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Background: Pediatric cervical kyphosis is a distinct entity with diverse etiology (congenital, syndromic, traumatic, metabolic or neoplastic). Surgical correction in pediatric population is challenging due to their growing spine and low blood volume. Purpose: To analyse their presentation, surgical techniques and outcome of pediatric cervical kyphosis and systematically review the pertinent literature. Design: Retrospective study. Patient sample: 16 patients aged ≤ 18 years who underwent correction for cervical kyphosis between 2009 and 2021. Outcome measures: Nurick’s grading, mJOA score and Global cobb’s angle. Methods: Clinical parameters (Nurick grading and mJOA score) were noted from database on admission and on follow-up at 6 months. Radiological parameters of assessment included Global Cobb’s angle. The C2–C7 Cobb angle was the angle of C2 vertebra lower end plate and C7 vertebra lower end plate. For C1–2 kyphosis, anterior border of C1 and anterior border of C2 angle was taken. Radiographic parameters were studied on CT and radiographs of cervical spine to assess for stability, the degree of deformity correction and fusion status at 6 months follow-up. Results: 16 patients with mean age of 14.2 ± 3 years (9 syndromic, 4 post-traumatic, 2 metabolic and 1 post-laminectomy). All underwent surgical correction, 6 underwent Antero-posterior spinal fusion, 6 underwent Posterior spinal fusion and 4 underwent Anterior spinal fusion. There was significant clinical improvement postoperatively with—Nurick grade (pre vs. post: 2.8 vs. 1.8, p= 0.004), mJOA score (pre vs. post: 11.3 vs. 14, p= 0.003). There was significant deformity correction of Cobb’s angle from 40.7 ± 26.5° to 14.9 ± 10° (p= 0.001). Early complications included intraoperative hemodynamic instability (3) and wound complication (1). Mean follow-up was 76.9 ± 59.3 months. Conclusion: Pediatric cervical kyphosis is a debilitating condition which are managed surgically. Approach has to be individualized to the pathology and good results can be achieved. Patients should be screened for syndromic association and followed-up regularly.

Craniopagus conjoined twins are extremely rare, reported 1 in 2.5 million live births. To date, 62 separation attempts in 69 well-documented cases of craniopagus twins have been made. Of these, 34 were performed in a single-stage approach, and 28 were attempted in a multistage approach. One or both twins died of massive intraoperative blood loss and cardiac arrest in 14 cases. We report our surgical experience with conjoined craniopagus twins (JB) with type III total vertical joining and shared circumferential/circular sinus with left-sided dominance. A brief review of the literature is also provided. In our twins, the meticulous preoperative study and planning by the multidisciplinary team consisting of 125-member, first-staged surgical separation consisted of creation of venous conduit to bypass part of shared circumferential sinus and partial hemispheric disconnection. Six weeks later, twin J manifested acute cardiac overload because of one-way fistula development from blocked venous bypass graft necessitating emergency final separation surgery. Unique perioperative issues were abnormal anatomy, hemodynamic sequelae from one-way fistula development after venous bypass graft thrombosis, cardiac arrest after massive venous air embolism requiring prolonged cardiopulmonary resuscitation, and return of spontaneous circulation at 15 minutes immediately after separation. This is the first Indian craniopagus separation surgery in a complex total vertical craniopagus twin reported by a single-center multidisciplinary team. Both twins could be sent home, but one remained severely handicapped. Adequate perioperative planning and multidisciplinary team approach are vital in craniopagus twin separation surgeries.

Objective: Dystrophic cervical kyphosis secondary to neurofibromatosis 1 (NF1) is rarely reported. The primary objective is to highlight the clinical presentation and surgical outcomes based on clinical and biomechanical parameters. The secondary objective is to highlight the early and late complications of these surgeries. Methods: The hospital records of six patients operated between 2008 and 2018 were retrospectively reviewed with a minimum follow-up of 24 months. Besides demographics information, radiological findings and operative details, the outcome measures reported were neurological (MJOA score, Nurick scale), pain (VAS score) and operative complications. Results: The mean age of patients was 15.1 years (8–32 years). The average kyphotic vertebra involved—3.6 bodies (range 2–5 bodies) with four patients showing intraspinal anomaly—neurofibromas, dural ectasia. Clinically, patients improved postoperatively with—VAS (pre vs. post-: 6.6 vs. 2.6, p− < 0.05), MJOA score (pre vs. post: 10.3 vs. 13.3, p− < 0.05), Nurick grade (pre vs. post: 3.5 vs. 2.1, p− < 0.05). There was significant deformity correction from 66.8° to 20.7° (pvalue < 0.031), mean T1 Slope (pre vs. post − 1.8 ± 20.4 to 0.6 ± 12.8, pvalue − < 0.43). Mean blood loss encountered was 1800 ± 434.6 cc; however, patients with paraspinal neurofibromas reported greater blood loss. Late complications included pseudoarthrosis (1), C5 palsy (1) and junctional kyphosis (1). Vertebral dysplasia and erosions continued in all patients post-operatively. Conclusions: Antero-posterior approach provides circumferential decompression and better sagittal balance correction. Cervical spine must be screened in all NF-1 patients and followed up regularly to assess for dystrophic changes.

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The purpose of the study was to analyze single fraction Gamma Knife stereotactic radiosurgery (SRS) for uveal melanoma (UM). In the treatment of UMs, the dose distribution exhibited by an irregular eye surface has more calculation uncertainty. A tissue-equivalent bolus was placed on the left eye surface of a human head-shaped phantom. It was assumed that the treated eye is fixed using retrobulbar anesthesia and suture on extraocular muscles for phantom study. Leksell stereotactic frame was fixed around phantom’s head and the stereotactic computed tomography (CT) was performed. Two sets of scans were acquired (a) without bolus and (b) with a bolus of 1.0 cm thickness. These scans were transferred into a treatment planning system (TPS). The skull contouring was performed using stereotactic CT images. The target, visual pathways, and eye lens were delineated in stereotactic CT space created on TPS. A clinical relevant plan was designed on the CT study set “a” to deliver a radiation dose of 30Gy at tumor margin. The plan superimposed over CT study set “b” and compiled for convincing treatment strategy. The tumor coverage was 95% at 50% prescription isodose line. The conformity index, selectivity and the gradient index were 1.27, 0.80 and 3.28 respectively. The left optic nerve and eye lens received a maximum dose of 11.1 Gy and 11.0 Gy respectively. The treatment plan overlay showed similar planning indices and critical organ doses. The plan comparison showed: an irradiated volume received the radiation dose > 15 Gy varies < 1.0% whereas the volume received < 15 Gy were larger (> 1.0%) in the study set “b”. The distant lateral points from the target volume which describe the phantom’s eyelid showed a radiation dose of 3.2 Gy - 2.5 Gy. The doses to these points were misled and ignored in the CT study set “a”. The eye bolus provides better dosimetric information in the estimation of low dose areas which is commonly misled on TPS in SRS planning for UMs.

Brachial plexus injuries (BPI) not only affect motor but also psychosocial aspects of patients' lives.

To analyze the therapeutic results of intervention and the factors affecting the outcome of patients with Cushing’s disease (CD) cared for at the All Indian Institute of Medical Science (AIIMS), New Delhi. DESIGN. Patients with Cushing’s disease treated at a teritiary care centre from January 2000 to December 2009 were prospectively studied. RESULTS. Ninety-seven patients received treatment for CD during this period. Mean duration of follow-up was 3.4 ± 2.2 (mean±SD) years. Eighty-one patients (83.5%) underwent transsphenoidal surgery (TSS) as the primary treatment modality. Fifty-four patients (66.7%) went into remission after initial TSS; ten (18.5%) of them relapsed after a mean follow-up period of 2.9±2.1 (mean±SD) years. Histopathologic examination of resected tissue showed corticotroph adenoma in 48 of the 54 (88.9%) who went into remission and 17 of the 27 (63.0%) who did not go into remission after the initial TSS. Sixteen patients with severe hypercortisolism underwent bilateral adrenalectomy (BA) as a life-saving measure which was followed by pituitary surgery 6 to 12 months later. Five patients including one with a large macroadenoma required three or more procedures to achieve eucortisolism. Fifty-four out of 81 (66.7%) of our patients with CD had remission following initial TSS, ten of whom relapsed later on. Sixteen patients unerwent BA as a life-saving procedure. Factors affecting outcome were, age, gender, low dose dexamethasone suppression test cortisol value and histologic confirmation of corticotroph adenoma.

Combined loss of chromosome arms 1p and 19q in oligodendroglial tumors has become a powerful predictor of prognosis and treatment response, and hence clinical testing for their detection is widely used nowadays. Polymerase chain reaction (PCR)-based loss of heterozygosity (LOH) analysis and fluorescence in-situ hybridization (FISH) are the 2 important relatively common clinical molecular diagnostic techniques used for this purpose and they have their unique advantages and limitations. The preference of methodology used depends on local expertise and existing laboratory capabilities. However, there is no consensus on which methodologic approach has a better potential. The objective of the study was to compare the accuracy, reliability, and feasibility of FISH and PCR in detecting the 1p and 19q LOH status. Using the PCR-based method, a LOH analysis was performed on 30 oligodendrogliomas and 10 glioblastomas using fresh-frozen tissue and peripheral blood as control. A FISH assay using paraffin blocks was performed on all the cases. Concordance for 1p and 19q was found in 92.5 (37 of 40) and 82.5 (33 of 40) cases, respectively. The relative advantages and limitations of both the techniques are analyzed and discussed. The main issue pertains to the use of the best technique in large clinical trials whose results are translated to patient care services. Unless the technique used is correct, the results of clinical trials and their correlations may be somewhat questionable.

The reported incidence of post-traumatic hydrocephalus (PTH) in literature varies from 0.7–29%. It is a treatable complication of head injury and presents with different clinical syndromes. We manage 38 cases of post-traumatic hydrocephalus in our hospital between January 2009 and April 2010. Clinicoradiology was studied at initial trauma, and at presentation with symptoms suggestive of increased ICP. Post ventriculo-peritoneal shunt outcome was analyzed. Sixty-eight percent cases were of severe head injury. Contusions (73.6%) and SAH (50%) were the most common CT findings. Sixty-five percent cases had been managed by decompressive craniectomy at the time of initial injury. Deterioration in consciousness (57.8%) and hemiparesis (26.3%) were most common presenting features of PTH, usually after 65±38 days (mean±SD) of initial injury. Patients were managed by antibiotic impregnated ventriculo-peritoneal shunt. Shunt revision and infection rates were 18.4% and 12.8% respectively. Thirty cases (78.9%) improved, 2 (5.2%) showed no improvement and 6 (15.7%) died. PTH is a treatable complication of head injury with a favorable outcome and therefore should be aggressively managed by CSF shunting.

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Respiratory dysfunctions in patients with craniovertebral junction (CVJ) anomalies may occur due to compression of brainstem affecting the respiratory centers, and weakening of the muscles of respiration. We assessed pulmonary functions forced vital capacity (FVC), forced expiratory volume in first second (FEV1), maximum mid-expiratory flow rate (FEF25-75), FEV1, mouth pressures (maximum inspiratory pressure, maximum expiratory pressure), and diaphragmatic movements in 30 patients of CVJ anomalies and compared them with their mean predictive values. These parameters were also assessed in the postoperative period. It was found that the mean values of FVC, FEV1, and FEF25-75were significantly lower (P<0.001) than their mean predictive values (2.4±0.8 L, 2.0±0.7 L, 2.5±0.9 L vs. 3.7±0.9 L, 3.2±0.7 L, and 3.4±0.7 L, respectively). In the postoperative period there was significant reduction (P<0.05) in all these parameters (2.2±0.8 L, 1.7±0.7 L, and 2.1±0.8 L, respectively). The postoperative FEV1was 78.8 compared with the preoperative value of 85.7. A restrictive pattern of lung disease was observed which persisted in the postoperative period. The postoperative maximum inspiratory pressure and maximum expiratory pressure were comparable to their preoperative values (47.9±19.6 and 47.0±16.7 cmH2O vs. 42.6±17.3 and 43.9±18.2 cmH2O, respectively). Similarly, the diaphragmatic movements were also comparable to the preoperative values, both during quiet and deep breathing (13.7±3.9 and 38.0±9.3 mm vs. 13.8±3.9 and 39.0±9.1 mm, respectively). There was no improvement of pulmonary functions in the early postoperative period. However, a long-term follow-up is needed to determine subsequent changes of these parameters.

Introduction This study aimed to identify important clinical and surgical predictors of perioperative complications in patients with CSM. This knowledge will help clinicians recognize their high-risk patients and allow them to institute appropriate prevention plans.Material and Methods This study aimed to identify important clinical and surgical predictors of perioperative complications in patients with CSM. This knowledge will help clinicians recognize their high-risk patients and allow them to institute appropriate prevention plans.Results A total of 80 patients experienced 92 perioperative complications (16.7%). Univariately, the major clinical risk factors were OPLL (p= 0.022), the number of comorbidities (p= 0.020), diabetes (p= 0.004), and coexisting gastrointestinal disorders (p= 0.045). Patients undergoing a two-stage surgery and those with a longer operative duration were also at a greater risk of perioperative complications. A final model consisted of diabetes (OR = 2.35, p= 0.039), age (OR = 1.02, 0.25), operative duration (OR = 1.003, p= 0.17), two-stage surgery (OR = 20.37, p= 0.012), OPLL (OR = 1.82, p= 0.064), gastrointestinal comorbidities (OR = 2.53, p= 0.020), and BMI (OR = 1.06,p= 0.10).Conclusion Patients are at a higher risk of perioperative complications if they are older; have OPLL, a higher BMI, diabetes or gastrointestinal disorders; and if they undergo a two-stage surgery and a long operation.

Introduction Recent studies conducted in North America have demonstrated the benefits of surgical treatment for symptomatic CSM. However, differences in pathology, comorbidities, treatment approaches, and cultural response to treatment may affect the generalizability of these findings at the global level.Patients and Methods Patients receiving surgery for clinically symptomatic CSM were enrolled in a prospective multicenter, cohort study which is continuing to accrue patients at 16 sites in Europe, Asia, and North and South America. Patients included were a part of a larger ongoing prospective observational study that has enrolled 492 patients with CSM involving 16 clinical sites in Europe, Asia, and North and South America. Of those, 108 received laminectomy and fusion, and 66 received laminoplasty. The choice of surgical approach was at the discretion of the surgeon. Outcome measures were mJOA, the Nurick scale, NDI, and the SF36 PCS and MCS component scores.Results Average age was 60.2 years (SD 10.8), 29.8% were female. Patients treated with laminectomy and fusion had more levels operated (5.0 vs. 4.4, p< 0.01), shorter length of stay (7.7 vs. 15.7 days, p< 0.01), and less severe neurologic impairment measured by mJOA (12.6 vs. 11.2, p< 0.01). There were no differences in age, baseline NDI, SF36v2 PCS, and SF36v2 MCS. At 12-month follow-up, there were no differences in neurologic and functional outcomes for laminoplasty compared with laminectomy and fusion; mJOA (3.0 and 2.3, respectively, p= 0.15). Moreover, there were no differences in NDI (13.3 and 12.0, respectively, p= 0.71), SF-36v2 PCS (8.5 and 7.7, respectively, p= 0.66), and SF-36v2 MCS (7.9 and 6.9, respectively, p= 0.56).Conclusion Patients undergoing laminectomy and fusion and laminoplasty surgery for CSM show similar improvements in generic and disease-specific outcome measures allowing for baseline differences in clinical presentation between the two groups of patients. Longer-term follow-up will be required to determine whether any differences in outcome between the two forms of treatment emerge.

Introduction Cervical spondylotic myelopathy (CSM) is a condition that is commonly seen in those over the age of 50 to 60 years. A progressive increase in the number of patients who present with CSM is expected in the coming decades as the proportion of those over 60 years is anticipated to double by 2050 according to the World Health Organization (WHO). Regional variations in the pattern of presentations, etiology, and surgical management of CSM are likely to be important determinants of outcome of treatment. Here, we report the current presentation and management of CSM in a large prospective international multicenter study (AOSpine CSM-International).Materials and Methods Between 2007 and 2011, all adult patients with imaging-confirmed CSM were enrolled at 16 international high-volume centers. Detailed data on presentation, treatment, and functional outcomes were collected prospectively. The decision on surgical approach, levels decompressed, and use of instrumentation was left to the attending surgeons. Patients with inflammatory, infective, or neoplastic myelopathic etiologies were excluded. Patients were followed-up for up to 24 months.Results Participating centers were based in Asia (AP, n= 150), Europe (E, n= 126), Latin (LA, n= 80), and North America (NA, n= 123). The mean age of the cohort was 56.4 years (range, 22–87 years) and majority of them were males. Patients from AP and LA were significantly younger (53.9 and 54.2 years, respectively) than those from NA and E (p< 0.0003). The presenting underlying CSM pathology varied between regions (p< 0.001). Posterior ligamentum flavum hypertrophy was most frequently seen in LA, and OPLL was prevalent in patients in AP (35%) and E (32%). Despite etiological variations, there were no differences in baseline mJOA, Nurick, and NDI scores (p< 0.1). However, patients in AP scored the highest and those in LA scored the lowest on SF36 PCS, and LA patients had highest SF36 MCS scores (p< 0.008). Anterior surgical decompression was performed in a majority in Europe (71.43%), AP (61.07%), and NA (56%) but not in LA (33%). Circumferential decompression surgery was rarely performed in NA (4.88%) and E (3.17%). At 24 months, there was significant improvement in overall outcome measures (p< 0.001) in all regions. Patients in Asia demonstrated the greatest improvement in NDI and SF-36 PCS/MCS and patients in Europe the least. Patients from Europe had lower SF-36 QOL scores and showed less functional improvement in mJOA. NDI score was highest in the AP region.Conclusion There were significant regional variations in etiology of CSM but not at presenting functional status. Anterior cervical approach for CSM was the most common surgical approach worldwide. Surgical decompression achieved statistically significant improvements in mJOA, NDI, Nurick score, and SF36v2 across centers. However, there were variations in the degree of functional improvements gained across the regions.

A retrospective cohort study of tractor-driving farmers (study group) and non–tractor-driving farmers (control group) matched for age, gender, generic/ethnic group, land-holding, and work routines.