OBJECTIVE: To summarize the clinical manifestations, imaging characteristics and experience of surgical treatment of tethered cord syndrome (TCS) accompanied by dermal sinus tract (DST) in adulthoods. METHODS: The authors retrospectively analyzed a series of 25 adult patients with TCS due to DST that were surgically treated under microscope from September 2010 to October 2019. There were 10 males and 15 females with an average age of 29.7 years (rang, 18-48 years). Characterized cutaneous malformation and dermal sinus were found in the lumbosacral region in all the 25 patients. Clinically, all the patients presented with chronic back and lower-extremity pain, numbness and weakness of lower limbs, and bowel and bladder dysfunction. Two cases were admitted to the emergency room with acute infectious cerebral spinal fluid (CSF) leakage complicated with meningitis. According to magnetic resonance imaging (MRI) images, the subdural course of DST whose traction of the spinal cord, the location of the conus medullaris, the presence of subdural lesions, and the diameter of the internal filum terminale were evaluated. The surgical procedure included separating and excising of the DST, section of the internal filum terminale, detethering of the TCS, and reconstruction of the dural sac under microscopy. The patients remained in prone position in 7 days postoperation. RESULTS: MRI showed that the position of the conus medullaris was lower than the level of lumbar 2 vertebrae, and the distal part of the DST entered the subdural stretched part of the spinal cord, to constitute one of the factors of TCS in all the 25 patients. Twenty patients had fatty infiltration of internal filum terminale and another patient had thickened (approximately 5 mm in diameter) internal filum terminale resulting in tightening the conus medullaris. A total of 25 operations were performed including completely dissection and resection of the DST through the skin down to the subdural space, section of the internal filum terminale, detethering of the TCS, and the subdural dermoid cysts were removed in two patients. There were no postoperative complications. The postoperative pathology was consistent with the structure of the DST and internal filum terminale. The local pain was relieved, and the lower-extremity weakness and bowel and bladder dysfunction were gradually relieved postoperatively. The period of follow-up ranged from 3 months to 9 years (mean, 3.9 years). The neurological function of all the patients was intact, and MRI showed that the physiological curvature of the thoracolumbar spine remained normal. There was no recurrence of TCS observed during the follow-up. CONCLUSION The adult TCS accompanied with DST is characterized by typical cutaneous malformation in the lumbosacral region and tethering of the spinal cord. The patients are usually combined with internal filum terminale enlargement tightening of conus medullaris as well. The surgical treatment including totally resection of the DST and section of the internal filum terminale to detethering the TCS at the same time under microscopy. The outcome of surgical treatment is satisfactory.
Male ; Female ; Humans ; Adult ; Spina Bifida Occulta/surgery* ; Retrospective Studies ; Neural Tube Defects/surgery* ; Cauda Equina/surgery* ; Spinal Cord/abnormalities* ; Magnetic Resonance Imaging/methods* ; Pain

Cervical kyphosis is a rare condition that can cause significant functional disability and myelopathy. Deciding the appropriate treatment for such deformities is challenging for the surgeon. Patients often present with axial neck pain, and it is not uncommon to find coexisting radiculopathy or myelopathy. The optimal approach for addressing this complex issue remains controversial. A comprehensive surgical plan based on knowledge of the pathology and biomechanics is important for kyphosis correction. Here we reviewed diagnoses of the cervical spine along with the literature pertaining to various approaches and management of cervical spine.
Congenital Abnormalities ; Diagnosis ; Humans ; Kyphosis ; Neck Pain ; Pathology ; Radiculopathy ; Spinal Cord Diseases ; Spine

STUDY DESIGN: Retrospective single institutional observational study. PURPOSE: Segmental spinal dysgenesis (SSD), a complex spinal dysraphic state caused by notochord malformation disorders, is named after its morphological presentation where a spine segment is dysgenetic, malformed or absent. This study’s objective was to examine and reassess SSD imaging findings and correlate them with an embryological explanation. OVERVIEW OF LITERATURE: Scott and his colleagues defined SSD as segmental agenesis or dysgenesis of the lumbar or thoracolumbar vertebrae and underlying spinal cord. Tortori-Donati and his colleagues defined it as a morphologic continuum ranging from hypoplasia to an absent spinal cord segment. METHODS: Fifteen children, whose imaging findings and clinical features were consistent with SSD, were included in the study. Magnetic resonance imaging (MRI) was performed per institutional spine protocol. RESULTS: Five children (33.3%) presented with a high-ending bulbous cord with no caudal segment, six (40%) presented with a dorsal or lumbar segmental dysgenetic cord with a low-lying, bulky caudal cord but without significant spinal canal narrowing, and four (26.6%) presented with segmental caudal dysgenesis with severe kyphoscoliosis, gibbus deformity, and spinal canal narrowing with a normal distal segment (normal or low-lying). CONCLUSIONS: SSD is a complex spinal anomaly in children requiring clinical-radiological assessment followed by multidisciplinary management based on the extent and severity of the dysgenetic cord and the type of SSD. MRI plays a crucial role in both diagnosing and classifying SSD prior to surgical treatment to prevent further impairment.
Child ; Congenital Abnormalities ; Humans ; Magnetic Resonance Imaging ; Notochord ; Observational Study ; Retrospective Studies ; Scoliosis ; Silver Sulfadiazine ; Spinal Canal ; Spinal Cord ; Spine

STUDY DESIGN: Retrospective and observational study.PURPOSE: The present study aimed to develop guidelines for segment salvage or sacrifice based on the amount and status of the remnant portion of the vertebra as assessed by coronal magnetic resonance imaging (MRI) in addition to sagittal and axial images in thoracic spine tuberculosis (TB).OVERVIEW OF LITERATURE: Indications for surgery have not changed significantly since the ‘middle path regimen’ was proposed by Tuli. Goals of modern surgical management of spinal TB include debridement of diseased vertebrae, spinal cord decompression, deformity correction, and spine stabilization. However, the extent of decompression has not been defined previously. Too less decompression will lead to compromised neurological recovery, whereas large extent of decompression is associated with increased surgical morbidity and longer segment to reconstruct.METHODS: Sixty-five patients with thoracic spine TB were divided into two groups (segment salvage/sacrifice) based on the thickness of the subchondral bone and endplate morphology of the vertebra as seen on MRI. The operative procedure in the form of instrumentation with Hartshill loop rectangle and sublaminar wire using the simultaneous anterior posterior approach in lateral position (versatile approach) was performed. The patients were analyzed for postoperative fusion, improvement in kyphosis angle, and followed up for development of complications.RESULTS: This method of deciding the level of fixation and segment salvage based on coronal MRI in addition to the sagittal and axial images provided good result in 64 of 65 patients, except for one patient in the segment sacrifice group who had graft buckling and resultant kyphosis.CONCLUSIONS: For segment salvage, having a clear three-dimensional idea about the viable remnant bone is important. Viable salvaged segment reduces the morbidity of the procedure, length of the construct, and unnecessary debridement without compromising on the neural recovery and fusion rate. Hence, additional cone down coronal cuts must be required when MRI is suggestive for spinal TB because it will help in the decision making.
Congenital Abnormalities ; Debridement ; Decision Making ; Decompression ; Humans ; Kyphosis ; Magnetic Resonance Imaging ; Methods ; Observational Study ; Retrospective Studies ; Spinal Cord ; Spine ; Surgical Procedures, Operative ; Transplants ; Tuberculosis

PURPOSE: Sacral dimples are a common cutaneous anomaly in infants. Spine ultrasonography (USG) is an effective and safe screening tool for patients with a sacral dimple. The aim of this study was to determine the clinical manifestations in patients with an isolated sacral dimple and to review the management of spinal cord abnormalities identified with USG. METHODS: We reviewed clinical records and collected data on admissions for a sacral dimple from March 2014 through February 2017 that were evaluated with spine USG by a pediatric radiologist. During the same period, patients who were admitted for other complaints, but were found to have a sacral dimple were also included. RESULTS: This study included 230 infants under 6-months-old (130 males and 100 females; mean age 52.8±42.6 days). Thirty-one infants with a sacral dimple had an echogenic filum terminale, and 57 children had a filar cyst. Twenty-seven patients had a low-lying spinal cord, and only one patient was suspected of having a tethered cord. Follow-up spine USG was performed in 28 patients, which showed normalization or insignificant change. CONCLUSION: In this study, all but one infant with a sacral dimple had benign imaging findings. USG can be recommended in infants with a sacral dimple for its convenience and safety.
Cauda Equina ; Child ; Diagnostic Imaging ; Female ; Follow-Up Studies ; Humans ; Infant* ; Lumbosacral Region ; Male ; Mass Screening ; Skin Abnormalities ; Spinal Cord ; Spine ; Ultrasonography

Among the spinal disorders, the treatment approach for spinal deformities has been discussed least among department of neurosurgery. But nowadays, more and more neurosurgeons are interested in spinal deformities as well as complex spinal disorders and are doing not a few surgeries for these kinds of disease. Nevertheless, it is mandatory to understand the course of spinal deformity, principles of treatment, and surgical outcomes and complications. Understanding of the biology, biomechanics and metallurgy of the spine and instrumentation are also required for successful spinal deformity surgery. We need senior mentors and good surgical and neurophysiologic monitoring team. Knowledge of spinal deformity may be augmented with spine fellowships and surgical experience. Step by step training such as basic knowledge, orthopedic as well as neurosurgical disciplines and surgical skills would be mandatory. Neurosurgeons can have several advantages for spinal deformity surgeries. By high-level technical ability of the spinal cord handling to preserve neurological function and familiarity with microscopic surgery, better synergistic effect could be expected. A fundamental understanding of pediatric spinal deformity and growing spine should be needed for spinal deformity surgery.
Biology ; Congenital Abnormalities ; Fellowships and Scholarships ; Humans ; Mentors ; Metallurgy ; Neurophysiological Monitoring ; Neurosurgeons ; Neurosurgery ; Orthopedics ; Recognition (Psychology) ; Scoliosis ; Spinal Cord ; Spine

STUDY DESIGN: Prospective clinical study. PURPOSE: The purpose of this study was to evaluate the effect of interlaminar fusion and short segment pedicle screw fixation on thoracolumbar vertebral injuries for preventing pain and post-traumatic kyphosis. OVERVIEW OF LITERATURE: The treatment of thoracolumbar injuries continues to be one of the most controversial areas in spine care. The main aim of surgical treatment is to decompress the spinal cord or nerve roots, realign the spine, and correct or prevent post-traumatic kyphosis. We evaluated the outcome of interlaminar fusion along with posterior decompression and short segment pedicle screw fixation in patients with thoracolumbar fractures with neurological deficit. METHODS: Twenty-two patients with traumatic thoracolumbar vertebral injuries and neurological deficit underwent short segment pedicle screw fixation above and below the fractured vertebrae, posterior decompression, and interlaminar fusion using a bone graft. RESULTS: All patients were followed up for 12 months postoperatively. The average operative time and blood loss was 142 minutes and 214 mL, respectively. Of the 22 patients, 14 recovered completely. Of the nine patients with American Spinal Injury Association (ASIA) grade A disease, two improved by 1 grade, whereas one each improved by grades 2, 3, and 4, and four did not recover. Radiologically, vertebral kyphosis angle improved from 20.91 preoperatively to 15.73 postoperatively, sagittal index improved from 24.77 to 18.73, the sagittal plane kyphosis angle improved from 17.45 to 11.41, regional angle kyphosis improved from 14.73 to 10.14, the superior inferior end plate angle from 16.14 to 13.00, and mean anterior body compression improved from 36.26 to 27.64 postoperatively. No implant failed and no patient had neurological deterioration. CONCLUSIONS: Short segment pedicle screw fixation with posterior decompression and interlaminar fusion provided considerable reduction in kyphosis, restored the vertebral height of patients with thoracolumbar vertebral injuries and neurological deficit, and prevented development of delayed kyphotic deformity.
Clinical Study ; Congenital Abnormalities ; Decompression* ; Humans ; Kyphosis ; Neurologic Manifestations ; Operative Time ; Pedicle Screws* ; Prospective Studies ; Spinal Cord ; Spinal Injuries ; Spine ; Transplants

STUDY DESIGN: Retrospective review. PURPOSE: To describe a safe and effective surgical procedure for old distractive flexion (DF) injuries of the subaxial cervical spine. OVERVIEW OF LITERATURE: Surgical treatment is required in old cases when a progression of the kyphotic deformity and/or persistent neck pain and/or the appearance of new neurological symptoms are observed. Since surgical treatment is more complicated and dangerous in old cases than in acute distractive-flexion cases, the indications for surgery and the selection of the surgical procedure must be carefully conducted. METHODS: To identify a safe and effective surgical procedure, the procedure selected, reason(s) for its selection, and associated neurological complications were investigated in 13 patients with old cervical DF injuries. RESULTS: No neurological complications were observed in nine patients (DF stage 2 or 3) who underwent the anterior-posterior-anterior (A-P-A) method and two patients (DF stage 1) who underwent the posterior method. It was initially planned that two patients (DF stage 2) who underwent the P-A method would be treated using the Posterior method alone; however, anterior discectomy was added to the procedure after the development of a severe spinal cord disorder. CONCLUSIONS: The A-P-A method (anterior discectomy, posterior release and/or partial facetectomy, reduction and instrumentation, anterior bone grafting) is considered to be a suitable surgical procedure for old cervical DF injuries.
Congenital Abnormalities ; Diskectomy ; Humans ; Methods ; Neck Pain ; Retrospective Studies ; Spinal Cord Diseases ; Spine*

OBJECTIVE: Laminoplasty is an effective surgical method for treating cervical degenerative disease. However, postoperative complications such as kyphosis, restriction of neck motion, and instability are often reported. Despite sufficient preoperative lordosis, this procedure often aggravates the lordotic curve of the cervical spine and straightens cervical alignment. Hence, it is important to examine preoperative risk factors associated with postoperative kyphotic alignment changes. Our study aimed to investigate preoperative radiologic parameters associated with kyphotic deformity post laminoplasty. METHODS: We retrospectively reviewed the medical records of 49 patients who underwent open door laminoplasty for cervical spondylotic myelopathy (CSM) or ossification of the posterior longitudinal ligament (OPLL) at Pusan National University Yangsan Hospital between January 2011 and December 2015. Inclusion criteria were as follows: 1) preoperative diagnosis of OPLL or CSM, 2) no previous history of cervical spinal surgery, cervical trauma, tumor, or infection, 3) minimum of one-year follow-up post laminoplasty with proper radiologic examinations performed in outpatient clinics, and 4) cases showing C7 and T1 vertebral body in the preoperative cervical sagittal plane. The radiologic parameters examined included C2–C7 Cobb angles, T1 slope, C2–C7 sagittal vertical axis (SVA), range of motion (ROM) from C2–C7, segmental instability, and T2 signal change observed on magnetic resonance imaging (MRI). Clinical factors examined included preoperative modified Japanese Orthopedic Association scores, disease classification, duration of symptoms, and the range of operation levels. RESULTS: Mean preoperative sagittal alignment was 13.01° lordotic; 6.94° lordotic postoperatively. Percentage of postoperative kyphosis was 80%. Patients were subdivided into two groups according to postoperative Cobb angle change; a control group (n=22) and kyphotic group (n=27). The kyphotic group consisted of patients with more than 5° kyphotic angle change postoperatively. There were no differences in age, sex, C2–C7 Cobb angle, T1 slope, C2–C7 SVA, ROM from C2–C7, segmental instability, or T2 signal change. Multiple regression analysis revealed T1 slope had a strong relationship with postoperative cervical kyphosis. Likewise, correlation analysis revealed there was a statistical significance between T1 slope and postoperative Cobb angle change (p=0.035), and that there was a statistically significant relationship between T1 slope and C2–C7 SVA (p=0.001). Patients with higher preoperative T1 slope demonstrated loss of lordotic curvature postoperatively. CONCLUSION: Laminoplasty has a high probability of aggravating sagittal balance of the cervical spine. T1 slope is a good predictor of postoperative kyphotic changes of the cervical spine. Similarly, T1 slope is strongly correlated with C2–C7 SVA.
Ambulatory Care Facilities ; Animals ; Asian Continental Ancestry Group ; Busan ; Cervical Vertebrae ; Classification ; Congenital Abnormalities ; Diagnosis ; Female ; Follow-Up Studies ; Gyeongsangnam-do ; Humans ; Kyphosis ; Laminoplasty* ; Longitudinal Ligaments ; Lordosis ; Magnetic Resonance Imaging ; Medical Records ; Methods ; Neck ; Orthopedics ; Postoperative Complications ; Range of Motion, Articular ; Retrospective Studies ; Risk Factors ; Spinal Cord Diseases ; Spine* ; Spondylosis

Rigid cervical deformities are difficult problems to treat. The goals of surgical treatment include deformity correction, achieving a rigid fusion, and performing a thorough neural decompression. In stiff and ankylosed cervical spines, osteotomies are required to restore sagittal and coronal balance. In this chapter, we describe the clinical and radiographic workup for patients with cervical deformities, and delineate the various factors that must be considered when planning surgical treatment. We also describe in detail the various types of cervical osteotomies, along with their surgical technique, advantages, and potential complications.
Congenital Abnormalities ; Decompression ; Humans ; Kyphosis ; Osteotomy* ; Spinal Cord Diseases ; Spine*