A rare case of "Brown tumor" of the axis with parathyroid adenoma and tertiary hyperparathyroidism.

"Brown tumors (BTs)" of the spine are benign rare lesions, seen in about 5%-13% of all patients with chronic hyperparathyroidism (HPT). They are not true neoplasms and are also known as osteitis fibrosa cystica or occasionally osteoclastoma. Radiological presentations are often misleading and may mimic other common lesions such as metastasis. A strong clinical suspicion is therefore necessary, especially in the background of chronic kidney disease with HPT and parathyroid adenoma. Surgical spinal fixation in case of instability due to pathological fracture may be required along with excision of the parathyroid adenoma being the treatment of choice, that maybe usually curative and carries a good prognosis. We would like to report one such rare case of BT involving the axis, or C2 vertebra, presenting with neck pain and weakness that was treated surgically. Only a few cases of spinal BTs have been reported so far in the literature. Involvement of cervical vertebrae and in particular C2 is rarer still with the one in this report only being the fourth such case.

The current status and surgical outcome of the minimally invasive techniques for lumbar interbody fusion in India: A systematic review and meta-analysis.

Objective: The global shift of trends to minimally invasive spine (MIS) surgery for lumbar degenerative diseases has become prominent in India for few decades. We aimed to assess the current status of MIS techniques for lumbar interbody fusion and their surgical outcomes in the Indian population. Materials and Methods: A systematic review (following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines) was performed using PubMed and Google Scholar till November 2020. The primary (visual analog scale [VAS] and oswestry disability index [ODI] scores; intraoperative blood loss; duration of surgery; duration of hospital stay, and fusion rate) and secondary (wound-associated complications and dural tear/cerebrospinal fluid (CSF) leak) outcomes were analyzed using Review Manager 5.4 software. Results: A total of 15 studies comprising a total of 1318 patients were included for analysis. The pooled mean of follow-up duration was 26.64 ± 8.43 months (range 5.7-36.5 months). Degenerative spondylolisthesis of Myerding grade I/II was the most common indication, followed by lytic listhesis, herniated prolapsed disc, and lumbar canal stenosis. The calculated pooled standard mean difference (SMD) suggested a significant decrease in postoperative ODI scores (SMD = 5.53, 95% confidence interval [CI] = 3.77-7.29; P < 0.01) and VAS scores (SMD = 6.50, 95% CI = 4.6-8.4; P < 0.01). The pooled mean blood loss, duration of postoperative hospital stay, duration of surgery, and fusion rate were 127.75 ± 52.79 mL, 4.78 ± 3.88 days, 178.59 ± 38.69 min, and 97.53% ± 2.69%, respectively. A total of 334 adverse events were recorded in 1318 patients, giving a complication rate of 25.34%. Conclusions: Minimally invasive transforaminal lumbar interbody fusion (TLIF) is the most common minimally invasive technique employed for lumbar interbody fusion in India, while oblique lumbar interbody fusion is in the initial stages. The surgical and outcome-related factors improved significantly after MIS LIF in the Indian population.

Minimally invasive cervical laminoforaminotomy - Technique and outcomes.

BACKGROUND: Cervical radiculopathy is a common pathological entity encountered by spine surgeons. Many surgical options have been described including anterior cervical discectomy with or without fusion to arthroplasty and posterior cervical laminoforaminotomy. Being a motion-preserving procedure, posterior cervical laminoforaminotomy is an excellent treatment for patients with unilateral radiculopathy secondary to a laterally located herniated disc or foraminal stenosis. With the advent of minimally invasive techniques, this procedure has regained popularity. OBJECTIVES: Although there is enough evidence in the literature highlighting the benefits, safety, and efficacy of minimally invasive versus conventional techniques, a detailed technical report along with long-term surgical outcomes is lacking. METHODS: The authors present their experience in minimally invasive cervical laminoforaminotomy (MIS-CLF) over a 7-year period (2013-2020) along with a technical note. Clinical evaluation was performed both before and after surgery, using the Visual Analog Scale (VAS) pain scores. Patient functional outcome was measured using the modified Odom's criteria. RESULTS: There were no major perioperative complications. No patient required surgery for the same level during the follow-up period which ranged from 1 to 3 years. Statistically significant results were obtained in all cases, reflected by an improvement in VAS for neck/arm pain. CONCLUSION: MIS-CLF is an effective technique for treatment of radiculopathy due to cervical disc herniation in a carefully selected subgroup of patients with good medium- to long-term outcomes. A larger study would possibly highlight the effectiveness of this procedure.

Complete Excision of Intradural-Extraforaminal Spinal Tumors Using a Minimally Invasive 2-Incision Technique With Fixed Tubular Retractors.

Spinal tumors are rare, of which intradural-extramedullary lesions form the majority of primary spinal tumors. Occasionally these may even be large, dumbbell shaped, with both intraspinal and extraspinal components. Complete gross total resection is the gold standard in the removal of these tumors since most are benign in nature. Traditionally this has been achieved using large open midline approaches that involve significant muscle dissection, extensive laminectomy, and even facetectomy. This may lead to instability, requiring stabilization to prevent deformity. Minimally invasive surgical approaches using fixed tubular retractors may obviate this need by minimizing the amount of muscle stripping and bony resection required for complete tumor excision. By utilizing facet sparing corridors, the authors describe a novel 2-incision minimally invasive surgical technique that combines a paramedian and a far-lateral approach to access both the intraspinal and extraforaminal, paraspinal portions of the tumor for achieving complete excision. Three illustrative cases are discussed with tumors in 2 different spinal locations that highlights the versatility of this technique-1 in the cervical region and the other 2 in the thoracolumbar region.

Syringo-Subarachnoid Shunt Placement: A Minimally Invasive Technique Using Fixed Tubular Retractors-Three Case Reports and Literature Review.

BACKGROUND: Placement of a syringo-subarachnoid shunt as a surgical management for syringomyelia has been well described in the literature. Good results in terms of clinical and radiological improvement have been documented especially for posttraumatic syringomyelia. Traditionally, this has been performed using open approaches which are fraught with risks of cerebrospinal fluid leak, delayed wound healing, and increased postoperative pain. With the help of minimally invasive techniques that are currently being used to treat various degenerative spinal disorders, most of these complications may be minimized. However, few reports in literature describe similar approaches for accessing intradural intramedullary spinal cord lesions and especially for syringomyelia. METHODS: Retrospective case review: using a 22-mm tubular retractor, a laminotomy was performed, durotomy done, and spinal cord identified. Myelotomy was performed at the dorsal root entry zone, syrinx visualized and entered, followed by placement of syringo-subarachnoid shunt. RESULTS: Three male patients aged 44, 57, and 37 underwent placement of syringo-subarachnoid shunts using minimally invasive fixed tubular retractors. Indications included posttraumatic or postsurgical spinal cord syrinx. Follow-up period was 1 year in all cases. There were no neurological or technique-related complications. All patients showed clinical improvement upon subsequent follow up. CONCLUSIONS: Our clinical experience on the treatment of syringomyelia via a minimally invasive fixed tubular retractor is presented. We find that this is an ideal approach for placement of syringo-subarachnoid shunts, as it provides direct access to the lesion with minimal collateral damage and wound-related complications. LEVEL OF EVIDENCE: 4. CLINICAL RELEVANCE: Relevant - in demonstrating the effectiveness of an already established procedure through a novel, minimally invasive approach which has the potential to significantly reduce the overall morbidity, in view of the inherent approach-related benefits as compared to conventional open approaches.

Minimally invasive lateral transpsoas approach for lumbar corpectomy and stabilization.

BACKGROUND: Here, we present our experience with the minimally invasive (MI) transpsoas approach for lumbar corpectomy and stabilization. Transpsoas approach accesses the lumbar spine and includes both the direct lateral interbody fusion and extreme lateral interbody fusion techniques. Both procedures utilize a tubular retractor system which facilitates adequate retraction and direct visualization of the target, while supposedly reducing soft tissue trauma. CASE DESCRIPTION: We evaluated two patients, one with a traumatic L2 wedge compression fracture and the other with an L3 pathological compression fracture due to multiple myeloma. Both patients underwent MI transpsoas lumbar corpectomy, anterior column reconstruction with an expandable cage, and posterior pedicle screw instrumentation to correct a kyphotic deformity. Both patients were mobilized on the 1st postoperative day and experienced significant postoperative pain relief. CONCLUSION: In two cases involving L2 and L3 compression fractures, MI transpsoas lumbar corpectomy was safely performed, with reduced perioperative and postoperative morbidity. Here, the transpsoas approach also allowed for early mobilization, adequate postoperative biomechanical stability, and resulted in immediate good outcomes.

Supraorbital Craniotomy for Large Anterior Skull Base Meningiomas: A Technical Note.

BACKGROUND: Supraorbital craniotomy (SOC) has brought a paradigm shift in approaching anterior skull base lesions. With better understanding of relevant anatomy, the indications are being stretched from highly selected, small-to-moderate-sized tumors to large and complex anterior skull base lesions. OBJECTIVE: We share our experience and discuss the nuances of surgery for large anterior skull base meningiomas using the SOC. METHODS: This is a single institute study using prospectively collected retrospective data from seven cases of large anterior skull base meningiomas (>3 cm) using the SOC. We reviewed the indications, safety, and procedural complications in these cases. RESULTS: Simpson's Grade 2 excision was achieved in all these seven cases, with faster postoperative recovery. Follow-up clinical outcome and cosmesis were satisfactory. CONCLUSION: SOC is a safe alternative for the standard skull base approaches in treating large anterior skull base meningiomas. The SOC can be effectively used to treat selected large anterior skull base meningiomas.

Rare manifestation of common disease with an unique method of minimally invasive spine stabilization: Cervical 2-3 facet lesion.

Cervical granulomatous infections of the posterior elements are very rare, it is often difficult to diagnose due to rarity and variable presentation of symptoms. Any cervical surgical procedure carries a certain morbid risk to the patient. We present a case of cervical 2-3 facet joint lesion which was managed by a minimally invasive technique with a favorable outcome.

Minimally Invasive Augmented Fixation for Anatomical Reduction of Grade 2 and Grade 3 Listhesis in Patients with Osteoporosis.

STUDY DESIGN: A retrospective study. PURPOSE: To study the efficacy of augmented fixation for anatomical reduction of grade 2 and grade 3 listhesis in patients with osteoporosis. OVERVIEW OF LITERATURE: Spondylolisthesis in osteoporotic patients requiring spinal fixation are associated with complications such as loss of surgical construct stability, screw pulling out, and screw loosening. Augmented fixation is a novel strategy to achieve necessary construct integrity. METHODS: Thirteen consecutive patients with grade 2 or grade 3 listhesis, with proven osteoporosis on dual energy X-ray absorptiometry (DEXA) scan, and who underwent augmented fixation for reduction of listhesis were retrospectively analyzed. In all patients, surgical access was achieved with a fixed 22 mm tubular retractor. A modified technique of bilateral, sequential, transforaminal decompression and discectomy, followed by reduction of listhesis using unilaterally placed augmented screws was employed in all the cases. Patients were followed up with plain X-rays at regular intervals to assess for implant stability and fusion status. All patients were started on medical treatment for osteoporosis. RESULTS: The mean age of the patients was 52.46 years, with 12 females and one male. The median T-score on DEXA scan was -3.0. Of the 13 patients, listhesis was at L4-L5 in five and at L5-S1 in eight. Nine patients had grade 2 listhesis, while four patients had grade 3 listhesis. Complete reduction was achieved in 10 patients. The median duration of follow-up was 18 months. Postoperative outcomes were satisfactory in all cases. CONCLUSIONS: Augmented fixation is a useful technique for achieving anatomical reduction of listhesis in patients with osteoporosis.

Giant posterior fossa dural cavernoma in a child.

PURPOSE: Extra-axial (dural) cavernomas are rare and constitutes 5% of all cavernomas. They are thought to arise from the venous plexus of the dura. They can reach large sizes before diagnosis and can have an aggressive presentation. METHODS: The authors report a rare case of giant cavernoma based on the posterior fossa dura adjacent to the sigmoid sinus (sino-dural angle) in an 8-year-old boy which was excised with good outcome. The authors describe its clinico-radiological profile and outcome characteristics along with a comprehensive review of relevant literature. RESULTS: This child underwent retromastiod craniectomy and complete excision of the dural cavernoma. The dural attachment was coagulated. Histopathological examination confirmed the diagnosis. CONCLUSION: We report cavernoma needs to be considered in the differential diagnosis of a dural-based posterior fossa lesion in paediatric population as complete excision is possible.

Minimally invasive atlantoaxial fusion: cadaveric study and report of 5 clinical cases.

OBJECTIVE Minimally invasive techniques are being increasingly used to treat disorders of the cervical spine. They have a potential to reduce the postoperative neck discomfort subsequent to extensive muscle dissection associated with conventional atlantoaxial fusion procedures. The aim of this paper was to elaborate on the technique and results of minimally invasive atlantoaxial fusion. MATERIALS Minimally invasive atlantoaxial fusion was done initially in 4 fresh-frozen cadavers and subsequently in 5 clinical cases. Clinical cases included patients with reducible atlantoaxial instability and undisplaced or minimally displaced odontoid fractures. The surgical technique is illustrated in detail. RESULTS Among the cadaveric specimens, all C-1 lateral mass screws were in the correct position and 2 of the 8 C-2 screws had a vertebral canal breach. Among clinical cases, all C-1 lateral mass screws were in the correct position. Only one C-2 screw had a Grade 2 vertebral canal breach, which was clinically insignificant. None of the patients experienced neurological worsening or implant-related complications at follow-up. Evidence of rib graft fusion or C1-2 joint fusion was successfully demonstrated in 4 cases, and flexion-extension radiographs done at follow-up did not show mobility in any case. CONCLUSIONS Minimally invasive atlantoaxial fusion is a safe and effective alternative to the conventional approach in selected cases. Larger series with direct comparison to the conventional approach will be required to demonstrate clinical benefit presumed to be associated with a minimally invasive approach.

Managing a Rare Malignant Sweat Gland Tumor Invading the Brain: Case Report and Literature Review.

BACKGROUND: Malignant sweat gland adnexal tumors are rare with an incidence of 0.001%. Of these, clear cell hidradenocarcinoma is an extremely uncommon subtype that accounts for 6% of malignant eccrine sweat gland tumors. They occur commonly in the head, neck, and extremities. Although they have a propensity for local recurrence, intracranial extension with brain invasion is extremely rare. CASE DESCRIPTION: We report a 76-year-old man with a large, recurring, ulcerated, fungating scalp swelling of 14 years who presented with focal seizures and drowsiness. Neuroimaging revealed a massive tumor arising from the scalp to invade the left parietal lobe and extending to the right side with occlusion of the superior sagittal sinus. The overlying parietal bone was lytic with a "moth-eaten" appearance. He underwent wide excision of the scalp lesion, near-total cerebral tumor decompression followed by titanium mesh cranioplasty, rotation flap reconstruction of the scalp, and adjuvant radiotherapy to the skull vault. Histopathology revealed clear cell hidradenocarcinoma. Whole-body positron emission tomography scan did not reveal any other lesion. At 24 months' follow-up, he remains recurrence free. CONCLUSION: We report a rare indolent case of clear cell hidradenocarcinoma invading the brain, which was managed with near-total decompression and adjuvant radiotherapy. Intracranial extension in such aggressive tumors poses challenges in management, and regular neuroimaging surveillance is advised.

Paediatric calcified intramedullary schwannoma at conus: A common tumor in a vicarious location.

Spinal schwannomas are commonly intradural extramedullary in location. As Schwann cells are not common in the central nervous system, intramedullary schwannomas are a rare entity. In adults, an estimated sixty cases have been reported in English literature. They are rarer in children (less than ten cases), and preoperative diagnosis becomes a prerogative in achieving total excision. Cervical cord is a common location and less commonly they occur in the conus. We report a rare case of calcified conus intramedullary schwannoma in a child without neurofibromatosis, who presented with conus-cauda syndrome of 1-year duration. Literature has been reviewed regarding its origin, pathophysiology, radiological features, and surgical management. This child underwent laminotomy and subtotal resection of the lesion. Histopathologically, tumor had typical features of schwannoma and was positive for S-100 immunoperoxidase. We believe that schwannoma needs to be considered in the preoperative differential diagnosis of a conus tumor in children as complete excision is possible in these benign tumors, thus affecting a cure.

Surgical management of Giant Lumbar Extradural Schwannoma: Report of 3 cases.

Standard surgical approach for extradural paraspinal tumours has been through a unilateral facetectomy, inter-transverse or retroperitoneal approach. Some of these approaches destabilise the spine and consequently require a fusion procedure. Access to these tumours through a minimal access route can decrease tissue damage, fasten post-operative recovery and obviate the need for a concomitant fusion procedure. However, proper case selection and adequate pre-operative planning are important in choosing cases for a minimally invasive approach. We discuss three cases of giant extradural, paraspinal schwannomas. One case that was associated with listhesis along with the tumour situated more anteriorly and embedded in the psoas muscle was managed by lateral retroperitoneal route with simultaneous interbody graft followed by posterior interspinous stabilising device. The other two cases were managed by minimal access route using a 22mm fixed tubular retractor, one by a paramedian approach and one by far lateral approach. The technique and merits of the procedure are discussed.

Spinous Process splitting Laminectomy: Clinical outcome and Radiological analysis of extent of decompression.

INTRODUCTION: Spinous process splitting laminectomy (SPSL) is a useful technique in achieving adequate decompression for lumbar canal stenosis, has the advantage of simultaneously decompressing multiple levels and minimising injury to the paraspinal muscles. Some concern has been expressed over the efficacy of this technique in decompressing lateral recesses. This study was undertaken to assess the clinical outcome of SPSL technique and radiologically assess the extent of decompression. PATIENTS AND METHODS: Thirty-nine consecutive patients treated by SPSL for degenerative lumbar spinal stenosis were methodically assessed for demographic data, clinical findings, Pre- and post-op VAS, JOA scores and spinal canal dimensions on imaging. Surgical technique for SPSL is described. RESULTS: The mean age of the patients was 66.9 yrs. The mean follow-up was 7.3 months. The mean pre- and post-operative VAS scores were 7.8 and 3.7, respectively. The mean pre- and post-operative JOA scores were 6.3 and 11.2, respectively. The mean JOA recovery rate was 57.3%. 77% of the patients were in the 'good' or 'excellent' McNab's grades at follow-up. Radiologic results were assessed separately at the 118 levels decompressed by the SPSL technique. The ratio increase for the spinal canal dimensions on post-operative images were as follows - Interfacet distance-116.6%; Effective AP distance-67.6%; Right lateral recess depth-165.1%; Right lateral recess angle-145.5%; Left lateral recess depth-149.3%; Left lateral recess angle-133.6%; Cross-sectional spinal canal area-163.8%. There was no worsening of pre-existing degenerative listhesis or scoliosis in any case. CONCLUSION: SPSL achieves effective central and lateral recess decompression, at the same time minimising injury to the paraspinal muscles thus reducing post-operative pain and aiding in quicker mobilisation and recovery. It is an effective tool to treat multiple level spinal stenosis, especially in elderly patients who have pre-existing spinal deformities which can precipitate into frank instability after conventional procedures.

Extraforaminal compression of the L-5 nerve root at the lumbosacral junction: clinical analysis, decompression technique, and outcome.

OBJECT: Extraforaminal compression of the L-5 nerve encompasses multiple pathological entities and may result from disc herniations as well as bony (osteophytes or sacral ala) or ligamentous (sacroiliac ligament and lumbosacral band) compression. Several other factors, such as disc space collapse or coronal wedging, can also contribute to narrowing of the extraforaminal space. The extraforaminal space at L5-S1 has unique anatomical features compared with the upper lumbar levels, which makes surgical access to this region difficult. Minimally invasive techniques offer easier access to the region. The purpose of this study was to analyze the contributing factors for extraforaminal compression of the L-5 nerve and assess clinical outcome following surgical decompression. METHODS: Fifty-two consecutive patients who underwent a minimally invasive far-lateral approach for extraforaminal compression of the L-5 nerve were retrospectively analyzed for clinical data, outcomes, and imaging features (type of disc prolapse, coronal wedging, degree of disc and facet degeneration, facet tropism, foraminal stenosis, osteophytes, and adjacent-level disease). The authors describe the surgical technique used in this study. RESULTS: The mean age of the patient sample was 57 years. Sixteen patients each had an extraforaminal ruptured disc or contained protrusion, and the remaining 20 patients had disc protrusions extending into the foraminal region or the lateral recess. Associated foraminal stenosis was found in 38.5%, and adjacent-level stenosis was noted in 22 cases (42.3%) and spondylolisthesis in 4 (7.7%). Osteophytes were noted in 18 cases. A coronal wedging angle ≥ 3° was found in 46.2%, and the laterality of wedging corresponded to the symptomatic side in 91% of cases. Fifteen patients (28.8%) complained of postoperative dysesthesias, which completely resolved in all cases within 6 months. The incidence of dysesthesias was more common in the ruptured disc group. There were no differences in clinical outcome among the different types of disc prolapses. The mean preoperative and postoperative visual analog scale scores were 7.6 and 3.6, respectively. The mean preoperative and postoperative Japanese Orthopaedic Association (JOA) scores were 6.4 and 13.8, respectively. The mean JOA recovery rate was 86.1%. According to the Macnab functional grading system, 96% of the patients had excellent or good grades at follow-up. CONCLUSIONS: A minimally invasive far-lateral approach to L5-S1 requires a good understanding of the regional anatomy and can provide good to excellent clinical results in properly selected cases. This approach is effective in decompressing the far-lateral and foraminal zones. Adequate preoperative diagnosis and tailoring the surgical procedure to address the relevant compressive element in each case is essential to achieving good clinical results.

Unique paradoxical atlantoaxial dislocation with C1-C2 facet diastases and isolated ligamentous injury to the craniovertebral junction without neurological deficits: A case report.

STUDY DESIGN: Retrospective review of the case file. OBJECTIVE: The primary objective was to report this rare case and discuss the mechanism of dislocation and technique of manual closed reduction of C1-C2 vertebrae in such scenarios. SUMMARY OF BACKGROUND DATA: Posterior atlantoaxial dislocation (AAD) is extremely rare and a few cases have been reported in English literature. This young man sustained a high speed car accident and survived an extreme hyperextension injury to the craniovertebral junction (CVJ) without any neurological deficits. On evaluation for neck pain he was noted with a dislocated odontoid lying in front of Atlas. There was C1-C2 facet diastases. No bony injury was noted at CVJ. Transverse axial ligament (TAL) was intact. He underwent a successful awake reduction of the dislocation. The joint had to be manually distracted, realigned, and released under the guidance of fluoroscopy. This was followed by single stage C1-C2 Goel's fusion with awake prone positioning. This patient was able to go back to work at the end of 3 months (GOS 5). CONCLUSIONS: This condition is extremely rare, can be carefully reduced manually under adequate neuromonitoring, and requires C1-C2 fusion in the same sitting.

Occipital dermal sinus with a vermian dermoid.

Congenital occipital dermal sinus with an underlying dermoid is a rare, benign lesion of embryological origin and may occur anywhere along the neuraxis. We present a case of a 15-year-old girl with a vermian dermoid and an occipital dermal sinus. Gross total resection of the lesion was done and post-operative period was uneventful. A detailed review of the literature is also covered.

Focal intradural brain infections in children: an analysis of management and outcome.

INTRODUCTION: Focal intradural infections of the brain include empyema and abscess in the supratentorial and infratentorial spaces. These are amenable to surgical management. Various other issues may complicate the course of management, e.g. hydrocephalus with infratentorial lesions or cortical venous thrombosis with supratentorial lesions. Here, we review the management and identify factors affecting outcome in these patients. MATERIALS AND METHODS: This is a retrospective analysis of all children (aged <18 years) treated at the National Institute of Mental Health and Neurosciences, Bangalore, India, between 1988 and 2004. Case records were analyzed to obtain clinical, radiological, bacteriological and follow-up data. RESULTS: There were 231 children who underwent treatment for focal intradural abscess/empyema at our institute. These included 57 children with cerebral abscess, 65 with supratentorial empyema, 82 with cerebellar abscess and 27 with infratentorial empyema. All patients underwent emergency surgery (which was either burr hole and aspiration of the lesion or craniotomy/craniectomy and excision/evacuation), along with antibiotic therapy, typically 2 weeks of intravenous and 4 weeks of oral therapy. The antibiotic regimen was empiric to begin with and was altered if any sensitivity pattern of the causative organism(s) could be established by culture. Hydrocephalus was managed with external ventricular drainage initially and with ventriculoperitoneal shunt if warranted. Mortality rates were 4.8% for cerebral abscess, 9.6% for cerebellar abscess, 10.8% for supratentorial subdural empyema and 3.7% for posterior fossa subdural empyema. The choice of surgery was found to have a strong bearing on the recurrence rates and outcome in most groups, with aggressive surgery with craniotomy leading to excellent outcomes with a low incidence of residual/recurrent lesions. CONCLUSIONS: Antibiotic therapy, emergency surgery and management of associated complications are the mainstays of treatment of these lesions. We strongly advocate early, aggressive surgery with antibiotic therapy in children with focal intradural infections.