Journal of Craniovertebral Junction and Spine 

About: Journal of Craniovertebral Junction and Spine is an academic journal published by Medknow. The journal publishes majorly in the area(s): Medicine & Oswestry Disability Index. It has an ISSN identifier of 0974-8237. It is also open access. Over the lifetime, 592 publications have been published receiving 4850 citations.

Tuberculosis of spine

Abstract: Tuberculosis of the spine is one of the most common spine pathology in India. Over last 4 decades a lot has changed in the diagnosis, medical treatment and surgical procedures to treat this disorder. Further developments in diagnosis using molecular genetic techniques, more effective antibiotics and more aggressive surgical protocols have become essential with emergence of multidrug resistant TB. Surgical procedures such as single stage anterior and posterior stabilization, extrapleral dorsal spine anterior stabilization and endoscopic thoracoscopic surgeries have reduced the mortality and morbidity of the surgical procedures. is rapidly progressing. It is a challenge to treat MDR-TB Spine with late onset paraplegia and progressive deformity. Physicians must treat tuberculosis of spine on the basis of Culture and sensitivity.

Pain management following spinal surgeries: An appraisal of the available options.

Abstract: Spinal procedures are generally associated with intense pain in the postoperative period, especially for the initial few days. Adequate pain management in this period has been seen to correlate well with improved functional outcome, early ambulation, early discharge, and preventing the development of chronic pain. A diverse array of pharmacological options exists for the effective amelioration of post spinal surgery pain. Each of these drugs possesses inherent advantages and disadvantages which restricts their universal applicability. Therefore, combination therapy or multimodal analgesia for proper control of pain appears as the best approach in this regard. The current manuscript discussed the pathophysiology of postsurgical pain including its nature, the various tools for assessment, and the various pharmacological agents (both conventional and upcoming) available at our disposal to respond to post spinal surgery pain.

Neurenteric cysts of the spine

Abstract: Neurenteric cysts account for 0.7-1.3% of spinal axis tumors. These rare lesions result from the inappropriate partitioning of the embryonic notochordal plate and presumptive endoderm during the third week of human development. Heterotopic rests of epithelium reminiscent of gastrointestinal and respiratory tissue lead to eventual formation of compressive cystic lesions of the pediatric and adult spine. Histopathological analysis of neurenteric tissue reveals a highly characteristic structure of columnar or cuboidal epithelium with or without cilia and mucus globules. Patients with symptomatic neurenteric cysts typically present in the second and third decades of life with size-dependent myelopathic and/or radicular signs. Magnetic resonance imaging and computed tomography are essential diagnostic tools for the delineation of cyst form and overlying osseous architecture. A variety of approaches have been employed in the treatment of neurenteric cysts each with a goal of total surgical resection. Although long-term outcome analyses are limited, data available indicate that surgical intervention in the case of neurenteric cysts results in a high frequency of resolution of neurological deficit with minimal morbidity. However, recurrence rates as high as 37% have been reported with incomplete resection secondary to factors such as cyst adhesion to surrounding structure and unclear dissection planes. Here we present a systematic review of English language literature from January 1966 to December 2009 utilizing MEDLINE with the following search terminology: neurenteric cyst, enterogenous cyst, spinal cord tumor, spinal dysraphism, intraspinal cyst, intramedullary cyst, and intradural cyst. In addition, the references of publications returned from the MEDLINE search criteria were surveyed in order to examine other pertinent reports.

Facet distraction spacers for treatment of degenerative disease of the spine: Rationale and an alternative hypothesis of spinal degeneration

Abstract: Degenerative diseases of the spine are common. The cervical and lumbar spine are more frequently affected and the dorsal spine is less commonly involved in the process. Degeneration of the disk or reduction in its ‘water’ content has been recognized as the principal initiating factor that starts off a cascade of secondary ‘degenerative’ effects on the spine. Numerous processes occur consecutively and the overall effect is reduction of the spinal canal and root canal dimensions, a phenomenon that is manifested by pain and symptoms of spinal cord, cauda equina, and spinal root compression. The disabling nature of the clinical symptoms leads the patient to a doctor. The accepted concept of spinal degeneration is that reduction of the disk space height results in posterior buckling of the posterior longitudinal ligament, and the ‘periosteal reaction’ thus initiates the formation of osteophytes. The osteophytes progressively increase in size resulting in an increasing indentation into the spinal canal. Simultaneous to the buckling of the posterior longitudinal ligaments, there occurs in-folding of the ligamentum flavum. Both these anterior and posterior indentations result in reduction of the spinal canal dimensions and ultimately cause symptoms of neural compression. The spinal degeneration is more common in the junctional zones of the spine at the C5-6 and C6-7 and the L4-5 and L5-S1 levels. Simultaneous to the events that occur in the midline, there occur relatively less apparent, but probably more significant, effects of degeneration on the facet joints. The facets are relatively small in size and the overall movements that occur at these joints are less obvious and get overwhelmed by the imposing presence of the intervertebral disk, which corners the entire focus. Although difficult to evaluate and quantify, reduction of the facet joint space can be an early sign that signals the initiation of the process of degeneration. In the cervical and dorsal spine, the facets being more horizontally (transversely) and obliquely inclined, there occurs a phenomenon of retrolisthesis, wherein, the superior facet slips on to the inferior facet. In the lumbar spine, the facets being more vertically aligned, the articular capsule becomes lax due to vertical facetal override (superior facet slips inferiorly in relationship to the inferior facet) and the joint appears bulkier. Degenerative osteophytes can also form in the facets. The degenerative effects on the facets ultimately result in the reduction in height of the spinal root canal or the intervertebral neural foramina. The symptom of local back pain could also originate from the facet joints. The symptom of claudication pain may also be related to muscle fatigue on walking and resultant exacerbation of facetal override. The entire process of degeneration results in spinal and root canal stenosis. Degeneration can occur at a single or more than one segments of the spine. More often the process of degeneration is generalized and multiple segments and regions of the spine are involved simultaneously. A number of theories and concepts of degeneration of the spine have been proposed and discussed over the last century. However, the basic premise of the hypothesis of origin of the disease process from the primary disk degeneration has been universally accepted and has not been questioned. In the year 2006, we proposed an alternative method of treatment for spinal degeneration, which involved distraction of the facets and forced introduction of ‘Goel facet spacers’.[1 2] Although the technique of introduction of the spacers into the facet joint varied in the lumbar spine, when compared to the cervical and dorsal spines, the basic concept and principle of its action was similar. The process of facetal distraction resulted in a remarkable reversal of almost the entire gamut of changes in the degeneration of the spine.[3] The increase in the height of the facets resulted in an increase in the spinal canal dimensions and in the height and diameter of the intervertebral foramina. The interlaminar distance increased. The intervertebral body height increased in its entirety and there was restoration of height of the disk space. The disk water content also seemed to increase and get restored. The posterior buckling of the posterior longitudinal ligament and the anterior bulge of the ligamentum flavum was simultaneously reduced. There was essentially a reversal of all the major known pathological events of spinal degeneration. Facetal instability could clearly be observed during surgery. Distraction of the facets by forced introduction of spacers resulted in restoration of the facetal height and fixation and alignment of the spinal segment. Over a period of five years, approximately a hundred patients underwent treatment by facetal distraction in our department. Specially designed instruments were used for the purpose. Goel facetal spacers were made from Titanium metal. [The implants are proprietary items of General Surgical Company (GESCO India) Pvt. Ltd. and patent has been filed by Dr. Goel. The implants are not yet commercially available.] The spacers were in the form of a disk, the height of which ranged from 2.5 to 4 mm and the diameter was 8 to 12 mm. The spacer impactor was fixed over the base of the spacer by a screw-type joint. The spacer impactor assisted in impacting the spacer within the facet joint and also directed and controlled its traverse. The procedure of impaction was remarkably safe with regard to the nerve root, spinal cord, and vertebral artery. Essentially, decompression of the spinal canal and root canal was obtained without removal of any part of the bone, ligaments or disk. It was observed that such a treatment was relatively straightforward and easy to perform when compared to the other available methods. The technique resulted in an immediate postoperative relief of symptoms of spinal cord and root compression. Apart from the preoperative clinical and radiological guides, direct intraoperative observation of the status of the facets also guided the decision regarding the levels of the spine that needed treatment. Superior and inferior extension of the level of surgery was significantly easier. Bone graft pieces harvested from the iliac crest were then placed over the laminae, between the spinous processes, and over the treated facets, after appropriately preparing the host area. The procedure ultimately resulted in fusion of the spinal segment. On the basis of our observations during the surgery that involved facetal distraction we present an alternative hypothesis regarding the pathogenesis and progress of spinal degeneration. It appears that spinal degeneration may not be initiated in the disk. Muscular laxity or weakness can lead to spinal instability that is manifested by facetal changes related to its incompetence. It appears that instability of the spinal segment may play a crucial role in the presenting clinical scenario and the observed radiological features. The entire phenomenon of spinal degeneration and resultant changes in the spine may be secondary to facetal incompetence. Such instability is rather easily observed on direct visualization of the joint during surgery, even when preoperative dynamic radiographs do not depict such an event. Reversal of all major known changes, generally associated with spinal degeneration, following a single process of insertion of distraction spacers within the joint, provides credence to this hypothesis. Spinal instability as a result of laxity of muscles of the spine can lead to retrolisthesis of facets of the cervical and dorsal spine and facetal overriding of the lumbar spine. The associated changes with reduction of the disk space height, osteophyte formation, buckling of the posterior longitudinal ligament and ligamentum flavum into the spinal canal, and reduction of the spinal canal and root canal dimensions, may all be secondary phenomena. The fact that traction of the cervical and lumbar spines has formed the principal and successful form of non-surgical treatment over several decades provides support to the concept. The effectiveness of traction as a treatment method can be gauged by its lasting popularity and clinical success. Advocacy of physiotherapy and muscle exercises and consequent relief from symptoms also point in the same direction. Our preliminary observations suggest that distraction of the facets by manual implantation of metal spacers within the articular cavity results in sustained traction and fixation of the spinal segment, and provide an opportunity for local arthrodesis in a distracted position. Although reduction of inter-facet space height has been discussed in the literature, it appears that this may be one important radiological guide that can determine the stability of the region. Decrease in height and retrolisthesis of the facets are indicators of instability and determine the need for distraction surgery. The oblique profile, relatively large size, firmness, and the biomechanical strength of the facets and of the pedicles can be used effectively and safely for distraction of the spinal segments and fixation. Distraction of the facets is done by surgically implanting specially designed spacers. Impaction of spacers in the facets results in several structural changes, all resulting in reversing the pathological effects of spondylosis.

Comparison of dural grafts in Chiari decompression surgery: Review of the literature

Abstract: Background: Decompression of Chiari malformation is a common procedure in both pediatric and adult neurosurgery. Although the necessity for some bony removal is universally accepted, other aspects of Chiari surgery are the subject of debate. The most controversial points include the optimal amount of bony removal, the use of duraplasty (and the type of material), the need for subarachnoid dissection, and the need for tonsillar shrinkage. Material and Methods: We critically reviewed the literature to elucidate the risks and benefits of different graft types and to clarify optimal treatment options therein. Based on our search results, 108 relevant articles were identified. With specific inclusion and exclusion criteria, we noted three studies that directly compared two tlpes of dural substitutes in Chiari malformation surgery. Results: Our review did not support the superiority of either autologous or nonautologous grafts when duraplasty is employed. Our institutional experience, however, dictates that when the pericranium is available and of good quality, it should be utilized for duraplasty. It is non-immunogenic, inexpensive, and capable of creating a watertight closure with the dura. Conclusions: Discrepancies between the three comparative studies analyzed are likely attributable to increases in pericranial quality and thickness with maturity. Future randomized studies with large numbers and the power to resolve differences in the relatively low rates of complications in Chiari surgery are warranted.