Surgical outcomes of traumatic C2 body fractures: a retrospective analysis.

BACKGROUND: C2 vertebral body fractures are relatively rare fractures with no defined management protocol and outcomes. The aim of the study was to evaluate the clinical and radiological outcomes of C2 body fractures. METHODS: The study was conducted at the Department of Neurosurgery, Nizam's Iinstitute of Medical Sciences, Hyderabad, India, following clearance from the Institutional Ethical Committee. The data of all patients with traumatic C2 body fracture who were managed at our Department between January 2008 and January 2019 were retrieved from the database. Functional status of the patients was assessed by Neck Disability Index while pain was assessed by VAS at follow-up after at least 6 months. Fusion and regional kyphotic angles (O-C2 and C2-C7) were assessed for radiological outcome. RESULTS: There were a total of 16 patients with isolated C2 body fractures in the defined time period. The male (N.=11): female (N.=5) distribution was 2.2:1. Ten patients had road traffic accidents while the remaining 6 had history of fall from height. Only 3 patients presented with neurological deficits. Benzel type 3 fracture pattern distribution was the most common fracture pattern (type 1=1, type 2=5, type 3=9). Of these, 10 were operated and 6 were managed conservatively. The VAS and NDI values improved significantly in all at follow-up when compared to values at presentation (P=0.001). Time to return to work was significantly shorter in those treated with surgical intervention (mean: 2.9±0.87) (P=0.001). Fusion was achieved in all the patients in both groups. Mean O-C2 angle at follow-up was 21.13±10.1. Mean O-C2 angle was significantly decreased in non-surgical group at follow-up (P=0.039) but no significant reduction was observed in surgical group. CONCLUSIONS: The management of C2 body fractures needs to be individualized, reserving surgical management for fractures requiring fragment retrival or restitution of alignment if facets were fractured.

Sagittal realignment of the subaxial spine following occipito-cervical fusion.

BACKGROUND: Sagittal imbalance after spine surgery may be a major source of pain and disability and this holds good even for highly mobile cervical region. However, very few studies have addressed the issue of the impact on adjacent and distant spinal segments following occipito-cervical fixations. The aim was to analyze the changes in the sagittal alignment of subaxial spine following occipito-cervical fixations. METHODS: A total of 24 consecutive patients who underwent O-C2 fixation, with at least 2 years follow-up were retrospectively reviewed for changes in the parameters of sagittal alignment using mid-sagittal CT scan. Sagittal parameters, McGregor's line, O-C2 angle, C2-C7 angle, O-C7 angle and T1 slope were measured in pre- and at the final follow-up using Auto CAD software 2010 version (AutoDesk, Mill Valley, CA, USA); moreover, statistical analysis was done by using SPSS Statistics for Windows (IBM Corp., Armonk, NY, USA) version 21.0. RESULTS: The mean values were as follows: 1) MG slope preoperative: 5.96 (SD=3.81), postoperative: 9.42 (SD=9.6) (P=0.097); 2) O-C2 preoperative: 13.56 (SD=10.58), postoperative: 14.67 (SD=10.66) (P=0.32); 3) C2-C7 preoperative: 23.71 (SD=12.10), postoperative: 18.29 (SD=13.68) (0.128); 4) O-C7 preoperative: 20.04 (SD=8.85), postoperative: 25.33 (SD=11.08) (P=0.069); and 5) T1 slope preoperative: 14.42 (SD=10.68), postoperative: 16.58 (SD=8.78) (P=0.291). There was significant positive correlation (r=0.384, P=0.046) between cervical lordosis and T1 slope and a significant negative correlation between O-C2 and C2-C7 (r=-0.415, P=0.044). Subgrouping of fixation angles at O-C2 beyond 20 degrees had major changes in the subaxial spine which also percolated to the thoraco-lumbar spine. CONCLUSIONS: Fixation angles of occipito-cervical spine do impact the sagittal alignment of the subaxial spine.

Brainstem epidermoid cyst: An update.

The incidence of epidermoid tumors is between 1% and 2% of all intracranial tumors. The usual locations of epidermoid tumor are the parasellar region and cerebellopontine angle, and it is less commonly located in sylvian fissure, suprasellar region, cerebral and cerebellar hemispheres, and lateral and fourth ventricles. Epidermoid cysts located in the posterior fossa usually arise in the lateral subarachnoid cisterns, and those located in the brain stem are rare. These epidermoids contain cheesy and flaky white soft putty like contents. Epidermoid cysts are very slow growing tumors having a similar growth pattern of the epidermal cells of the skin and develop from remnants of epidermal elements during closure of the neural groove and disjunction of the surface ectoderm with neural ectoderm between the third and fifth weeks of embryonic life. We are presenting an interesting case of intrinsic brainstem epidermoid cyst containing milky white liquefied material with flakes in a 5-year-old girl. Diffusion-weighted imaging is definitive for the diagnosis. Ideal treatment of choice is removal of cystic components with complete resection of capsule. Although radical resection will prevent recurrence, in view of very thin firmly adherent capsule to brainstem, it is not always possible to do complete resection of capsule without any neurological deficits.