In this reflective narrative, the author recounts her pioneering experience of establishing India’s first center dedicated to the fetal repair of open spina bifida at Bai Jerbai Wadia Children’s Hospital – a landmark step in the evolution of perinatal neurosurgery in the country. It delves into not only the medicolegal, ethical, and social challenges encountered along the way but also the limited awareness and diagnostic delays surrounding prenatal anomalies and Medical Termination of Pregnancy. Beyond the technical aspects discussed in Part-1, the author reiterates the humanized dimension of fetal repair and its potential to transform lives for babies once deemed nonviable, while also offering families hope in situations traditionally met with despair. She calls upon neurosurgeons, obstetricians, neonatologists, and allied specialists to recognize the moral and scientific imperative of giving these infants a chance at life. It emphasizes that interdisciplinary collaboration, societal education, and empathetic counseling are as vital as surgical expertise in realizing the promise of this transformative intervention. Ultimately, this work serves not only as a clinical milestone but also as a call to action – urging the medical community to expand the boundaries of fetal care and to view spina bifida not only as a reason for termination but also as a condition deserving of timely intervention, compassion, and life-affirming opportunity.
Introduction: Open spina bifida, also known as myelomeningocele (MMC), ranks among the most prevalent severe congenital defects, traditionally addressed through postnatal repair. Nevertheless, this approach fails to prevent neurological damage, reverse hindbrain herniation, or prevent hydrocephalus. To mitigate the need for numerous medical procedures, lifelong morbidities, and associated complications, fetal surgery was introduced around 30 years ago. Objectives and Methodology: This innovative surgery has since evolved into the standard therapeutic protocol for MMC, particularly following the pivotal Management of Myelomeningocele Study (MOMS) trial. First conceptualized and pioneered by Dr. Michael Harrison at the University of California in the 1980s, the encouraging findings in both animal studies and various clinical series, laid the groundwork for a prospective multicentre randomized controlled trial known as- the MOMS. It methodically evaluated the efficacy and safety of prenatal versus postnatal MMC repair, providing Level-1 evidence of success. The trial was infact terminated prematurely due to the superior outcomes associated with prenatal repair, thereby establishing open fetal MMC repair as the definitive standard of care. This discourse intends to elucidate the historical development of this extraordinary procedure, along with its justifications and benefits for both the fetus and the mother, as well as its immediate and prolonged advantages and limitations. Conclusions: Furthermore, a concise overview of the operative technique and diagnostic criteria, along with other vital resources, will be provided. Additionally, I would be sharing my personal experience on the challenges faced in the Indian population including prospective parents and doctors, which may help to alleviate the apprehensions encountered regarding this procedure.
This article comprehensively delivers the relevant literature review along with the 1st author’s own experience from 1991 till date on the basic principles in dealing with Congenital Spinal Dysraphism, which has been given various nomenclatures over last many decades. The types of dysraphism, relation to embryological development, their clinical implications, the timing for surgery, and how the management have evolved with newer developments in diagnostic tools and microsurgical techniques as well as intra-operative electrophysiological monitoring of the limbs and sphincters so as to preserve maximum function as possible.
Background: This study evaluates the role of atlantoaxial instability in the pathogenesis of Chiari malformation in children. Objective: The entity of Chiari formation in pediatric patients and issues in its management are presented. The role of atlantoaxial fixation in pediatric Chiari formation has been analyzed. Material and Methods: Results of 74 pediatric patients with Chiari formation surgically treated by us with atlantoaxial fixation were analyzed. Apart from conventional imaging with plain radiographs, magnetic resonance imaging, and computerized tomography (CT), all patients in the subsequent part of the series underwent dynamic head flexion–extension, head right–left rotation, and lateral right–left head tilt CT imaging. Results: All patients were treated with atlantoaxial fixation using the techniques described in 1994 and 2004. No bone or soft tissue decompression was done in any case. The syrinx was not manipulated in any patient. All patients had gratifying and sustained clinical improvement. Conclusions: Satisfactory clinical outcome in all our patients after atlantoaxial fixation and without any manipulation of neural structures, dura, or bone in the region of foramen magnum consolidates the viewpoint that atlantoaxial instability is the nodal point of pathogenesis of Chiari 1 formation. Dynamic imaging helps in identifying atlantoaxial instability in cases with Chiari formation, even when the other validated parameters are within the range of “normal”. The role of foramen magnum decompression surgery needs to be reassessed.
Pediatric patients for spine surgery present unique anesthetic challenges due to the wide spectrum of pathologies, varying age-related physiology, and the complexity of surgical techniques. This comprehensive review was conducted using PubMed and Scopus databases covering publications till date focusing on major perioperative concerns. Search terms included “paediatric spine surgery” AND “anaesthetic management” AND “intraoperative neurophysiological monitoring” AND “airway management” AND “blood loss” AND “perioperative complications” AND “pain management.” The information was synthesized narratively and supported by clinical experience to provide a practical overview for perioperative care. A detailed preoperative evaluation is crucial to identify associated anomalies, systemic involvement, and airway difficulties, especially in syndromic cases. Intraoperative goals of anesthesia include maintaining adequate spinal cord perfusion, facilitating intraoperative neurophysiological monitoring, and preventing and managing intraoperative complications. Most commonly, these surgeries are performed in prone positioning, and meticulous attention is required to prevent potential complications such as airway edema or postoperative visual loss, and nerve compression injury, and intraoperative complications including significant blood loss, venous air embolism, spinal cord injury, and airway obstruction. Cardiac arrest in the prone position, though rare, necessitates prompt recognition and effective chest compressions. Postoperative pain management should follow a multimodal approach combining opioids, nonsteroidal anti-inflammatory drugs, and regional techniques. Extubation should be individualized based on airway patency, respiratory reserve, and intraoperative course. Successful anesthetic management demands close multidisciplinary coordination, anticipation of complications, and individualized care to minimize morbidity and ensure optimal neurological outcomes in pediatric spine surgery.
Hemangiomas are benign vascular lesions that are uncommon in the spine and primary intraspinal epidural hemangiomas are particularly rare. We report the case of a 38-year-old male who presented with progressive spastic paraparesis and clinical features of dorsal myelopathy. Magnetic resonance imaging demonstrated a D3–D6 dorsal extradural mass producing significant cord compression. He underwent D4–D6 laminectomy with en bloc microsurgical excision, and histopathology confirmed a capillary hemangioma. The patient experienced marked neurological improvement postoperatively. We also review the available literature, summarizing the epidemiology, clinical presentation, imaging characteristics, histopathology, management strategies, and outcomes associated with primary epidural hemangiomas.
Pediatric syndromic cervical kyphosis are challenging deformities to manage. This case based review highlights the technical nuances in managing such complex deformities.
Background and Objectives: Myxopapillary ependymomas (MPEs) are rare, slow-growing World Health Organization Grade 2 tumors arising from the filum terminale, most commonly affecting adults in the third to fifth decades of life. This study presents the clinical features, diagnostic workup, surgical management, and outcomes of seven patients treated at our institution, along with a review of current treatment approaches. Methods and Materials: We retrospectively analyzed seven patients diagnosed with histologically confirmed MPE between 2020 and 2025. Clinical, radiological, operative, and follow-up data were collected, including symptoms, neurological status, imaging characteristics, extent of resection, postoperative recovery, and recurrence. Results: Patients (age 16–36 years) presented with chronic back pain, radiculopathy, and variable motor-sensory deficits. Magnetic resonance imaging (MRI) demonstrated well-defined intradural extramedullary contrast-enhancing lesions. All patients underwent microsurgical resection through a posterior approach, with gross total resection achieved in six cases and subtotal resection in one. Symptomatic improvement was noted postoperatively in all patients. During a follow-up period of 12–24 months, no recurrences were observed. Conclusion: Early diagnosis and meticulous microsurgical resection remain central to the management of MPEs. Gross total and preferably en bloc resection provide optimal local control. Adjuvant radiotherapy should be considered for subtotal resection or recurrence. Larger studies incorporating molecular profiling are needed to refine the prognostic markers and guide future therapeutic strategies.
Background: Craniovertebral junction (CVJ) diseases pose a unique challenge to the surgeon owing to its complex anatomy and bio-mechanical characteristics. CVJ not only performs majority of the cervical flexion, extension, and axial rotation but also accommodates key vascular and neural structures. Hence, it is not surprising that it may present with myriad clinical and radiological features. However, there is extremely limited number of papers in the literature focusing on pediatric CVJ diseases in children younger than 5 years. Objective: The aim of this paper is to highlight the surgical management of CVJ diseases in children <5 years of age. Material and Methods: A retrospective chart review of all pediatric patients of CVJ anomalies <5 years of age, treated in our department from September 2015 to January 2024 was carried out. Preoperative and postoperative clinical, radiological, surgical data, and outcomes were analyzed in detail. Results: A total of 23 patients, <5 years of age were included for the analysis. The youngest child in the series is 11 months old. All patients underwent a rigid screw placement by standard posterior approach. 20/23 showed improvement in their neurological outcome following surgery. There was no mortality or instrumentation failure noted in this series. Conclusion: We describe the largest series of rigid screw instrumentation for CVJ anomalies in children <5 years of age. Careful preoperative assessment helps to determine the type and size of screw which are feasible and safe.
Background: Various Cranio-vertebral junction anomalies are frequent diseases treated by neurosurgeons regularly. This is a region with high variations in anatomy; and a region packed with crucial blood vessels- the vertebral artery and the craniospinal junction which has to be safeguarded during such complex surgery. Despite refinements in surgical technique and expertise, surgery in this region is still fraught with high rates of complications like vertebral artery injuries, screw malposition, failed surgery etc. Lack of a stereoscopic understanding of the highly variable CVJ anatomical relationships is believed to be main reason for these problems. Hence the potential for the 3 dimensional models which give exact understanding and stereoscopic visualisation of the CVJ anatomy on case to case basis to improve outcomes is examined in this study. Objective: Highlight our institutional experience with these 3-dimensional printed models and analyse their benefits in reducing intra-operative complications Materials and Methods: Retrospective study of 65 patients operated for various CV Junction anomalies over the last 3 years. Results: Total number of patients in our study was 65. Of these 37 (62.5%)were males and the rest 28 (37.5%) were females. Atlanto-Axial dislocation was the most common pathology. In this study, we had a low complication rate. There were no cases of screw malposition or vertebral artery injury. We found clinical improvement in 61/65 cases with 03 being the same. On retrospective analysis, higher rate of mortality, vertebral artery injury and screw malpositions (and hence revision surgery) with significant longer operative times were seen in cases without the 3 dimensional models. Conclusion: 3D models replicate the congenital bone and joint defects abnormal lie of vertebral artery hence giving the neurosurgeon the exact intra- operative scenario and boosts his confidence performing the surgery. • It facilitates pre operative planning of screw trajectory and allows real time practice of placing the screws and evaluating the construct. • It has a direct implication in improving the accuracy of instrumentation and prevention of disastrous complication like VA injury. • It will be beneficial to include these models as pre-operative routine workup in CV Junction cases.
Holocord syringomyelia is a rare complication following spinal cord injury, characterized by a syrinx extending the entire length of the spinal cord. This case report presents a 45-year-old male who developed symptoms 25 years after a childhood spinal injury, manifesting as burning pain and sensory deficits without motor weakness. MRI revealed a holocord syrinx from C1 to the conus in association with an old L1 fracture and cord compression. The patient underwent posterior decompression and stabilization without shunt placement, leading to improvement in sensory symptoms. Literature review highlights that holocord syrinx can arise decades after trauma and poses diagnostic and therapeutic challenges. Management strategies focus on restoring cerebrospinal fluid dynamics and relieving cord compression, and outcomes vary between surgical approaches. Intensive postoperative rehabilitation is crucial for recovery. Early recognition, individualized treatment, and multidisciplinary follow-up are essential for optimizing outcomes in holocord syringomyelia after spinal cord injury.
Background: Deep-vein thrombosis (DVT) is a serious complication of spine surgery, with the potential to cause fatal pulmonary embolism. The value of routine preoperative screening with Doppler ultrasound remains controversial and relatively understudied. Objective: To determine the prevalence of lower-extremity DVT in patients undergoing elective lumbosacral spine surgery. Material and Methods: A cross-sectional prospective study was conducted on 114 consecutive patients scheduled for elective lumbosacral spine surgery at our institution. All patients underwent bilateral lower-extremity Doppler ultrasonography (DUS) prior to surgery. Demographic data and comorbidities were recorded and analyzed. Results: The mean age of patients was 54.5 ± 12.1 years, and 68.4% were female. Preoperative DUS detected DVT in only one patient (0.9%), who had a history of malignancy. Surgery was canceled, and anticoagulation therapy was initiated. No other patients showed evidence of thrombosis. A secondary aim of the study was to explore the potential risk factors for DVT, if a sufficient number of DVT-positive cases were identified. However, since only one case was detected, meaningful statistical analysis was not feasible. Conclusion: In this study, the prevalence of preoperative DVT in elective lumbosacral spine surgery patients was extremely low (0.9%). Our findings suggest that routine preoperative Doppler screening has limited value in the general spine surgery population. However, screening should be considered for high-risk patients. As this remains a relatively understudied topic, further research is warranted to define optimal screening strategies.
Background: Degenerative lumbar spondylolisthesis (DLS) commonly affects the elderly and may require lumbar fusion when conservative treatments fail. Restoration of sagittal alignment has gained attention as a determinant of postoperative outcomes, but its impact in DLS-specific populations remains under-investigated. Objective: The objective of the study was to evaluate the relationship between postoperative sagittal alignment and functional recovery in patients undergoing lumbar fusion for symptomatic DLS. Material and Methods: This prospective single-center pilot study included 16 patients with DLS who underwent lumbar decompression and fusion between April 2022 and May 2023. Postoperative sagittal alignment parameters – sagittal vertical axis (SVA), pelvic incidence (PI), lumbar lordosis (LL), pelvic tilt, sacral slope, and PI–LL mismatch – were measured using standardized radiographs. Functional outcomes were assessed with the Oswestry Disability Index (ODI) at baseline and 12 months postsurgery. Results: Mean ODI scores improved significantly from 60.6 ± 13.9 preoperatively to 16.5 ± 13.1 postoperatively ( P < 0.001; Cohen’s d = 2.3). Patients with SVA <50 mm had better ODI scores, and those with PI–LL mismatch <10° tended to do better functionally, though statistical comparisons were limited due to small subgroup sizes. Conclusion: Optimizing sagittal alignment, particularly achieving SVA <50 mm and minimizing PI–LL mismatch, may enhance early functional recovery in DLS patients undergoing lumbar fusion. Larger multicenter studies are needed to confirm these findings and guide alignment-based surgical planning.
Spine surgery is almost always prefixed with “minimally invasive” over the last decade. Preventing or minimalizing the collateral damage while achieving the goal stands as the principle in minimally invasive spine surgery. Reducing collateral/access-related injuries helps in faster recovery and return to normalcy. Full endoscopic spine surgery (FESS) is by far the best armamentarium available currently for spine surgeons to provide targeted access to spinal pathologies utilizing these principles. In this article, we share our experience with FESS, the first hundred cases since we started doing it 30 months back.
Background: Thoracic myelopathy due to ossified ligamentum flavum (OLF) is a rare cause of spinal cord compression, accounting for less than 2% of spinal disorders. Patients typically present with progressive sensorimotor dysfunction and gait disturbances, with surgical decompression being the primary treatment. Objective: To present our institutional experience in the clinical profile, imaging, surgical management, and outcomes of dorsal OLF. Materials and Methods: We retrospectively analyzed 47 patients (36 males, 11 females; age 35–65 years) who underwent surgery for thoracic OLF between 2001 and 2023. Clinical presentation, radiological characteristics, surgical techniques, and postoperative outcomes were evaluated. Results: Sensory disturbances and gait impairment were the most common symptoms. The mean duration of symptoms was 19 months. Imaging showed continuous (50%), isolated (30%), and non-continuous (20%) OLF, most frequently at D10–11. Surgical procedures included laminectomy with or without facetectomy and fusion. At ≥3 months follow-up, most patients showed improved motor function and gait. Complications occurred in 8.5%, including CSF leak and transient neurological worsening. Conclusion: Thoracic OLF is an uncommon but important cause of myelopathy. Early recognition and timely surgical decompression are crucial for favorable outcomes, whereas delayed diagnosis, acute deterioration, and co-morbidities adversely affect prognosis.
Background: Spinal extradural arachnoid cysts are rare cerebrospinal fluid filled meningeal lesions producing symptoms by compressing neural structures or as expansile bony lesions. The aim of our research is to systematically review and discuss the various surgical techniques, outcomes, patient demographics, symptomatology, and neurological findings in our patient. Materials and Methods: We have studied 11 cases of symptomatic extradural spinal arachnoid cysts managed surgically at our institute from 2019 to 2023. The history, clinical presentation, radiological findings, operative findings, surgical techniques, and outcomes were retrospectively analysed. The patients were evaluated for recurrence if any at the 3rd-month, 6th-month, and 1-year follow-up period. Results: Progressive neurological motor weakness and radiculopathy were the chief presenting complaints. Magnetic resonance imaging was the main imaging technique, with 7 dorsal, 2 dorsolumbar, 1 cervicodorsal, and 1 cervical cyst with an average size of 6 ± 2 cm length. Surgical technique was complete excision or marsupialization of the cyst with obliteration of the dural communication. All patients had favourable outcomes and no recurrences. Conclusion: Symptomatic patients have good results with complete excision of the cyst and obliteration of the subarachnoid dural communication with metal clips, which ensures low or no recurrences.
Cervical radiculopathy caused by a foraminal disc herniation is a common clinical condition that may require surgical decompression when conservative treatments fail. Full Endoscopic Posterior Cervical Foraminotomy and Discectomy (FE-PCFD) is an emerging minimally invasive technique that offers direct decompression with reduced soft-tissue damage. To evaluate the clinical outcomes, technical considerations, and safety profile of FE-PCFD in patients with cervical radiculopathy at our institution. A retrospective review of 26 patients undergoing full endoscopic posterior cervical foraminotomy and discectomy over 1 year was conducted. Inclusion criteria were cervical radiculopathy refractory to non-surgical management, with complete clinical and imaging records. Patients were assessed using the visual analog scale (VAS) for arm pain and the Neck Disability Index (NDI) preoperatively, on postoperative day 1, and day 14. Surgical details, complications, and the need for revision surgery were documented. The mean patient age was 40.42 years. The C6–C7 level was most commonly affected (65.4%). Significant pain reduction was noted postoperatively (VAS improvement, P < 0.001), and NDI scores improved from a preoperative mean of 49.77–16.77 on day 14 (P < 0.001). Motor improvement was observed in 93.3% of patients with preoperative deficits. One patient (3.8%) developed new motor weakness, and one required revision surgery. The average operative time was 80.7 min, and the mean hospital stay was 2.69 days. FE-PCFD is safe and effective for treating lateral cervical disc herniations and foraminal stenosis, providing substantial pain relief and functional recovery with minimal complications.
The craniovertebral junction (CVJ) is a complex anatomical and biomechanical region that demands precise surgical techniques to address instability and compressive pathologies. Multiple fixation methods have been developed, including anterior odontoid screw fixation, C1–C2 transarticular and lateral mass screw constructs, pedicle screw systems, and occipitocervical fusion. Despite advances in instrumentation, these procedures remain associated with significant morbidity, most notably vertebral artery injury, dural tears, implant failure, neurological deficits, and wound complications. This review analyzes published literature on the complications of various CVJ fusion techniques and compares them with findings from our retrospective series of 154 patients operated over a 10-year period. The series highlighted vertebral artery injuries (1.9%), dural tears (1.2%), pressure sores (2.5%), implant failures (0.6%), as well as postoperative neurological deterioration, infections, and mortality. Nevertheless, most patients demonstrated significant postoperative improvement in pain (VAS) and neurological function (Nurick’s grade). Our analysis underscores that complication rates vary depending on surgical approach, anatomical variations, surgeon expertise, and preoperative planning. Advanced imaging, meticulous preoperative risk assessment, and the use of 3D-printed CVJ models for trajectory planning can substantially reduce vascular and neurological complications. In conclusion, careful selection of fixation technique, knowledge of anatomical variations, and surgeon experience are pivotal in achieving optimal outcomes while minimizing perioperative risks in CVJ surgery.
