Defining role of atlantoaxial and subaxial spinal instability in the pathogenesis of cervical spinal degeneration: Experience with "only-fixation" without any decompression as treatment in 374 cases over 10 years.

Aim: The authors analyze their published work and update their experience with 374 cases of cervical radiculopathy and/or myelopathy related to spinal degeneration that includes ossification of the posterior longitudinal ligament (OPLL). The role of atlantoaxial and subaxial spinal instability as the nodal point of pathogenesis and focused target of surgical treatment is analyzed. Materials and Methods: During the period from June 2012 to November 2022, 374 patients presented with acute or chronic symptoms related to radiculopathy and/or myelopathy that were attributed to degenerative cervical spondylotic changes or due to OPLL. There were 339 males and 35 females, and their ages ranged from 39 to 77 years (average 62 years). All patients were treated for subaxial spinal stabilization by Camille's transarticular technique with the aim of arthrodesis of the treated segments. Atlantoaxial stabilization was done in 128 cases by adopting direct atlantoaxial fixation in 55 cases or a modified technique of indirect atlantoaxial fixation in 73 patients. Decompression by laminectomy, laminoplasty, corpectomy, discoidectomy, osteophyte resection, or manipulation of OPLL was not done in any case. Standard monitoring parameters, video recordings, and patient self-assessment scores formed the basis of clinical evaluation. Results: During the follow-up period that ranged from 3 to 125 months (average: 59 months), all patients had clinical improvement. Of 130 patients who had clinical evidences of severe myelopathy and were either wheelchair or bed bound, 116 patients walked aided (23 patients), or unaided (93 patients) at the last follow-up. One patient in the series was operated on 24 months after the first surgery by anterior cervical route for "adjacent segment" disc herniation. No other patient in the entire series needed any kind of repeat or additional surgery for persistent, recurrent, increased, or additional related symptoms. None of the screws at any level backed out or broke. There were no implant-related infections. Spontaneous regression of the size of osteophytes was observed in 259 patients where a postoperative imaging was possible after at least 12 months of surgery. Conclusions: Our successful experience with only spinal fixation without any kind of "decompression" identifies the defining role of "instability" in the pathogenesis of spinal degeneration and its related symptoms. OPLL appears to be a secondary manifestation of chronic or longstanding spinal instability.

"Only fixation" in cases with failed decompression for lumbar canal stenosis - Analysis of outcome in 14 cases.

Aim: The rationale of "only fixation" of affected spinal segments without any form of bone or soft-tissue decompression in cases with failed decompressive laminectomy for lumbar canal stenosis is discussed on the basis of an experience with 14 cases. Materials and Methods: During the period between 2010 and 2022, 14 patients who symptomatically worsened or did not improve following a long-segment "wide" decompressive laminectomy for multisegmental lumbar canal stenosis were identified. All patients were treated by segmental spinal stabilization aimed at arthrodesis by facetal distraction by Goel's facetal spacers (6 cases) or Camille's transarticular facetal fixation (8 cases). No bone, soft tissue, or disc resection was done for spinal or neural canal "decompression." Oswestry Disability Index and Visual Analog Scale were used to clinically assess the patients before and after the surgery and at follow-up. In addition, video recordings of patient's self-assessment of clinical outcome were used to monitor the outcome. Results: During the average period of follow-up of 71 months (range 6 months to 16 years), all patients recovered in majority of their major symptoms, the recovery was observed in the immediate postoperative period. During the period of follow-up, none of the patients complained of recurrent symptoms or needed any additional surgery. There was firm stabilization and evidences of bone fusion of the treated spinal segments in all patients. There were no infections or implant failure. No patient worsened after treatment. Conclusions: Instability of the spinal segments is the primary issue in cases with lumbar canal stenosis and stabilization in the treatment.

Looking beyond Pertussis in Prolonged Cough Illness of Young Children.

Pertussis, commonly known as whooping cough, is one of the most poorly controlled vaccine-preventable diseases in the world. South-East Asia is estimated to contribute the most to childhood disease burden while this remains largely unexplored in India. The clinical diagnosis of pertussis in young children is a challenge as the classical four-stage presentation with paroxysmal cough or whoop may be absent. It is also difficult to differentiate from other respiratory infections which can cause pertussis-like illness. Children below two years with prolonged cough illness attending an urban pediatric center in western India, were evaluated for pertussis and viral infections by molecular methods. Bordetella pertussis and B. holmesii were confirmed in three each of 45 suspected cases, and RSV-A and hMPV were the most common viruses that were detected. These organisms can mimic mild cases of pertussis and need to be considered in differential diagnosis of prolonged cough illness in young children. The accurate etiology of prolonged cough illness needs to be detected and documented to ensure appropriate management and accurate estimates of disease burden.

Pertussis seroprevalence in mother-infant pairs from India: role of maternal immunisation.

OBJECTIVE: To evaluate pertussis antibody status of pregnant women and their newborns, and the impact of antenatal immunisation. DESIGN: Observational study. SETTING: Hospitals in urban western India. PARTICIPANTS: Pregnant women and their newborns. METHODS: Pertussis antibody titres in mothers and their newborns were determined. Vaccinated and unvaccinated mothers and their newborns were compared for baseline characteristics, geometric mean titres (GMTs) and placental transfer ratio of antibodies. Multivariate logistic regression was performed to understand the influence of different factors on protective antibody titres. RESULTS: Of 284 mother-infant pairs, 75 mothers and 73 of their newborns were seropositive for anti-pertussis toxin (PT) IgG antibodies. 94 women were vaccinated in pregnancy; 51 (54.3%) of these mothers and newborns were PT IgG positive, compared with 24 (12.3%) of the women (and 22 newborns) not vaccinated in pregnancy. Women vaccinated in pregnancy and their newborns had higher GMT (30.88 and 32.54 IU/mL), compared with women who were not vaccinated (12.63%, 2.24 IU/mL) and their newborns (11.58%, 2.53 IU/mL). Placental transfer ratios in newborns of mothers vaccinated in pregnancy and those who had childhood immunisation or natural immunity were similar (1.05 and 1.12, respectively). Protective titres of antibodies at birth (>20 IU/mL) were observed in 72.3% vs 21% of newborns of vaccinated and unvaccinated pregnant women, respectively; influenced by mother's vaccination status and seropositivity. CONCLUSION: Protection against pertussis is low in newborns of mothers who are only immunised during childhood. Vaccination early in pregnancy boosts maternal and neonatal immunity.

Evidence-Based Health Behavior Interventions for Cholera: Lessons from an Outbreak Investigation in India.

In rural India, since 2014, the Swachh Bharat Abhiyan (Clean India Mission) has ensured construction of more than 100 million toilets and is now focusing on reinforcement of sanitation behaviors. We report a cholera outbreak in a remote village in western India where open defecation was implicated in causation. A water pipeline was damaged in the vicinity of a stream flowing from a site of open defecation. Despite the availability of a toilet facility in the majority of households (75%), open defecation was widely practiced (62.8%). Many reported not washing hands with soap and water before eating (78.5%) and after defecation (61.1%). The study emphasizes the need for focused health behavior studies and evidence-based interventions to reduce the occurrence of cholera outbreaks. This could be the last lap in the path toward achieving the United Nations Sustainable Development Goal 6, which aims to "ensure availability and sustainable management of water and sanitation for all."

Outcome Measures and Variables Affecting Prognosis of Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations.

This study is conducted to review the literature systematically to determine most reliable outcome measures, important clinical and radiological variables affecting the prognosis in cervical spondylotic myelopathy patients. A literature search was performed for articles published during the last 10 years. As functional outcome measures we recommend to use modified Japanese Orthopaedic Association scale, Nurick's grade, and Myelopathy Disability Index. Three clinical variables that affect the outcomes are age, duration of symptoms, and severity of the myelopathy. Examination findings require more detailed study to validate their effect on the outcomes. The predictive variables affecting the outcomes are hand atrophy, leg spasticity, clonus, and Babinski's sign. Among the radiological variables, the curvature of the cervical spine is the most important predictor of prognosis. Patients with instability are expected to have a poor surgical outcome. Spinal cord compression ratio is a critical factor for prognosis. High signal intensity on T2-weighted magnetic resonance images is a negative predictor for prognosis. The most important predictors of outcome are preoperative severity and duration of symptoms. T2 hyperintensity and cord compression ratio can also predict outcomes. New radiological tests may give promising results in the future.

Exploring a Tumor Spectrum in a Patient with Familial Angiolipomatosis.

Angiolipomas are uncommon spinal tumors which differ from their cutaneous counterparts in having larger caliber vascular stroma. Although slow growing, they can cause rapid spinal cord compression and sudden-onset sensorimotor symptoms due to vascular engorgement, hemorrhage, or thrombosis. The goal of surgery is spinal decompression, and favorable outcome is the rule. We report a patient with spinal angiolipoma, vertebral hemangioma along with subcutaneous lipomas and angiolipomas, exhibiting the entire histopathological spectrum of these related soft-tissue tumors. Analysis of his family tree revealed a hereditary predilection. Familial angiolipomatosis is an uncommon genetic condition which has not been reported to occur with spinal angiolipomas thus far.

Atypical subgaleal haemangioma causing calvarial erosion: a case report.

BACKGROUND: Infantile haemangiomas are the most common soft tissue tumours of infancy and childhood, with an incidence rate of 4-10 %. These lesions commonly present between 2 and 10 weeks after birth and characteristically involute around 8-10 years of age. Most lesions occurring in the scalp are managed conservatively, with surgery reserved for those with complications. CASE DESCRIPTION: A 5-year-old girl presented with a swelling over the left occiput noticed since birth, with a gradual increase in size and rapid progression since the last 1 year. She had undergone six sessions of intralesional steroids over the past 3 years. However, recent MRI and CT scans showed an increase in the swelling size with full-thickness erosion of the underlying calvarium without neuroparenchymal involvement. The patient underwent surgical excision of the lesion with an excellent outcome. Our literature review revealed only a single case of haemangioma which arose from the scalp and caused significant underlying calvarial erosion and intracranial extension. CONCLUSION: We present a case of an atypical infantile haemangioma arising in the subgaleal plane causing full-thickness erosion of the underlying calvarium.

Spontaneous Resolution of Non Traumatic Chronic Subdural Haematoma Despite Continued Antiplatelet Therapy: A Case Report.

Spontaneous resolution of traumatic chronic subdural haematoma (CSDH) has been reported in literature. However, those with non traumatic CSDH are exceedingly rare and none reported with continued antiplatelet therapy where it itself is an aetiological agent for development of non traumatic CSDH. A 50-year-old male presented to us with a non haemorrhagic cerebellar infarct with a concomitant CSDH without history of any trauma. Patient's PT/INR, Bleeding time and Clotting time were normal. Patient was started on antiplatelet therapy (Tablet Aspirin 150 mg OD) for the acute infarct. MR Brain at 1 month showed an increased size of CSDH. However patient denied surgical evacuation hence we continued conservative line of management, however we continued anti-platelet therapy with close neurological and coagulation profile monitoring that remained within normal range throughout the period of observation. CT at 5(th) month showed complete resolution of CSDH. Patient was on antiplatelet drugs throughout the period of observation. Our case argues about the role of antiplatelet therapy in patients with CSDH with contrary lesions requiring anticoagulation.

Madurella mycetoma--a rare case with cranial extension.

BACKGROUND: Madurella species of fungus causes chronic subcutaneous infection of lower extremities; the infection is commonly labeled as Madura foot. We report a case of Madurella infection involving the cranial cavity. Such an involvement by Madurella fungal infection is not recorded in the literature. CASE DESCRIPTION: A 31-year-old non-immunocompromised male patient presented with complaints of left hemifacial pain for 1 year and diplopia on looking toward left side for a period of 2 weeks. On examination, he had ipsilateral sixth nerve paresis. Investigations revealed a large paranasal sinus lesion that extended in the cavernous sinus. The lesion was partially resected. Histologic examination revealed that the lesion was a fungus Madurella mycetomi. CONCLUSION: A rare cranial extension of Madurella fungal infection is reported.

Pathological crying as a manifestation of spontaneous haemorrhage in a pontine cavernous haemangioma.

A 53-year-old man presented with a sudden onset severe headache associated with ataxia. His family observed labile emotions and frequent episodes of crying. Investigations revealed a pontine cavernoma with evidence of bleeding. The lesion was treated conservatively. Over approximately 6 months, the patient's ataxia improved and he recovered from the crying episodes. To our knowledge, pathological crying has not been previously associated with brainstem cavernoma.

Cavernoma in the pineal region.

A 19-year-old girl presented with symptoms of severe headache and diplopia. Investigations revealed a large and partly calcified lesion in the pineal region. At surgery a large cavernoma was identified and was radically resected. Following surgery, the patient recovered from all her symptoms. Giant cavernomas in the pineal region are rare. The literature on the subject is reviewed.

Atlantoaxial manual realignment in a patient with traumatic atlantoaxial joint disruption.

We report a patient with complex traumatic translatory atlantoaxial dislocation, who we treated by joint exposure and reduction of the dislocation by facet manipulation and subsequent plate and screw atlantoaxial fixation. A 28-year-old male had fallen 7.6m (25 feet), and following the fall had severe neck pain but no neurological deficit. Investigations revealed a fracture at the base of the odontoid process and posterior displacement of the entire atlas over the axis, resulting in a translatory atlantoaxial dislocation. Head traction failed as he developed severe vertigo following its application. The patient was operated upon in a prone position. We opened the atlantoaxial joint and realigned the facets using distraction and manipulation techniques and secured the joint using a plate and screw interarticular method. The patient tolerated the treatment well and was symptom-free after 28 months. Postoperative images showed good craniovertebral alignment. Although technically challenging, direct manipulation of the facets of the atlas and axis can result in excellent craniovertebral realignment.