination of the tissue specimen and raised serum parathyroid hormone levels, we arrived at a diagnosis of Brown tumor. Our review of the literature revealed 62 cases of vertebral Brown tumor resulting in neurologic symptoms. The lesion was more common in females (58%), those aged between 40 and 49 years (26%), and in the thoracic spine (51.6%). Early surgical intervention and management of the underlying cause of hyperparathyroidism lead to sustained symptomatic improvement. Brown tumor should be considered in the differential diagnosis of expansile vertebral lesions in the presence of hyperparathyroidism or chronic kidney disease. Treatment of the underlying hyperparathyroidism and decompression of the neural structures with or without stabilization is recommended.
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Fractured cervical facet osteophyte causing acute traumatic myelopathy: Case report p. 214
Bharat K Patel, Mihir R Bapat, Arpit Upadhyay
DOI:10.4103/isj.isj_44_20  
A 52-year-old gentleman presented with acute onset quadriparesis of ten days duration after a trivial fall. Both extremities had grade-2 power. Bilateral hand grip was poor with interossei weakness. The sensation was reduced below C6 with positive Lhermitte’s sign. Deep tendon reflexes were exaggerated except absent bilateral biceps jerk. The bowel and bladder had urgency and frequency. Neck movements were terminally painful. CT and MRI showed a floating bony spicule adjacent to left C5-6 facet joint encroaching the spinal canal causing cord compression. A focal left C5 hemi-laminectomy and foraminotomy were performed. A onecm floating bony spicule adjoining to left C5-6 facet joint was excised. Biopsy ruled out osteochondroma and synovial cyst. The power improved to grade-4 in both extremities with moderate grip and he became dependent ambulatory within three months of surgery. At the end of two years, he recovered almost completely with residual mild left-hand grip weakness.
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Eosinophilic granuloma of the thoracolumbar junction in the adult spine: A case report and review of literature p. 218
Saumyajit Basu, Rohan Bharat Gala, Aditya Banta, Anil Maganbhai Solanki
DOI:10.4103/isj.isj_17_20  
Langerhans cell histiocytosis (LCH) is a common disease in the pediatric population with a peak incidence between 5 and 10 years of age. Eosinophilic granuloma (EG) accounts for less than 1% of all primary bone tumors primarily affecting the skull, pelvis, ribs and metaphyses of long bones and is a benign localized form of LCH. It is extremely rare in adults, more so in the spine, with a predilection for the thoracic spine than the lumbar and cervical region. A 35-year-old gentleman presented with transitional mid back pain for two months radiating to the right flank which worsened at night. There was no history of fever or trauma. Physical examination revealed right dorsolumbar tenderness without any neurological deficit. Serological parameters were normal and C-reactive protein (CRP) was negative. X-ray showed radiolucency in the right D12 pedicle with CT scan showing a lytic lesion in D12 body extending into the right pedicle. Magnetic resonance imaging (MRI) showed a hypointense lesion on T1 and hyperintense lesion on T2. Transpedicular biopsy was done and histopathology revealed Langerhans cell with abundant basophilic cytoplasm and a centrally placed nucleus with a groove. On further confirmation with IHC, a diagnosis of LCH was made. He then received radiotherapy for 12 days. PET CT done one year after diagnosis revealed near-total metabolic response of the tumor after comparing the PET CT done prior to diagnosis. The patient has reported complete relief since 2 years with recent radiological evidence of no recurrence. A precise diagnosis of LCH largely relies on biopsy and histopathology and once definitive diagnosis is established, EG can be managed by chemotherapy and/or radiotherapy in patients with no neurological deficit. Despite its rarity, EG should be considered as an important differential for solitary osteolytic lesions at the thoracolumbar junction in the adult spine.
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Endovascular stents––boon or bane? A case report of spondylodiscitis following aorto-illiac stent insertion p. 223
Sushma Krishna, Sumanth Kaiwar, Amrithlal A Mascarenhas, Adarsh Raghurama
DOI:10.4103/isj.isj_33_20  
Spondylodiscitis after aorto-illiac stent insertion for the management of peripheral vascular disease is a rare but serious complication. We report the first case that we encountered as it provided insight into the device-related infections and the treatment dilemma that we went through. Within a week following insertion, a 43-year-old patient developed symptoms of infection. Imaging, laboratory cultures, and inflammatory markers were sought. The patient was treated with antibiotics for over six months to achieve a complete cure. Acute stent-graft infections require prompt and aggressive management. Centers specialized in carrying out endovascular stent insertions should monitor this device-related infection as a health-care-associated infection. The case may be looked on as a learning experience for the spine surgeons, vascular surgeons, microbiologists, and the infection control team of the hospital.
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Midline solitary osteochondroma of C2 vertebra with myelopathy in a child: A case report with review of literature p. 229
Saumyajit Basu, Naveen Agarwal, Somashekar Doddabhadre Gowda, Aditya Bhanta
DOI:10.4103/isj.isj_53_20  
Spinal osteochondromas with neurological deficits are rare. Only 0.5% to 1% of spinal osteochondromas present with neurological dysfunction. We hereby present a case of osteochondroma of the C2 lamina with neurological deficit and unique presentation.A 10-year-old female presented with a history of severe weakness of all four limbs after a fall. Weakness had spontaneously improved over initial three days and she presented to us with mild weakness of the right upper limb about two weeks after the fall. On examination, neck movements were full and painless with spastic quadriparesis and a motor power of grade 4/5 in all four limbs with extensor plantars.On radiology, CT scan of the cervical spine showed an osseous outgrowth from the C2 lamina in the midline projecting into the spinal canal, directed superiorly toward the dens. An MRI showed spinal-cord compression with cord deformation and signal changes.She underwent en bloc excision of the tumor mass, which was severely impinging on the spinal cord. Histopathology confirmed a diagnosis of osteochondroma. At four-year follow-up, there was complete recovery with no signs of recurrence.Spinal osteochondroma is a rare but potential cause of spinal-cord compression in a child with varied presentation.
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Direct Anterior Screw Fixation for a Pediatric Odontoid Fracture with Associated Skull Fracture: A Case Report p. 234
Dilip Dutta, Arjun Shankar Dasgupta
DOI:10.4103/ISJ.ISJ_62_20  
The upper cervical spine remains the most susceptible region for spinal trauma in children, with odontoid fractures being the most common ones in this age group. Concomitant traumatic brain injuries or skull fractures can pose therapeutic challenges in such cases. We report a case of an 11-year-old boy who presented in the semiconscious state with a deep scalp laceration in the left frontoparietal region. A computed tomography (CT) scan revealed a depressed skull fracture requiring an emergency left frontoparietal decompressive craniectomy and an associated fracture of the odontoid process at the base with anterior displacement. Odontoid fractures usually heal well after immobilization, and the use of instrumented fusion is still debated in view of skeletal immaturity. The usual management of Halo vest could not be instituted in his case owing to the skull fracture, and a single cannulated screw fixation was done under fluoroscopic guidance. Direct operative fusion of the odontoid process has been described in younger children with apophyseal fractures, but the evidence of such procedures is rare in elder children with a fused odontoid process. This case report, thus, confirms the anterior odontoid screw fixation as an effective mode of treatment in children of the 7- to 12-year age group.
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An atypical presentation of metastatic Ewing sarcoma to the spine p. 240
Wei Jie Tan, Hwei Yee Lee, Wayne Ming Quan Yap, Colum Patrick Nolan, Jacob Yoong-Leong Oh
DOI:10.4103/ISJ.ISJ_2_21  
Ewing sarcoma (ES) is a rare malignancy of the young, primarily arising from the bones. Uncommonly, it can arise extraskeletally and, among the rarest cases, from the spinal extradural tissues. The patient is a previously well 26-year-old male who presented with radicular low back pain. Magnetic resonance imaging revealed an L5-S1 spinal canal mass with possible metastases to the vertebral and pelvic bones. The initial diagnosis was challenging, with differentials of an intradural tumor, infection, solid organ tumor metastasis, and lymphoma. The patient subsequently underwent decompression and debulking of his spinal tumor, which was found to be extradural. Histological and pathological studies supported the diagnosis of metastatic ES. This case report highlights an atypical presentation of ES. Although exceedingly rare, young patients can still present with metastatic spinal disease. Clinicians should always consider more sinister diagnoses and investigate further, especially if red flag symptoms are present.
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Symptomatic epidural cement leakage after percutaneous vertebroplasty: A case report of successful management by surgical excision with literature review p. 243
Hitesh N Modi, Utsab Shrestha, Nagesh Bhandari, Udit D Patel
DOI:10.4103/ISJ.ISJ_78_20  
The purpose of this case report was to present successfully treated case of symptomatic cement leakage after percutaneous vertebroplasty procedure (PVP) with technical tips to avoid such injury and to present literature review. PVP is a simple solution to treat osteoporotic vertebral compression fracture (OVCF) if it is performed with right indications. Cement leak into spinal canal during PVP can lead to catastrophic accident and cause severe neurological deficit that requires an urgent exploration and removal of cement. To avoid medial pedicle breach, there should be a definitive guideline during PVP. An 81-year-old lady had PVP after injury for OVCF at D12. She developed severe neurological deficit immediately after the procedure; however, she was managed conservatively. On presentation to us, urgent investigations with CT scan revealed cement leak into spinal canal from medial pedicle breach extending from D10-12 level with severe cord compression. Her surgery was performed with wide laminectomy at D10-D12 levels with transpedicular stabilization D9-L2 along with neuromonitoring. Cement mass was isolated from the dura and removed achieving decompression of the cord. Postoperatively, patient showed significant neurological improvement and walked independently with the help of stick in three months. In conclusion, although PVP is a convenient solution for painful OVCF, care must be taken while considering this option such as timing, insertion of needle, viscosity of cement, and C-arm monitoring. If neurological deficit occurs, urgent CT scan for the diagnosis and exploration with removal of cement with or without stabilization is mandatory.
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Scoliosis associated with HGPPS syndrome: What do we know? p. 250
Venugopal Menon, Naveen S Tahasildar, Thirunavukkarasu Sivaraman, Bhaskar M Venkateshappa
DOI:10.4103/ISJ.ISJ_17_21  
Horizontal gaze palsy with progressive scoliosis (HGPPS) syndrome is a rare genetic abnormality causing cranial dysinnervation manifesting as absence of conjugate lateral eye movements, nystagmus, and scoliosis. While the genetics, imaging abnormalities, and ocular manifestations have been well described in literature, the spinal deformity has not been addressed adequately. An 11-year-old girl presented with progressive thoracic scoliosis who on evaluation was detected to have all the features of HGPPS syndrome. The patient underwent posterior correction of scoliosis uneventfully. A thorough literature search was performed to understand the descriptors of spinal deformity and its surgery in HGPPS syndrome. The spinal deformity in HGPPS resembles adolescent idiopathic scoliosis. Rapidly progressive right thoracic scoliosis was the usual pattern. Surgical and anesthetic considerations during surgery are similar to idiopathic scoliosis. These children tolerate surgery and anesthesia well. Neuromonitoring changes during surgery need to be interpreted correctly in the background of uncrossed sensory and motor tracts.
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A rare case of primary high cervical intramedullary cysticercosis: Uncomplicated surgery but a preoperative diagnostic predicament p. 255
Sunit Mediratta
DOI:10.4103/ISJ.ISJ_75_20  
Neurocysticercosis (NCC) is the most common parasitic infection involving the central nervous system. The involvement of spine by this disease is extremely uncommon. When the spine does get affected, it generally develops as a synchronous infection with an existing cerebral cysticercosis and usually involves the intradural extramedullary space. Primary intramedullary involvement is rare. A case of primary high cervical intramedullary cysticercosis with non-progressive symptoms is described. In this case, a pre-operative diagnosis could not be ascertained. The patient underwent total surgical resection of the lesion and made excellent recovery. Post-operative evaluation did not reveal disease at other sites. This case highlights the safety and ease of surgical resection in intramedullary NCC.
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Single-stage decompression of C1–D9 anterior epidural abscess by a gas-producing enteric pathogen p. 260
Vetri Nallathambi, M Atharsh Chander
DOI:10.4103/ISJ.ISJ_85_20  
Multilevel pyogenic spinal epidural abscess is a rare presentation, and there are only a few documented cases. This is a case report of a cervicothoracic epidural abscess (C1–D9) presenting with sepsis and neurological impairment due to a gas-producing enteric organism that was managed by surgical decompression. The abscess was drained in a single-stage multilevel procedure. The patient recovered gradually in the postoperative period clinically and neurologically and is on follow-up for two years. The peculiarity of this case is the absence of any vertebral or disc involvement in the presence of such an extensive anterior epidural abscess.
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ERRATUM Top

Erratum: Surgical management of high-grade spondylolisthesis: Current recommendations p. 265

DOI:10.4103/2589-5079.321592  
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