Ten years' experience in the management of spinal intramedullary tumors in a single institution.

We retrospectively reviewed the outcomes of 195 patients with intramedullary tumors who underwent surgery between January 2001 and December 2010 at a single institution. The symptomatology, neurological and neuroradiological findings, operative details, perioperative and postoperative complications, histopathological data and follow-up examinations of the 137 (70.2%) males and 58 (29.7%) females were studied and analyzed. Epidermoid was the most common intramedullary tumour in children (23%), whereas in adults, ependymomas were more common (46%). Ependymomas were more amenable to resection (total excision in 57.7% and near-total excision in 39.4%) as compared to astrocytomas (total excision in 29%; near total excision in 60.5%). At the final clinical follow-up, 24 patients (16.4%) had improved in McCormick grade, 112 patients (76.7%) remained unchanged and 11 patients (7.5%) had worsened. Complete removal of the lesion is the primary goal of surgery. We conclude that the strongest predictor of functional outcome was the preoperative neurological condition, beyond the histological differentiation of the intramedullary tumor.

Primary tethered cord syndrome--clinical and urological manifestations, diagnosis and management: a prospective study.

Primary tethered cord syndrome refers to a group of neural tube defects that are not externally obvious, and, if detected at an early age, surgical intervention may prevent the significant irreversible neurological deficits. This study was performed to evaluate the presenting clinical features of patients with primary tethered cord syndrome and the indications of surgery in such patients as well as the clinical and urological outcome. In all cases, the indication for surgery was the presence of a tethered cord on magnetic resonance imaging, the criteria for tethering being a low-lying conus (below L1-L2) and a thickened filum (>2 mm). Urodynamic studies were performed before detethering. Microsurgical detethering of low-lying cord was then performed, and the patients were then followed clinically and urologically for 6 months. Pain responded the most to detethering while limb weakness and urological symptoms responded the least. Clinical improvement in urological symptoms correlated with improvement in urodynamic parameters. A urodynamic study identified improvement in a larger number of patients and also deterioration in a few patients which was not visible clinically; this may point to its high sensitivity and usefulness in preceding clinical manifestations in a future follow-up.

Pediatric bony craniovertebral junction abnormalities: Institutional experience of 10 years.

OBJECTIVE: To study the clinical features and treatment outcome of pediatric patients with bony craniovertebral abnormalities. MATERIALS AND METHODS: The authors studied 189 consecutive cases of pediatric bony craniovertebral junction abnormalities operated between 2001 and March, 2010. RESULTS: The pathologies were developmental (n = 162), traumatic (n = 18) and tuberculous (n = 9). Surgical procedures included transoral decompression (n = 118), occipitocervical fusion (OCF, n = 139), C 1 -C 2 fusion (n = 45), and posterior fossa decompression (n = 5). Methods for OCF included contoured stainless steel rods (n = 86), titanium lateral mass screws and plates (n = 47) and steel wires (n = 6). Constructs of all patients of posterior fixation with contoured rods and wires or lateral mass screw and rod who could be followed up were either stable/fused or were fused and stable. No implant failure was noticed among these two surgical procedures. However, 6 patients with C 1-C 2 fusion had broken wires on follow-up requiring repeat posterior fixation. Good neurological outcome was observed even in poor-grade patients. No significant effect on the curvature or growth of the spine was observed at follow-up. CONCLUSIONS: Pediatric craniovertebral junction anomalies can be managed successfully with good outcomes using a low cost contoured rod and wires.

Use of O-arm for spinal surgery in academic institution in India: experience from JPN apex trauma centre.

There is a relatively high incidence of screw misplacement during spinal instrumentation due to distortion of normal anatomy following spinal trauma. The O-arm® is the next-generation spinal navigation tool that provides intraoperative 3-D imaging for complex spine surgeries. In this prospective study over 1-month period, 25 patients (mean age 29.16 years (range 7-58 years), 22 (88%) males) with spinal injury who underwent spinal instrumentation under O-arm® guidance were included. Fall from height (64%) was the most common etiology seen in 16 patients. The majority (68%) had dorsolumbar fractures. Spinal canal compromise was seen in 21 patients (84%). Ten patients (40%) had American Spinal Injury Association (ASIA) grade A injuries, two patients (8%) had grade B, five patients (20%) had grade C, four patients (16%) each had grade D, and grade E injuries. A total of 140 screws were inserted under O-arm guidance. Of these, 113 (81%) were dorsolumbar pedicle screws, 2 were odontoid screws, 12 were anterior cervical screws, and 12 screws (48%) were lateral mass screws. Mean duration of surgery was 4.5 h with a mean blood loss of 674 mL. The mean postoperative stay was 6.3 days. None of the patients had screw malplacement ort canal breach. No patient deteriorated in ASIA grade postoperatively. The system was rated as excellent for ease of use by all faculty using the system. Accurate screw placement provides better patient safety and reduces the in hospital stay thereby leading early patient mobilization and may reduce the cost incurred in patient management.

Extraventricular neurocytomas: a morphological and histogenetic consideration. A study of six cases.

AIMS: Various molecular markers have been used for diagnosis, management and prognostication of gliomas. Neurocytomas are close morphological mimics of oligodendrogliomas. While combined 1p/19q deletion has been used as a molecular signature of oligodendroglial tumours, it has also been variably reported to occur in neurocytomas, especially those in extraventricular locations (EVN). In recent studies, presence of IDH1 mutation has shown immense prognostic significance in glial tumours including oligodendrogliomas, but its role in neurocytoma pathogenesis remains unexplored. In this study, EVN cases were analysed for histomorphological features, IDH1 mutation using an antibody for specifically detecting mutant IDH1 protein, and 1p/19q deletion by fluorescence in situ hybridisation (FISH) assay. RESULTS: Over a period of 10 years (2000-2009), 60 cases of neurocytoma were diagnosed, of which six were EVN. These six cases were assessed for histomorphology, IDH1 mutation and 1p/19q deletion. Five cases showed atypical histological features. While none showed mIDH1, four of the five atypical cases harboured 1p/19q deletion either in isolation or in combination. The only case which was well-differentiated (typical) did not show 1p/19q loss. CONCLUSIONS: EVNs are more commonly associated with aggressive histological features. IDH1 mutations, although frequent in oligodendrogliomas, are not seen in EVN. However, similar to oligodendrogliomas, 1p/19q deletion is found in these tumours. Thus, a potential histogenetic link between oligodendrogliomas and EVN remains debatable. This molecular alteration may also have prognostic connotations, being associated with atypical morphological features. Due to the rarity of these tumours, multicentric pooling of larger studies is needed to have an insight into the impact of these molecular aberrations on their biological behaviour.

An unusual case of spinal dysraphism with four splits including three posterior spurs.

BACKGROUND: Composite-type split spinal cord malformation (SCM) is very rare and results from 2 separate foci of ectoendodermal adhesions and endomesenchymal tracts leading to the development of SCM with an intervening normal cord in the same patient. Posterior spurs are even rarer. We report a unique case of composite SCM, where the patient had 3 posterior bony spurs and 1 fibrous spur at different levels. To our knowledge, this is the first reported case of a patient having composite-type SCM with posterior spurs at 3 different levels. CLINICAL PRESENTATION: A 3-year-old girl presented to us with progressively worsening scoliosis. Neurological examination was unremarkable except for mild weakness in the left lower limb. Three-dimensional CT imaging demonstrated posterior bony spurs located at T(6), T(12) and L(3) levels. The patient underwent T(11)-L(5) laminoplasty and T(5)/T(6) laminectomy and excision of SCM type 1 with division of the thickened filum terminale. All the bony spurs arose from the inner surface of the lamina, where the base of the spur was located. CONCLUSIONS: The unique point of this case report is the rarity of such a presentation. Careful planning and knowledge of the occurrence of such conditions can make surgery in these children safe, and all the levels can be treated in a single setting.

Long-segment type 1 split cord malformation with two-level split cord malformation and a single dural sac at the lower split.

OBJECTIVE AND IMPORTANCE: Two-level bony spurs are rare and also a very long segment of bony spur is very rare. Bony spur with a single dural covering is not reported in the literature. Here, we report a case of prophylactic surgery performed on a patient with a bony spur with a single dural covering who showed a good postoperative outcome. This case highlights the importance of prophylactic surgery in such patients to avoid cord injuries. CLINICAL PRESENTATION: Since birth a 1-year-old child had had a tuft of hair at the dorsal (D6 and D7) region. The patient was examined and found to have scoliosis with convexity towards the right. There was no neurological deficit. MRI and CT spine scans showed 2-level type 1 split cord malformation (SCM) and there was a low-lying conus at the L(3-4) level. INTERVENTION: The patient was operated on at the age of 1 year and 2 separate bony septae were observed. The upper one extended from D5 to D9 and the lower one was at the D11 level. The bony spurs were excised. The filum was sectioned at the L(4-5) level by a separate incision. The patient had a good postoperative recovery. CONCLUSION: With meticulous planning and careful surgery, prophylactic surgery can have a very good outcome in long-segment and two-level type 1 SCM.

Novel treatment of traumatic CSF rhinnorhea using titanium mesh and onlay graft.

Post-traumatic rhinnorhea due to large frontobasal fractures remains a difficult entity to treat. The authors report the case of a 9-year-old boy who had persistent CSF rhinnorhea due to extensive frontobasal fractures and who was managed with transcranial extradural surgery with titanium mesh placement and only pedicled pericranial flap.