Degenerative cervical myelopathy (DCM) is the leading cause of adult spinal cord dysfunction worldwide, and surgical decompression remains the mainstay treatment to arrest the progression of neurological deterioration. A number of clinical factors can predict and influence the outcomes of surgery, including patient demographics, baseline myelopathy severity, duration of symptoms, imaging characteristics, and types of surgical approach. Understanding the influence and relationship of these factors on surgical outcomes allows the treating clinician the ability to provide the patient with realistic expectations when discussing surgical intervention for DCM.

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Endoscopic spine surgery has started replacing conventional microdiscectomy in various centers across the globe. With development in the field of optics and instrumentation, the field of percutaneous endoscopic spine surgery has evolved immensely. With increasing experience, endoscopic spine surgeons have expanded the indications not only to lumbar paramedian disc herniations but also to central disc herniations, high-grade migrated disc herniations, sequestered herniations, thoracic and cervical disc herniations, and more recently, lumbar canal stenosis. With broadening indications, unexpected adverse events are bound to increase. Hence, it is essential for the endoscopic spine surgeons to be aware of the potential hazards and unexpected complications of the procedure so that appropriate care is taken to avoid adverse events as much as possible. In this article, we summarize all the complications of transforaminal endoscopic discectomy reported in the literature. We have classified the complications into intraoperative, immediate postoperative, and late postoperative complications. The senior author has also suggested the tips to avoid these complications and carry out the procedure as safely as possible. As percutaneous instrumentation, particularly, percutaneous pedicular screws, is also becoming common with the development of minimally invasive spine surgery, we have also summarized its complications and limitations. An insight into these complications will help the endoscopic surgeons to take special precautions when performing the procedure.

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Atlantoaxial chordomas being quite uncommon pose a significant therapeutic challenge to the surgeon due to their critical location and often late presentation. Recurrences are common after intralesional excision. Although en bloc excision is the preferred treatment, it may not be feasible due to anatomical constraints in this location. Hence, multimodality treatment in the form of surgery (maximal tumor excision) followed by targeted chemotherapy and radiotherapy is considered to be the next best treatment option. We present the case of a young male patient with C2 chordoma treated at our institution by multimodality approach, and follow-up for 21 months after surgery.

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Giant cell tumor (GCT) constitutes around 5% of all the skeletal tumors which usually occur between second and fourth decade. Cervical spine GCT is very rare, and only a few case reports have been reported. In view of complex anatomy, variable aggressiveness, and scanty literature, there is a lack of clear consensus in the evaluation and management of high cervical GCT. We present a 30-year-old male patient, a case of GCT involving C2 vertebral body with severe neck pain, C1–C2 instability, and neurological deficit (visual analog scale [VAS] - 10/10, Nurick Grade-IV, NDI - 97.7%) managed by staged procedures. Posterior occipitocervical stabilization followed by anterior corpectomy, intralesional excision of the mass through anterior mandibulotomy, and reconstruction with iliac crest bone graft was performed. Postoperatively, the patient received adjuvant Denosumab therapy for 6 months. Complete neurological improvement was seen by 3 months. The VAS and NDI scores were 1/10 and 11.1%, respectively, at 1-year follow-up. No radiological recurrence was seen on radiograph and magnetic resonance imaging at 2-year follow-up. C2 GCT managed by intralesional excision and global stabilization combined with Denosumab therapy provides good clinical improvement without recurrence on medium-term follow-up. We believe that extended transoral transmandibular approach provides an excellent wide field for excision of high cervical aggressive tumors.

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Spondyloptosis or complete anterior dislocation of the L5 vertebra over S1 is a rare clinical condition. In general, the surgical management of spondyloptosis includes either posterior long-segment in situ fusion (with total disregard for altered biomechanics) or restoration of lumbosacral kyphosis by reduction of spondyloptosis using multistaged procedures. Reduction is possible in spondyloptosis only after sacral dome osteotomy or L5 corpectomy with interbody fusion of L4 over S1 as described by Robert Gaines. We present the case of a 29 year old manual laborer who presented with complaints of severe low back pain and bilateral sciatica. He was diagnosed to have spondyloptosis of L5 over S1 with modified Newman's score of 10 + 10. The patient underwent three-staged modified Gaines procedure in the form of L5 corpectomy, reduction of L4 over S1 and interbody fusion between L4 and S1. The reduction was maintained at the end of 18 months and he was able to resume his job as a manual laborer.

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Background: Wide exposure to the anterior part of the upper cervical spine is difficult due to anatomical constraints. The Labio-Mandibulo-Glossotomy (LMG) approach is considered a difficult approach with high morbidity. The objective of this study is to describe the authors experience with the approach and it's outcomes in six cases and offer tips and pearls to the surgical access. Methods: This is a retrospective review of a small series of six cases that were operated for upper cervical lesions by the LMG approach. Two had mandible fractures that needed fixation and in the others osteotomy of the mandible was performed. The patients were followed up for minimum two years or death (in malignancy). We specifically looked for cosmetic or functional problems related to osteotomy, glossotomy, and, hospital and ICU stay duration. Surgical access is described in detail. Results: The hospital stay was similar to other major spine trauma or tumour surgeries at our center (median 14 days) and mean ICU stay 2.8 days. There were no long-term issues related to the access. Several tips and tricks are offered to minimize intra and post-operative problems. Conclusions: The LMG approach, though apparently formidable, is quite a safe and simple procedure with few residual complications.

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Background: Nontraumatic coccygodynia is poorly understood. Dynamic radiographs help to identify a radiological lesion. This study was performed to evaluate these parameters and define a line of management. Materials and Methods: A total of 46 cases with nontraumatic coccygodynia and 46 controls who met the inclusion criteria were evaluated using dynamic radiographs between June 2015 and May 2017. Radiological parameters, such as sagittal movement of coccyx, intercoccygeal angle (ICA), base angle (BA), and angle of pelvic rotation (APR), were calculated and compared between cases and controls to identify the radiological lesion in cases. On the basis of clinico-radiological findings, a treatment algorithm for these patients was proposed. Results: A total of 46 cases and 46 controls were studied. The mean age was 41.8 years in cases and 40.6 years in controls. Body mass index (BMI) ranged from 19 to 33. Twenty-nine cases had BMI >25. Average visual analog scale score at initial presentation (6.9), at 6 weeks (4.7), and final follow-up (3.9) was noted. ICA ranged from 1° to 21° (mean 11.12°). BA ranged from 0° to 83° (mean 41.41°). APR ranged from 2° to 33° (mean 14.74°). Twenty-seven patients had a good relief with local hydrocortisone injection and manipulation, whereas nine cases needed coccygectomy. Conclusion: Dynamic radiographs help in defining the radiological parameters and planning treatment. The sagittal movement of extension, posterior subluxation, higher BA, and low APR are the radiological findings seen in patients of nontraumatic coccygodynia. Majority of patients respond to conservative management; however, few may need surgical intervention.

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Background: Low back pain is a common ailment affecting individuals all around the globe. Animal models are required to study and further explore the treatment modalities. Lumbar spinal surgeries and disc repair is an important tissue engineering research domain. Dorsal and ventral approaches to access rat spine have been traditionally performed but suffer from a number of shortcomings such as higher morbidity, loss of neurology, high postoperative pain, and longer surgery. Methods: We used ten male Sprague Dawly rats, 3 months of age, and weighing an average of 280 gm. The surgeries were performed under dissociative anesthesia (ketamine: 50 mg/kg body weight). The spine was approached by left lateral incision extending from iliac crest and centering the level to be exposed. Skin and subcutaneous tissues were cut, external and internal oblique muscles were split in the direction of fibers, transverse abdominis was split vertically, and psoas was sacrificed. This made the spine and disc levels visible from the left lateral aspect. The muscles were approximated, and skin was closed with nonabsorbable mattress sutures. Postoperative analgesics (meloxicam 5 mg/kg body weight) and antibiotics (ceftriaxone 30 mg/kg body weight) were used. Results: This work has led to the development of a novel in vivo rat model using lateral retroperitoneal approach. This approach provides less pain and faster recovery in the postoperative stage. Moreover, it allows easy exposure and little surgery-related peri- or post-operative complications. Conclusion: Lateral retroperitoneal approach is a novel and safe method of spinal exposure in rats which may pave way for various live rat spine surgery models and experiments in future.

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Cervical spondylotic myelopathy (CSM) is one of the most common among causes of spinal cord dysfunction worldwide. In this article, we provide a broad narrative review of the options to treat CSM from an anterior approach to the cervical spine. Anterior procedures are effective and safe, especially for one or two level disease (although can be used up to 7-8 levels). This approach can be used in patients with lordotic, neutral, or kyphotic cervical spine alignment and provide excellent access for direct neural decompression. The most common adverse effects of anterior cervical operations are dysphagia and dysphonia, but fortunately, these are mild and transient in the majority of cases. Severe complications, such as vertebral arterial injury, spinal cord injury or airway compromise, are rare but must be taken into consideration, especially when additional risk factors are present (multilevel procedures, revision surgeries, older, and infirm patients). The primary anterior cervical procedures for treating CSM are anterior cervical discectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), oblique cervical corpectomy, and cervical disc arthroplasty. A combination (hybrid) of ACDF and ACCF is also utilized as an option to allow for wide decompression, deformity correction, and provide more surface area of exposed, and bleeding cancellous bone. More recently, the senior author (KDR) has utilized a hemi-corpectomy and fusion hybrid technique which will be described in this text. Advantages and disadvantages of each of these options are discussed in detail, as well as the need for posterior instrumentation supplementation in selected patients; such as those with concomitant cervical deformity, poor bone quality, or those at risk for pseudarthrosis following multilevel arthrodeses. The management of patients with cervical spinal cord compression without myelopathy or with mild symptoms is also discussed.

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Both anterior and posterior approaches for thoracolumbar burst fractures are reasonable surgical options. While an anterior approach was previously considered to be the best method to achieve adequate decompression and stabilization, posterior pedicle screw constructs have gained wide acceptance owing to their biomechanical strength and ability to achieve and maintain indirect decompression. We performed a literature review to analyze biomechanical factors and alignment, canal decompression with neurologic outcomes, and perioperative factors related to anterior and posterior approaches. A review of the literature reveals that anterior reconstruction does appear to provide improved resistance to kyphosis compared to posterior stabilization. However, long-segment fixation and the use of fracture-level pedicle screws have demonstrated improved ability to prevent the loss of intraoperative deformity correction. Neither anterior nor posterior approaches have definitively demonstrated superior canal decompression and neurologic outcomes. Perioperative data likely favor a posterior approach regarding the operative time and blood loss. In the end, the data do not obviously favor a single approach, and surgeons should take into consideration the goals of surgery and their comfort performing surgery through either an anterior or posterior approach.

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