Diagnosis and Prevalence (1975-2010) of Sudden Death due to Atlantoaxial Subluxation in Cervical Rheumatoid Arthritis: A Literature Review.

Rheumatoid arthritis (RA), a chronic inflammatory disease primarily affecting synovial joints and tendons, can potentially impact various organs within the body. One notable complication associated with RA is upper cervical spine instability, medically termed atlantoaxial subluxation (AAS). This condition can lead to adverse consequences, including chronic myelopathy and acute mechanical compression of the medulla oblongata, with the potential for sudden death. While AAS may often remain asymptomatic, some nonspecific symptoms, such as neck pain, have been documented. Severe atlantoaxial subluxation can trigger more distinct symptoms, including delayed occipital pain attributed to the compression of the exiting C2 nerve root. Recent studies have elucidated a spectrum of symptoms preceding sudden death, encompassing vertigo, dizziness, convulsions, dysphagia, disorientation, and seizures. Remarkably, some cases have reported sudden death occurring during sleep. Historical data reveal a fluctuating incidence of this phenomenon, with eleven cases reported between 1969 and 1975 and six cases documented between 1990 and 2010. Notably, one of the most prevalent causes of sudden mortality in individuals with RA is the acute mechanical damage inflicted upon the medulla oblongata due to atlantoaxial subluxation.

Case of compressive myelopathy due to juvenile xanthogranuloma of cervicothoracic junction in a 28-year-old male.

Background: Juvenile xanthogranuloma (JXG) is a proliferative disorder of non-Langerhans histiocytes. The lesions typically occur in children as solitary cutaneous lesions, but are only rarely found in adults in their late twenties to thirties. Approximately 5-10% of JXG are extracutaneous in location, with spinal JXG being only rarely encountered. Here, we described a 28-year-old male with an extradural spinal JXG resulting in severe C6- T1 spinal cord compression and a progressive quadriparesis that warranted a decompressive laminectomy/C6-T2 fusion. Case Description: A 28-year-old male presented with a progressive quadriparesis of 12 months' duration that rapidly worsened over the last 3 months. When the MRI revealed severe cord epidural C6-T1 cord compression, the patient successfully underwent a C6-T1 laminectomy for gross total tumor excision followed by a C6-T2 instrumented fusion. The histopathology confirmed the diagnosis of a spinal JXG. Conclusion: Spinal JXGs in adults are only rarely encountered and should be treated with gross total tumor excision with/without fusion to achieve the best long-term outcomes.

Comparison of autograft and implant cranioplasty in pediatrics: A meta-analysis.

Background: Cranioplasty in pediatrics is quite challenging and intricated. The ideal material for it is still debatable until now due to the limited study comparing autologous and implant grafts. This meta-analytic study was conducted to evaluate the risk of infection and revision in pediatric patients after autograft and implant cranioplasty. Methods: A systematic review and meta-analysis were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A thorough literature search was conducted on PubMed, Cochrane, Scopus, and ScienceDirect database. Articles published from 2000 to 2021 were selected systematically using PRISMA based on the predetermined eligibility criteria. The relevant data were, then, analyzed and discussed. Results: A total of four publications investigating the outcome of autograft and implant cranioplasty were included and reviewed. Postoperative infection and revision rate after 126 cranioplasty procedures (both autograft or implant) from 119 patients below 21 years during time frame of study were analyzed. This meta-analysis study showed that the rate of infection and revision after cranioplasty were not different between the autograft and implant groups. Conclusion: Autograft and implant cranioplasty have no significant difference in postoperatively infection and revision rate. This study showed that cranioplasty using implant is a plausible option in pediatric patients with cranial defects, depending on the patients' condition due to similar outcome with autograft cranioplasty. Further studies with larger population and more specific details are necessary to determine the comparison of autograft and implant material in cranioplasty procedure.

One-stage anterior approach for long-segment subaxial cervical spondylitis tuberculosis: A case report.

BACKGROUND: Spondylitis TB on cervical region is a rare disease, that may lead to severe neurological complications. The anterior approach is considered as a gold standard for cervical spine tuberculosis. Available studies and literature have not precisely mentioned on how many levels are acceptable for this disease and still up for discussion. CASE PRESENTATION: A 45-year-old Asian male was brought from a rural hospital to our outpatient clinic with progressive weakness of all extremities for 3 months. Cervical x-ray and MRI showed three-levels of vertebral body destruction, suggesting a cervical spondylitis TB. Patient had debridement, corpectomy on C4, 5, 6, fusion with cage, and anterior plating from C3 to Th1 in a one-stage anterior approach. Immediately after the surgery, the patient had no complaints of pain, and he was able to walk on his own. One year follow-up after the surgery, no residual neurological impairment is detected and had no limitation in daily activities. Cervical x-ray and MRI showed good ossification and improvement of lordotic curvature. CONCLUSION: Treatment of cervical spondylitis TB which involved three-levels of vertebrae using one-stage anterior approach provides a good rate of deformity correction along with clinical improvement and long-term well-being of the patient.

Lumbar disc herniation in a 15-year-old girl: A case report.

INTRODUCTION: Lumbar disc herniation (LDH) is uncommon in the pediatric population. The lumbar spine biodynamics and architecture change with age, with adults being more susceptible to LDH than children. When conservative treatment fails for pediatric LDH, surgery may be considered. We described an unusual instance of pediatric lumbar disc herniation that was successfully treated with microdiscectomy. CASE PRESENTATION: A 15-year-old patient presented with back discomfort and pain in her left leg that had been deteriorating for over 4 years. Conservative treatment with nonsteroidal anti-inflammatory medications and piriformis injection is ineffective. An MRI of her lumbosacral spine revealed that the left L4 root was compressed by a disc herniation at the L4/L5 level. A microdiscectomy was performed on the patient. Within 48 h of surgery, the patient was released home with significant alleviation in sciatic discomfort. DISCUSSION: In the pathogenesis of LDH, trauma and a sedentary lifestyle are important factors. Back pain and radiating pain are typical LDH symptoms. If conservative treatment does not result in a positive outcome, the microdiscectomy procedure is the surgical approach of choice. Long-term outcomes have demonstrated the efficacy and safety of this procedure. CONCLUSION: Every child who presents with back pain or radiculopathy should undergo a thorough evaluation for LDH especially if they have a high body mass index (BMI) or a history of trauma. Careful patient selection and preoperative evaluation result in extremely excellent surgery outcomes in pediatric LDH.

The Effect of ACTH(4-10) PRO8-GLY9-PRO10 Administration on the Expression of IL-6 and IL-8 in Sprague Dawley Mice with Spinal Cord Injury.

Background Spinal cord injury (SCI) is a significant cause of morbidity since it results in the inflammation process which leads to necrosis or apoptosis. Inflammatory response to the tissue damage increases IL-6 and IL-8 levels. ACTH4 - 10Pro8-Gly9-Pro10 is a peptide community that has been shown to have a beneficial effect on minimizing the morbidity and increasing the recovery time. Methods This study is a true experimental laboratory research with a totally randomized method. The subjects were animal models with light and extreme compression of spinal cord, respectively. Results The administration of ACTH 4-10 in mild SCI in the 3-hour observation group did not show a significant difference in IL-6 expression compared with the 6-hour observation group. The administration of ACTH 4-10 in severe SCI showed a significantly lower expression level of IL-6 in the 3-hour observation group compared with the 6-hour one. The administration of ACTH 4-10 in severe SCI led to a significantly lower IL-8 expression in the 3-hour observation group compared with the 6-hour one. However, there was no significant difference in IL-8 expression in the group receiving ACTH 4-10 in 3 hours observation compared with that in 6 hours observation. Conclusion The administration of ACTH4-10Pro8-Gly9-Pro10 can reduce the expression of IL-6 and IL-8 at 3-hour and 6-hour observation after mild and severe SCI in animal models. Future research works are recommended.

Novel Silicone Rubber and Polyvinyl Alcohol (PVA) Compound as Nucleus Pulposus Replacement in Intervertebral Disc Herniation Surgery.

AIM: To identify a novel material with biomechanical properties identical to the nucleus pulposus in the lumbar vertebrae of goats for use in intervertebral disc herniation surgery. MATERIAL AND METHODS: In this laboratory-based experimental study, the silicone rubber material test group consisted of sample compositions 35PVA65SR, 30PVA70SR, and 40PVA60SR. Axial compression mechanical tests were conducted to assess the biomechanical properties of the resulting material in terms of stress, strain, load, and displacement. RESULTS: The mechanical compression test results revealed that the stress (MPa) and strain (%) values of the 40PVA60SR material were closest to the control group (p=1.00) with a load of 684 N in each group. The value of material displacement (mm) for 40PVA60SR was also the closest to control (p=1.00) with a loading of 684 N. CONCLUSION: The new material presents biomechanical properties closest to human nucleus pulposus and is promising in nucleus pulposus replacement therapy. Further clinical research is needed to evaluate other biomechanical properties and the bioavailability of the novel material.

Surgical treatment approach of cervicothoracic junction spinal tuberculosis in pediatric: A case report.

INTRODUCTION AND IMPORTANCE: The cervicothoracic junction is prone to infection by tuberculosis bacteria, which leads to spinal instability. Meanwhile, cervicothoracic junction spinal tuberculosis is a disease that affects the C7 to T3 vertebral, and it accounts for 5% of all spinal tuberculosis cases. Surgical procedures of treating this disease vary, and the most commonly used method is the combined anterior and posterior approach. This case report presents the disease with uncommon location in pediatric, which is rarely reported, and performed with the single-stage posterior approach to treat the patient, which showed a good clinical and radiological result. CASE PRESENTATION: A 15-years old girl with one-month history of progressive inferior paraplegia (within a month, her muscle strength went from score 5 to 0) initially complained of neck pain, gradual weakness of the lower extremities, and hypoesthesia below T4. The spine's MRI also showed a tuberculous spondylitis in the T1 to T3 vertebral and a huge paravertebral abscess at the C5 to T3 level. Subsequently, an adequate decompression, debridement, maintenance and reinforcement of stability as well as deformity correction were carried out using the single-stage posterior approach. CONCLUSIONS: The cervicothoracic junction spinal tuberculosis with huge paravertebral abscess makes surgical procedures difficult, specifically in pediatric patients. However, the single stage posterior approach produced a better clinical and radiological result with a short operation time. The selection of appropriate surgical approach management with good perioperative planning as well as effective medical management improved the patient's condition.

Periosteum-induced ossification effect in skull defect through interleukin-8 and NF-κB pathway: An experimental study with Oryctolagus cuniculus rabbits.

Background: The purpose of this study was to analyze the response of inflammatory cytokines interleukin-8 (IL-8) and NF-κB to the closure of skull defect with periosteum as a scaffolding material in bone healing used after surgery. Methods: Thirty Oryctolagus cuniculus rabbits underwent a craniotomy to create a 20 mm diameter round defect in the parietal bones. The parietal bones were returned to its place and stabilized by an internal plate fixation. The defects were either left empty or implanted with periosteum. At 6 weeks, the specimens were euthanized and examined. Results: Histological examination showed a more well-developed formation of woven bone in the periosteum group. Immunohistochemical examinations showed that the use of periosteum in the closure of skull defects reduced the NF-κB and IL-8 response which affected the ossification process. Conclusion: The experiment showed that the use of periosteum was linked with IL-8 and NF-κB downregulation toward ossification effects at any point throughout the trial. Periosteum usage might be beneficial as a scaffolding material in bone healing for autograft cranioplasty in animal model and could be applied to clinical practice.

Emergency surgery for traumatic spinal cord injury in a secondary hospital: A case report.

BACKGROUND: Cervical spinal cord injury (SCI) is a life-threatening condition. Prompt surgical intervention is needed to avoid hemodynamic and respiratory catastrophe. In Indonesia, however, spine surgery is more common in tertiary hospitals and thus might prolong the time gap to surgery due to referral waiting time. CASE DESCRIPTION: We performed an emergency surgery for a patient with complete SCI due to unstable cervical fracture. The patient was in spinal shock and experienced respiratory arrest after radiological workup. Stability was achieved in the ICU and patient was directly sent to operating theater. Anterior-posterior approach was chosen to decompress and stabilize the cervical spine. The patient was discharged on postoperative day 17 and was seen well at 1-month follow-up. CONCLUSION: The capability to perform spine procedures should not be exclusive to tertiary hospitals in Indonesia. Satisfying results can be achieved with the presence of capable neurosurgeons or orthopedic surgeons and anesthesiologists in lower-level hospitals.

Scrotal abscess due to urethral fistula in spinal cord injured patient with prolonged indwelling urinary catheter.

We report a case of scrotal abscess due to urethral fistula in a paraplegic patient with spinal cord injury. On clinical examination, an urinary catheters was placed, and the left scrotal area were swollen, redness and painless. Retrograde urethrography suggested an urethral fistula with extension spreading of contrast medium into the scrotum. The case was diagnosed as urethral fistula with scrotal abscess. The patient was successfully treated with cystostomy, scrotal incision, and pus drainage. Early detection and proper management provide opportunities to improve the outcome of this disease.

The effects of the coronavirus disease 2019 pandemic on neurospine surgery practice in the referral center hospital developing country.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic represents a once in a century challenge to human health care with over 4.5 million cases and over 300,000 deaths thus far. Surgical practice has been significantly impacted with all specialties writing guidelines for how to manage during this crisis. This study reported the effect of the COVID-19 pandemic on the neurosurgical practice, especially neurospine, in the outpatient visit, emergency department, and the surgical procedure. METHODS: This study is the comparative retrospective about neurospine practice in the outpatient visit, emergency department, and the surgical procedure among before and during COVID-19 pandemic. We recorded data from January to December 2019 (before COVID-19 pandemic) and compared with the same period in the 2020 (during a COVID-19 pandemic). RESULTS: A total of the outpatient visits, the average number per month was 28 ± 10.5 visits per month before the pandemic. The average number outpatient visit per month during the pandemic was 19 ± 11.1 visits per month, with the lowest in July 2020. The result of the average monthly neurospine surgical procedure before the pandemic was 5 ± 1.9 operations per month. Compared during the pandemic, there was decreased in the neurospine surgical procedure with the average number was 2 ± 2.7 operations per month. The decreased number significantly happens in the surgical procedure and emergency department patient (P < 0.05), while in the outpatient visit, the decreased statistically not significantly (P > 0.05). CONCLUSION: The COVID-19 pandemic changed all scopes of medical practice and training. Considering the limitation in the available resources, the number of educational cases may decrease in subspecialized disciplines such as neurospine neurosurgery. The COVID-19 pandemic affects in the neurospine and neurosurgery treatment policy in the referral tertiary hospital.

Neurosurgery at the epicenter of the COVID-19 pandemic in Indonesia: experience from a Surabaya academic tertiary hospital.

OBJECTIVE: Global outbreak of the novel coronavirus disease 2019 (COVID-19) has forced healthcare systems worldwide to reshape their facilities and protocols. Although not considered the frontline specialty in managing COVID-19 patients, neurosurgical service and training were also significantly affected. This article focuses on the impact of the COVID-19 outbreak at a low- and/or middle-income country (LMIC) academic tertiary referral hospital, the university and hospital policies and actions for the neurosurgical service and training program during the outbreak, and the contingency plan for future reference on preparedness for service and education. METHODS: The authors collected data from several official databases, including the Indonesian Ministry of Health database, East Java provincial government database, hospital database, and neurosurgery operative case log. Policies and regulations information was obtained from stakeholders, including the Indonesian Society of Neurological Surgeons, the hospital board of directors, and the dean's office. RESULTS: The curve of confirmed COVID-19 cases in Indonesia had not flattened by the 2nd week of June 2020. Surabaya, the second-largest city in Indonesia, became the epicenter of the COVID-19 outbreak in Indonesia. The neurosurgical service experienced a significant drop in cases (50% of cases from normal days) along all lines (outpatient clinic, emergency room, and surgical ward). Despite a strict preadmission screening, postoperative COVID-19 infection cases were detected during the treatment course of neurosurgical patients, and those with a positive COVID-19 infection had a high mortality rate. The reduction in the overall number of cases treated in the neurosurgical service had an impact on the educational and training program. The digital environment found popularity in the educational term; however, digital resources could not replace direct exposure to real patients. The education stakeholders adjusted the undergraduate students' clinical postings and residents' working schemes for safety reasons. CONCLUSIONS: The neurosurgery service at an academic tertiary referral hospital in an LMIC experienced a significant reduction in cases. The university and program directors had to adapt to an off-campus and off-hospital policy for neurosurgical residents and undergraduate students. The hospital instituted a reorganization of residents for service. The digital environment found popularity during the outbreak to support the educational process.

Posterior Surgical Techniques for Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations.

OBJECTIVE: This study was conducted to determine and recommend the most up-to-date information on the indications, complications, and outcomes of posterior surgical treatments for cervical spondylotic myelopathy (CSM) on the basis of a literature review. METHODS: A comprehensive literature search was performed, using the MEDLINE (PubMed), the Cochrane Register of Controlled Trials, and Web of Science databases, for peer-reviewed articles published in English during the last 10 years. RESULTS: Posterior techniques, which include laminectomy alone, laminectomy with fusion, and laminoplasty, are often used in patients with involvement of 3 or more levels. Posterior decompression for CSM is effective for improving patients' neurological function. Complications resulting from posterior cervical spine surgery include injury to the spinal cord and nerve roots, complications related to posterior screw fixation or instrumentation, C5 palsy, spring-back closure of lamina, and postlaminectomy kyphosis. CONCLUSION: It is necessary to consider multiple factors when deciding on the appropriate operation for a particular patient. Surgeons need to tailor preoperative discussions to ensure that patients are aware of these facts. Further research is needed on the cost-to-benefit analysis of various surgical approaches, the comparative efficacy of surgical approaches using various techniques, and long-term outcomes, as current knowledge is deficient in this regard.