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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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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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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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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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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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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This study is a narrative review performed to summarize the current knowledge about the epidemiology, natural history and pathogenesis of cervical spondylotic myelopathy (CSM). A comprehensive search was undertaken to look at all available articles between January 1, 1956 to May 1, 2018, on PubMed and the Cochrane Collaboration Library. The natural history of CSM is variable. The main determinants of the clinical course of CSM are the extent of neurological impairment, age, cervical instability, abnormalities of cord conduction, canal diameter, congenitally stenotic spinal canal and the extent of involvement and tract disruption on diffusion tensor imaging (DTI) imaging. There is little data on the true incidence and prevalence of CSM across the globe and none from India. The pathoanatomic basis of CSM is cord compression, either dynamic or static. The biological events that are thought to play a significant role in the development of CSM are ischemia, derangement of the blood-spinal cord barrier, chronic neuronal inflammation, and apoptosis. Emerging knowledge about the molecular biology holds promise for potential intervention, both for prevention and for cure, of this common and debilitating condition.

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The trend of using smaller operative corridors is observed in various surgical specialties. The development of smart technologies with the overall aim of reducing surgical trauma has resulted in the concept of minimally invasive surgical techniques. Enhancements in microsurgery, tubes, endoscopy, and various percutaneous techniques, as well as improvement of implant materials, have proven to be milestones. The ease of performing surgery through tubes has recently evolved into percutaneous placement of spinal instrumentation, including intervertebral spacers, rods, and pedicle screws. The advancement of training of spine surgeons and the integration of image guidance with precise intraoperative imaging, computer-, and navigation-assisted treatment modalities constitute the era of reducing treatment morbidity in spinal surgery. This progress has led to the present era of preserving spinal function. In this report, we present a chronological perspective of the use of tubular retractors, the learning curve of tubular retractor in dealing complex cases and its wide applications, and expanding the horizon using tubular retractors.

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The aim of a minimally invasive spine surgery is to decrease the collateral damage to the surrounding soft tissue, while performing the same task as that of a conventional open spine surgery. With widening of applications of the tubular retractor system, complications are prone to occur while performing surgery using tubular retractors. The aim of this review was to assess the spectrum of complications that are associated with tubular access spine surgery. A systematic review in English language literature on PubMed for clinical outcomes or complications in minimally invasive spine surgery using tubular retractors was carried out. A total of 11 articles were filtered from 2010 to 2018. Articles that were excluded were those with focus on open spine surgery, surgeries without using tubular retractors, Destandau technique, and endoscopic spine surgeries. The studies were divided into discectomy, decompressions, and fusions. Overall complications that were observed in the review were incidental durotomy, neurodeficits, infection, instability, reherniation, implant malposition, pulmonary embolism, hematoma, and urinary retention. The manifold advantages that are offered by the tubular retractor system include decreased iatrogenic tissue damage, decreased probability of surgical wound infections, decreased chances of instability, and rapid ambulation of the patients, providing an impetus to the number of day care procedures being performed for spine conditions. The complication profile in this review is comparable to the open spine surgeries except the risk of higher radiation hazard in minimally invasive transforaminal lumbar interbody fusion surgery but more high-quality randomized studies are required.

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Minimally invasive spine surgery (MISS) is a set of techniques and procedures that aims to minimize local tissue damage while achieving the same goals of traditional open surgery. In this article, we will provide a brief synopsis of the current state of MISS including its advantages over open surgery and its limitations. We will also describe basic techniques and essential tools needed to perform MISS effectively. As such, we have identified six interrelated fundamental principles to achieve success in MISS. They are the six Ts: Target, Technology, Technique, Training/Teaching, Testing, and Talent.

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Study Design: This study is comprehensive literature review. Aims and Objectives: This study aimed to evaluate the effectiveness of transforaminal endoscopic technique for managing symptomatic lumbar disc herniations and foraminal/extraforaminal/lateral recess stenosis and to assess the comparative status vis-à-vis existing treatment methods. Materials and Methods: A comprehensive systematic literature search of PubMed, Embase, and Cochrane library databases was performed for articles, including case series, randomized controlled trials (RCTs), controlled clinical trials (CCTs), reviews, and metanalysis with the following search terms: transforaminal endoscopic disc surgery, full endoscopic transforaminal surgery, selective endoscopic discectomy, percutaneous endoscopic lumbar discectomy, transforaminal endoscopic surgery for lumbar stenosis, and endoscopic surgery for foraminal stenosis in various combinations. Results: Results were analyzed in terms of efficacy, safety, complications, recurrence rate, and learning curve in comparison with standard preexisting open procedures. Overall, the reviewed literature pointed toward the following observations: the endoscopic techniques had shorter operating times, less blood loss, less operative site pain, faster postoperative rehabilitation, shorter hospital stay, faster return to work than the microsurgical techniques, although some of the observations were limited in their scope. Endoscopic foraminal stenosis decompression could help avoid facetectomy and fusion procedures. Conclusion: Full endoscopic transforaminal surgeries for lumbar disc herniations and foraminal stenosis are safe and effective alternative to open surgery. Similar clinical outcomes as compared with conventional open surgeries can be reached with lesser incidence of complications and better opportunities for revision surgeries, if and when needed.

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Thoracolumbar spine fractures form a significant portion of any spine surgeon's practice. It is important to classify the injuries, which may vary from minor transverse process fractures to unstable fracture–dislocations in order to aid communication, plan management, anticipated outcome, and prognosis. It is imperative that such a classification must be simple, reliable, comprehensive, and reproducible as well as be validated by multiple observers. In spite of having several classification systems in practice, the ideal one remains elusive. This article reviews the history of classification, evolution of the classifications, the relative merits and demerits of each classification, and highlighting the lacunae which the subsequent line of thought intended to fill. Till date, the AOSpine thoracolumbar spine injury severity system is probably the most comprehensive and management-oriented classification after Magerl and Denis.

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The thoracolumbar (TL) region is a common site of injury after high-energy trauma which can result in significant disability. Despite advances, controversies continue to exist regarding the management of the injury and indications for surgery. This review is aimed to provide an insight into the existing literature on the nonoperative and operative management of TL trauma. Many classifications of spinal fractures have been proposed to guide management. However, there are no high-level studies comparing the outcomes of surgical and conservative management using these classification systems. These classifications have also not been validated by randomized clinical trials. In general, surgical stabilization is indicated for biomechanically unstable fractures such as flexion distraction injuries, unstable burst fractures, and fracture dislocations whereas simple compression fractures are treated conservatively. There is conflicting evidence in trials comparing conservative and surgical management in TL burst fractures with intact neurology. Progressive neurological deficits, significant kyphosis, and significant canal compromise are generally accepted indications for surgery without proper Level 1 or Level 2 evidence.

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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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Spondylolisthesis is the slippage of one vertebra over the adjacent vertebrae and a usual cause of low back pain and spinal imbalance. High-grade spondylolisthesis (HGS) is defined as Meyerding grades III, IV, and V or greater than 50% anterior translation of vertebrae resulting in spinal canal stenosis and neural compression. Management of HGS has been varied and fraught with opinions and its spectrum of management consists of in situ fusion, fusion and reduction combination techniques and vertebrectomy. Literature review was done on the various modalities of treatment and studies showed good clinical outcomes with the procedures. This review highlights the biomechanics of HGS and spondyloptosis, description of techniques of in situ fusion, reduction and fusion and, thereby, evaluate and give current recommendations in the surgical management of HGS. A systematic search of PubMed, Cochrane, and Google Scholar for papers relevant to HGS was performed. Twenty-one articles were included after title, abstract, and full-text review and grouped to analyze the effect of surgical approach, instrumentation, reduction, and decompression on patient radiographic and clinical outcomes. The level of evidence was low in ascertaining the superiority of one technique over the other. HGS is a complex disorder that can be addressed with varying procedures for it. No single technique has been proven to be better than the other. Each of the procedures described earlier has their own advantages and disadvantages, and these have to be weighed with the clinical scenario and the individual skill level of the treating surgeon before deciding on the appropriate procedure. The ideal recommendations for doing the above procedures were enumerated. However, no single procedure can be taken as the best fit for the given condition as the literature does not show one to be better than the other.

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