Background: Intradural or intraradicular lumbar disc herniations are uncommon presentations of a relatively frequent pathology, representing less than 1% of all lumbar disc hernias. Methods: The purpose of this study was to analyze the mechanism, clinical, radiological, and the surgical treatment requires a transdural discectomy. Ten cases of intradural and intraradicular disc were analyzed retrospectively. The cases comprised 0.5% of the 620 cases of lumbar disc that underwent surgery from 2000 to 2015. The data described the causes of this pathology, and analyzed it from clinical, diagnostic, and therapeutic perspectives. The difficulties in the preoperative diagnosis issues and the surgical techniques will be interpreted. Results: The commonest involved site is at level L4–L5. In intradural herniation, most patients reported a chronic history of back pain, complicated later by neurologic signs. In intraradicular extension, the patients were usually complaining of severe sciatica. In the present series, diagnosis was obtained by means of magnetic resonance image. All patients underwent surgery were reporting excellent results in six cases and good results in the other four. Surgery was performed either with laminectomy for intradural extension and fenestration discectomy for intraradicular extension. Dorsal dural was repaired only, with no leakage of the cerebrospinal fluid. Conclusions: In intradural and intraradicular disc herniations; the diagnosis is mainly intraoperative, but MRI could help, the surgical technique has some special aspects, and the prognosis is good.
An adult male presented with spasticity in all 4 limbs and difficulty in walking of recent onset. No trauma was reported. He had no other systemic symptoms. Lateral X-ray and computerised axial tomography CT scan revealed atlanto-axial dislocation with basilar invagination. We describe the surgical procedure and outcome of this case. CASE REPORT Clinical summary An adult male presented with spasticity in all 4 limbs and difficulty in walking of recent onset. No trauma was reported. He had no other systemic symptoms. Lateral X-ray and computerised axial tomography CT scan revealed atlanto-axial dislocation with basilar invagination (Figure 1 and Figure 2). Figure 1 Plain X-rays lateral view flexion and extension showing basilar invagination with irreducible atlanto-axial dislocation. Figure 2 CT scan with saggital view showing basilar invagination with atlanto-axial dislocation. Procedure: The atlanto-axial joints were exposed under general anaesthesia in supine position by an anterior extrapharyangeal approach. Joint cartilage was curetted and endplates were abraded. Special wedge titanium cages of 5 mm in height (Jayon Surgical Co India) were filled with bone substitute and impacted into the joints on both sides. Additionally, the lateral mass of the atlas (C1) was fixed to Anterior Retropharyangeal Titanium Cage Distraction Of The Atlantoaxial Joints For Reducing Basilar Invagination: A First Report In The Literature 2 of 4 the body of the axis ( C2) using titanium plates and screws (Figure 3). Figure 3 Implants: Wedge shaped cages of different heights, titanium plates 2 mm thickness and titanium screws 3.5 mm in diameter and 18 mm in length. Postoperative CT scan and X-ray showed reduction of the basilar invagination and fixation of the atlantoaxial dislocation. (Figure 4, Figure 5, and Figure 6). Figure 4 Postoperative CT scan showing downward migration of dens and reduction and fixation of the atlanto-axial dislocation. Figure 5 Post-operative dynamic X-rays showing reduction of the basilar invagination and reduction with fixation of the atlanto-axial dislocation. Figure 6 Post-operative coronal CT scans showing position of cages and plate screw construct. DISCUSSION: Basilar invagination can be reduced by spacer insertion into the atlantoaxial joint1. Recently this technique has been recommended for syrinomyelia and Chiari malformation2. However, posterior surgery has inherent difficulties such as risk vertebral artery injury, paravertebral venous plexus hemorrhage and necessity of sacrificing the C2 ganglion in most cases3. The anterior extrapharyangeal approach offers a safe corridor to achieve all the aims of the posterior operation without all the problems of the posterior approach4. The surgery is performed in supine position with extension resulting in reduction of the atlanto-axial dislocation in most cases. The anterior approach is using through muscle planes unlike the posterior approach which disrupts the suboccipital and C2 spinous process muscle attachments which are so very essential for craniovertebral stability6. A wedge shaped cage distracts the joint and reduces the atlantoaxial dislocation. The large bone mass of the atlas and body of axis allow ample opportunity for easy, safe and rigid fixation of the atlanto-axial joint6. Anterior Retropharyangeal Titanium Cage Distraction Of The Atlantoaxial Joints For Reducing Basilar Invagination: A First Report In The Literature 3 of 4 This is the first report of a clinical case of basilar invagination reduced and fixed by anterior surgery. References 1 Goel A. Craniovertebral anomalies: Role for craniovertebral realignment. Neurol India 2004;52:427-9 2 KimS, M.D., Hong JT , M.D. Sung JH, M.D., ByunJH, M.D . Vertical Reduction Using Atlantoaxial Facet Spacer in Basilar Invagination with Atlantoaxial Instability J Korean Neurosurg Soc. 2011 Dec; 50(6): 528–531. 3 Goel A Atlantoaxial joint jamming as a treatment for atlantoaxial dislocation: a preliminary report. Technical note. J NeurosurgSpine. 2007 Jul;7(1):90-4. 4 Goel A, Shah A. Atlantoaxial joint distraction as a treatment for basilar invagination: A report of an experience with 11 cases. Neurol India [serial online] 2008 [cited 2015 Sep 23];56:144-50 5 Patkar S Anterior Fixation of Atlanto-axial Joints : Techniqe and pitfalls. J Spinal Surg 2014;1(2):60-68. 6 Sakaura H1, Hosono N, Mukai Y, Fujimori T, Iwasaki M, Yoshikawa Preservation of muscles attached to the C2 and C7 spinous processes rather than subaxial deep extensors reduces adverse effects after cervical laminoplasty. Spine. 2010 Jul 15;35(16). Anterior Retropharyangeal Titanium Cage Distraction Of The Atlantoaxial Joints For Reducing Basilar Invagination: A First Report In The Literature 4 of 4 Author Information Sushil Patkar Associate Professor, Bhartividyapeeth Medical College & Hospital, Poona Hospital & Research Center Pune, India patneurosurgeon@gmail.com
Study Design. Retrospective review. Objective. To evaluate private practice application of anterior cervical discectomy and fusion (ACDF) surgery using autologous anterior iliac crest bone, anterior cage, and anterior spinal instrumentation for treatment of symptomatic cervical disc disease. Summary of Background Data. ACDF using autologous iliac crest bone is frequently used to treat patients with cervical disc disease. However, there are limited data on outcomes of private practice use of ACDF with autologous bone, cage, and plate, and few studies that included 3and 4-level fusions. Methods. 308 consecutive patients with cervical radiculopathy and/or spondylosis underwent ACDF with autograft, cage, and plate via a modified Smith-Robinson technique, including one-, two-, three-, and four-level fusions. Results. Clinical and radiographic follow-up showed that the fusion rate was 99.4% (467 out of 470 total levels). Mortality rate was 0%, and overall morbidity was 4.5%. Complications included three non-unions, two instrumentation failures, two isolated pelvic fractures that healed spontaneously, and residual hip pain in one patient. Conclusions. The private practice use of ACDF with autologous bone graft, cage, and instrumentation can provide high success rates and few complications.
Degenerative causes of instability like spondylolysthesis occur more commonly in lower lumbar region. L4-L5 level is affected 6 to 8 times more commonly than any other adjacent level. Internal fixation and stabilisation of spinal lesion allows early mobilization of all patients, while protecting the neurological structures from further injury and enhancing their recovery. The goals of surgery are to achieve stability, to correct deformity, early mobilization, to expedite post-operative recovery and to decrease pseudoarthrosis. The pedicle screw and rod construct helps to achieve all these. In this study, we have stabilized cases of spondylolisthesis with pedicular screw and rod fixation and postero-lateral fusion using iliac bone graft. The pedicle screw system has gained much popularity in recent times. We have evaluated all patients for maintenance of spinal correction and neurological improvement after posterior instrumentation of lumbar spinal lesions and clinical outcome in terms of spinal scoring system called as Denis work and pain
