Prospective Nonrandomized Analytical Comparative Study of Clinicoradiological Relationship and Quality of Life between Lumbar Interbody Fusion and Posterolateral Lumbar Fusion.

STUDY DESIGN: This prospective, nonrandomized, analytic comparative study analyzed the outcome of 100 patients who underwent spinal fusion surgeries (Posterolateral fusion (PLF) and posterior lumbar interbody fusion [PLIF]) with 6 months of follow-up. OBJECTIVE: The aim of our study was to compare clinicoradiological outcome of the lumbar spinal fusion surgeries (PLF vs. PLIF/transforaminal lumbar interbody fusion [TLIF]), to assess the quality of life pre- and post-operatively in all patients, and to compare the results within the groups. SUMMARY OF BACKGROUND DATA: We retrieved the articles related to posterolateral fusion (PLF) and PLIF/TLIF through computer-assisted PubMed and Cochrane database search. Most of the studies in previous literature did not show any significant difference in the success of fusion between the two groups. However, the global outcome in terms of clinical and radiological parameters was good in all the studies. MATERIALS AND METHODS: Senior neurosurgeons who are part of the study treated 100 patients presented with degenerative disc disease (DDD). Patients underwent two types of spinal fusion surgeries: Posterolateral fusion (PLF) and PLIF/TLIF, and those two groups were compared for clinicoradiological outcome, successful fusion, and quality of life at 6 months of follow-up. Results were analyzed statistically using SPSS version 21.0 and presented in terms of frequency, percentage, mean, and standard deviation. Measurements were compared between groups using the Student's t-test (independent and paired) for normally distributed variables. Percentage was compared with Chi-square test in various parameters. Statistical significance was determined with P values; P < 0.05 was considered statistically significant. RESULTS: Patients aged between 30and 65 years with lumbar DDD who met the inclusion criteria were included in the study. Patients were operated for 1-3 vertebral levels and showed clinical satisfactory outcome on visual analog scale (P = 0.004) and modified-Oswestry low back pain disability questionnaire (Oswestry disability index) (P = 0.000) at 6 months as compared to the preoperative data, which was statistically significant. Radiological outcome in terms of lumbar lordotic angle (LLA, P = 0.000) and ratio of disc space height (DSH) and height of immediate superior vertebral body (P = 0.000) at 3 months of follow-up was also statistically significant. All of our patients showed a well-placed implant (screws and cage) in the follow-up period. Our patients showed successful fusion more in the PLIF group (81.25%) as compared to the PLF group (67.30%), but those results are not statistically significant (P = 0.112), and all of our patients showed statistically significant difference (P = 0.000) in quality of life score at 6 months of follow-up when compared with the preoperative score. CONCLUSIONS: We concluded from our study and after the review of literature that the patients with lumbar DDD should undergo spinal instrumentation surgery either PLF or PLIF as per the requirement as these surgeries provide good clinical and radiological outcomes in terms of pain, disability index, LLA, and maintenance of DSH. Although both the groups have few degrees of risks and complications, these are not major one and can be managed easily. The fusion rates are similar in both the groups (PLF and PLIF). Quality of life index showed significant difference within 1 week, after 3 months, and after 6 months of surgery in all of our patients.

Intrinsic epidermoid of the brain stem: case report and review of the literature.

PURPOSE: Purely cystic brain stem epidermoid is a rare diagnosis among all brainstem cystic lesions. Further, it is very rare in pediatric age group. METHODS: Here, we are reporting a rare case of completely cystic brain stem epidermoid in a child. The patient presented with clinical features of brain stem involvement. MRI brain was suggestive of cystic brain stem lesion. RESULTS: Patient went through surgical procedure. Final diagnosis of epidermoid cyst was confirmed on histopathological report. CONCLUSION: With the help of various advanced sequences of MRI like diffusion and ADC, diagnosis of epidermoid cyst can be established at unusual intracranial site also. Surgical resection of epidermoid cyst at brain stem should be attempted judiciously utilizing all modern tools of neurosurgery.

Choroid plexus tumors: A clinico-pathological and neuro-radiological study of 23 cases.

BACKGROUND: Choroid plexus tumors are intraventricular tumors derived from choroid plexus epithelium. AIM: To study the choroid plexus tumors with reference to their clinical, radiological, and pathological features. MATERIALS AND METHODS: The study was performed by the retrospectively reviewing the clinical, radiological, and pathological records of patients of choroid plexus tumors. RESULTS: A total of 23 cases (11 males, 13 females) of choroid plexus tumor were diagnosed from 1997 to 2009. Fourteen patients were below 15 years of age. Raised intracranial pressure was the main presenting feature in all the cases. Tumor was located in lateral ventricle (n = 14; in 3 cases tumor was going into third ventricle), fourth ventricle (n = 7), and cerebellopontine angle (n = 2). Total tumor excision was achieved in 21 cases. The histopathology was suggestive of choroid plexus papilloma (n = 19), atypical choroid plexus papilloma (n = 1), and choroid plexus carcinoma (n = 2). Clears cell areas were noted in three cases. Other histopathological features observed were foci of calcification (n = 5), Psammoma bodies (n = 2), hemorrhage (n = 5), hyalinization (n = 2), and oncocytic changes (n = 1). CONCLUSIONS: Choroid plexus tumors are intraventricular tumors arising from choroid plexus epithelium. The predominant clinical presentation is raised intracranial pressure. Surgery is the mainstay of treatment; histopathologically, they include choroid plexus papilloma, atypical choroid plexus papilloma, and choroid plexus carcinoma.

Primary midbrain germinoma.

An 11-year-old boy presented with a 4-month history of progressive holocranial headache, intermittent vomiting and visual blurring. Later, he began walking unsteadily, with progressive bilateral visual and hearing loss. He had had two episodes of abnormal tonic posturing the day prior to admission. On examination, the patient was drowsy and did not respond to commands. Imaging showed an enhancing midbrain mass with an exophytic component with hydrocephalus. Emergency ventriculoperitoneal shunt was performed, following which there was neurological improvement. Later he underwent a midline suboccipital craniectomy with vermian splitting and decompression of the exophytic component of the tumor from the midbrain. Biopsy of the tumor revealed a germinoma. Post-operatively, the patient received chemotherapy followed by radiotherapy. Primary midbrain germinoma is an extremely rare entity and to the best of our knowledge only two cases to date have been reported in the literature.

Pediatric intracranial aneurysms: an institutional experience.

INTRODUCTION: Intracranial aneurysms are extremely uncommon in the pediatric population. Their epidemiology is poorly understood, and certain features make them unique. In our study we analyzed pediatric intracranial aneurysm patients to gain an insight into the epidemiology, clinicoradiological profile and outcome. MATERIAL AND METHODS: Out of 36 children (< or =18 years of age; male:female ratio = 1.076:1; mean age 13.19 +/- 3.72 years, age range 5-18 years) presenting with subarachnoid hemorrhage (SAH; n = 33; 91.67%) and mass effect (n = 3; 8.33%), 27 who were positive on digital subtraction angiography and treated for intracranial aneurysms between January 1991 and February 2007 were included in this study. RESULTS: At presentation, the majority (n = 21) of the pediatric intracranial patients showed a good grade, and 23 (85.18%) presented with SAH. Sudden severe headache (n = 19; 70.37%) and loss of consciousness (n = 14; 51.85%) were the most common symptoms, and meningeal signs (n = 18; 66.66%) most commonly elicitable. There were 7 patients with giant aneurysms and 8 patients with posterior circulation aneurysms. Internal carotid artery (ICA) bifurcations (n = 6; 18.18%) followed by middle cerebral artery (MCA) bifurcations (n = 4; 12.12%) were the most common sites. At a mean follow-up of 18.67 +/- 10.85 months (range 1-42 months), there were 21 (77.77%) patients with favorable outcome and 3 patients died. CONCLUSIONS: Intracranial aneurysms in children commonly present with SAH; there is a male predominance, and ICA bifurcations followed by MCA bifurcations are the most common sites. The incidence of posterior circulation aneurysms and giant aneurysms is higher as compared to adults. The pediatric patients present with better grades and have better overall surgical results.

Extruded lumbar disc associated with epidural hematoma. Case report.

Lumbar disc herniation and spinal epidural hematomas (SEHs) are highly unusual causes of secondary lumbar canal stenosis in the adolescent population. The authors report a unique concomitant occurrence in a 16-year-old boy who presented with left-sided L-5 radiculopathy. Magnetic resonance imaging T1-weighted sequences revealed a left-sided posterolateral prolapsed L4-5 disc with an isointense extruded fragment lying behind the L-5 body. On T2-weighted sequences a hyperintense area was seen in the region of the extruded disc fragment with thecal compression. At surgery the extradural encapsulated hematoma was removed, together with the extruded disc fragment and the L4-5 disc. The characteristics of the biopsy specimen from the epidural collection were consistent with those of a hematoma. At 6 months' follow up, the patient had returned to his normal activities. An SEH may result from tearing of delicate epidural veins following disc extrusion. It can occur at any age, regardless of whether there is a history of significant trauma. Magnetic resonance imaging allows preoperative characterization of the lesion. Results after surgical evacuation are excellent. Distinguishing between a solitary SEH and one caused by a lumbar disc extrusion has significant implications, as the former may resolve completely with conservative management.

Multiple subpial lipomas with dumb-bell extradural extension through the intervertebral foramen without spinal dysraphism.

BACKGROUND: Intradural subpial lipomas not associated with spinal dysraphism, account for less than 1% of spinal cord tumors. The simultaneous existence of multiple intradural subpial lipomas with dumb-bell extradural extension through the intervertebral foramen in the same patient without any evidence of spinal dysraphism has not been previously reported. CASE DESCRIPTION: A 38-year-old man presented with progressive spastic paraparesis, and weakness of right elbow extension and opposition of the medial three fingers. He also had ascending paraesthesia from the C6 dermatome to the saddle region and loss of joint and position sense of both lower limbs with hesitancy and precipitancy of micturition. There was no spinal tenderness, deformity, neurocutaneous markers, or spinal dysraphism. The total duration of illness was 11 years. The oblique views of the plain radiographs of the cervical spine revealed an enlarged right C7-D1 intervertebral foramen. The T1- and T2-weighted magnetic resonance (MR) images showed two intradural, hyperintense lesions (with extensive loss of signal on fat suppression sequences), one extending from C5 to D2 and the other opposite the C3-4 disc space. The parasagittal and axial images showed the extradural component of the lesion emerging from the right C7-D1 intervertebral foramen. At surgery, a C2 to D2 laminectomy was performed. The lipoma, enclosed in a fine pial membrane, was situated on the right posterolateral aspect of the cord. The right-sided nerve roots from the C6 to D1 levels were completely enmeshed by the lipoma. There was a separate superficial subpial lipoma adherent to the posterior aspect of the cord at the C3-4 level. A distinct area of normal cord was present between the two lesions. A subtotal decompression of the lesions including the component emerging through the right C7-D1 intervertebral foramen and a duraplasty were performed. At follow-up after 18 months, the posterior column impairment, lower limb hypoaesthesia, and right upper limb paraesthesia had improved. However, residual elbow extension and lower limb weakness, mild lower limb spasticity and sphincteric dysfunction persisted. CONCLUSIONS: The multiplicity of intradural subpial lipomas without spinal dysraphism points to a dysembryogenetic basis similar to that seen in patients with spinal dysraphism that results in lipomas, but in which the defect is not severe enough to give rise to coexisting vertebral and soft tissue anomalies. The dumb-bell extradural extension through the intervertebral foramen is extremely rare. The magnetic resonance imaging and surgical principles are discussed.