Symptoms Of Myelopathy Research Articles

RADT-21. EFFICACY AND SAFETY OF DONUT-SHAPED CIRCUMFERENTIAL SPINE CYBERKNIFE STEREOTACTIC BODY RADIOTHERAPY FOR METASTATIC SPINE DISEASE

Abstract BACKGROUND Spinal metastases (SM) with epidural spinal cord compression (ESCC) are challenging to manage due to the risk of radiation-induced injury. Traditional approaches often avoid circumferential stereotactic body radiotherapy (SBRT) because of these risks. The efficacy and safety of donut-shaped circumferential SBRT, which envelops the spinal column while sparing the cord, remains underexplored. OBJECTIVE This study evaluates the safety and efficacy of donut-shaped circumferential spine CyberKnife SBRT in treating spinal metastases, focusing on preventing radiation-induced myelopathy and achieving local tumor control. METHOD We retrospectively analyzed patients treated with donut-shaped circumferential spine SBRT from 2014 to 2023. We evaluated demographics, grade of ESCC (Bilsky), prior treatments, symptoms, treatment parameters, and outcomes. Key measures included SBRT dosimetric data, radiation exposure to the spinal cord or cauda equina, adherence to dose-volume constraints, occurrence of post-SBRT myelopathy, other radiation-induced complications, and local tumor control. RESULTS Forty-eight lesions from 43 patients (median age: 65 years; range: 20-78) were analyzed. Only one patient underwent separation surgery for severe ESCC (Bilsky grade 3). The median clinical target volume (CTV) was 63.77 cc (range: 20.31-270.05), and the median margin dose was 24 Gy (range: 18-30). Over a median follow-up of 8 months (range: 1-91), local tumor control rates were 91.1% at 6 months, 87.1% at 1 year, 82.8% at 3 years, and 62.1% at 5 years. Median overall survival was 17 months. Of 20 lesions exceeding dose constraints, only one patient displayed clinical myelopathy symptoms, correlating with local tumor recurrence. There was no radiographic myelopathy or other radiation-induced complications during follow-up. CONCLUSION Donut-shaped circumferential spine CyberKnife SBRT provides effective and safe treatment for spinal metastases with or without epidural involvement. It achieves substantial local tumor control and has a minimal incidence of radiation-induced myelopathy, offering a viable non-surgical option for managing this complex condition.

Traditional Chinese Medicine treatment for postoperative axial symptoms of cervical spondylotic myelopathy: a systematic review

BackgroundAxial symptoms (AS) represent one of the primary complications after cervical spondylotic myelopathy (CSM) surgery. Traditional Chinese Medicine (TCM), as a complementary and alternative therapy, is widely used in the...

Utility of cervical dynamic magnetic resonance imaging for evaluating patients with cervical myelopathy: a retrospective study.

Retrospective observational study. This study aimed to evaluate the utility of cervical dynamic magnetic resonance imaging (dMRI) in the assessment of cervical canal stenosis. Cervical spondylotic myelopathy has been intricately linked to both static and dynamic narrowing of the cervical spinal canal. Traditional MRI with the neck in a neutral position fails to identify the dynamic changes and may lead to misdiagnosis. Cervical dMRI is a promising tool for evaluating cervical myelopathy, enabling clinicians to assess spinal cord compression, segmental instability, and alterations in range of motion, often missed on conventional imaging. A retrospective analysis was conducted on 369 patients with symptoms of cervical myelopathy assessed using cervical dMRI. After assessing the subaxial cervical spine at each disc level (C3-T1), significant changes in the degree of central canal stenosis were determined. The appearance and extent of hyperintense lesions on T2-weighted sequences were also noted. Overall, 653/1,845 (35.39%) disc levels showed an increase in stenosis grade on extension MRI, with 168/653 (25.72%) and 180/653 (27.56%) disc levels changing from grades 0/1 to grades 2 and 3, respectively. Moreover, 120/369 (32.52%) patients showed a mean increase of 1.55±0.75 levels of compression on extension MRI when compared to neutral MRI. A fresh-appearing hyperintense lesion was observed in 79 (4.28%) disc levels on flexion MRI, which was not visualized on neutral MRI. Cervical dMRI may help surgeons plan for surgery, discuss the prognosis with the patient, and safeguard themselves from medico-legal issues arising from improper or missed diagnosis and treatment.

Neuroimaging feature in identifying acute myelopathy etiologies: comparison between neuromyelitis optica spectrum disorder and cervical spondylotic myelopathy

ObjectiveThe clinical symptoms of neuromyelitis optica spectrum disorder (NMOSD) and acute cervical spondylotic myelopathy (CSM) may overlap in some cases. This study aimed to investigate the differences in imaging features between NMOSD and CSM in acute myelopathy.MethodsWe included 78 patients in this retrospective study, including 28 NMOSD patients and 50 CSM patients. The demographic characteristics and clinical symptoms of the two groups of patients were compared. The T1 signal intensity, length of the spinal cord involved by T2 hyperintensity, degree of intervertebral disc degeneration, proportion of thoracic and lumbar cord involvement, proportion of brain involvement and lesion enhancement rate in magnetic resonance imaging (MRI) were compared between the two groups of patients. The number, length, location on the sagittal image, pattern on the sagittal image, and distribution on the axial image of the lesions in the contrast-enhanced MRI of the two groups were evaluated.ResultsThere were differences between NMOSD and CSM patients in the proportion of women, the proportion of bowel and bladder symptoms, mRS levels, the length of the spinal cord involved by T2 hyperintensity, degree of intervertebral disc degeneration, the proportion of thoracic and lumbar cord involvement, the proportion of brain involvement, the enhancement rate and number of lesions (p < 0.05). Among NMOSD patients, linear, patchy and ring or semi-ring enhancement were present in 8(30.8%) ,14 (53.8%) and 4(15.4%)patients, respectively, and axial gray and white matter were involved in 17 (65.4%) patients. Among patients with CSM, 9(36.0%) patients showed longitudinal oriented flake, 16 (64.0%) patients showed pancake-like enhancement, and 21 (84.0%) patients showed axial white matter involvement only. The differences in enhancement pattern on sagittal images and axial involvement were statistically significant (p < 0.05).ConclusionsEarly differential diagnosis of NMOSD and CSM in acute myelopathy can be made by analyzing images and the number, length, sagittal enhancement pattern, and axial involvement of gadolinium-enhanced lesions.

Endoscope-Assisted Revision Surgery after Lumbar Fusion with Pedicle Screw Fixation: A Case Series and Literature Review.

Lumbar internal fixation and fusion can be subject to failure requiring revision surgery. Endoscopic revision surgery with minimal invasiveness may be a helpful therapeutic intervention in the management of certain fusion-related complications. According to the author's knowledge, there are few references to this technique in English literature. This study aimed to investigate the efficacy of endoscope-assisted revision surgery in patients with recurrent radiculopathy after lumbar fusion surgery, discuss the necessity of revision surgery, and review the relevant literature. We report a case series and review relevant literature. Information was gathered from the electronic medical record in our hospital. A total of 231 patients who underwent endoscopic spine procedures from January 2021 to October 2022 were reviewed. Three patients who underwent endoscopic decompressive procedures after lumbar fusion surgeries at a correspondence segment were identified, and the clinical courses and radiological findings of these patients were retrospectively reviewed. The average interval from initial to revision surgery was 30.74 (range 10.50-48.00) months. The patients include one man and two women with an average age of 75.67 (range 68-81) years at the initial operation. Three patients developed symptoms of recurrent myelopathy after their initial surgery due to canal stenosis in the fusion segment and hyperostosis. All patients experienced symptom relief after revision surgery. At a mean follow-up time of 0.96 months, endoscopic decompression resulted in the average numerical rating scale (NRS) score for lower limb pain on the symptomatic side being reduced by 2.67. Patients rated their leg pain on average as 4.5 ± 0.5. Endoscope-assisted revision surgery after lumbar fusion with pedicle screw fixation is a promising therapeutic strategy in treating recurrent radiculopathy. Spinal stenosis and hyperostosis are two of the most significant reasons for revision surgery. Resection of intraspinal lesions and endoscopic foraminal decompression appear to have promising outcomes. Certain fusion-related complications may be effectively treated with endoscope-assisted revision surgery. Further research should be conducted to investigate the clinical efficacy of revision surgery.

Aggressive giant dumbell-shaped thoracic vertebral hemangioma: illustrative case.

Vertebral hemangioma is the most common benign tumor of the spine, diagnosed incidentally in most cases. In 0.4% of patients, the lesion is considered aggressive, causing neurological deficits. This subtype of hemangioma is characterized by strong postcontrast enhancement, cortical lysis, and epidural extension causing myelopathy and/or radiculopathy. A 52-year-old man presented with myelopathy symptoms, namely lower-limb hypoesthesia up to the T4-5 sensory level, right leg hyposthenia, and urinary incontinence. Imaging studies revealed a giant dumbbell-shaped lesion causing spinal cord compression, associated with signal alteration of the T3 vertebral body. The diagnosis of schwannoma was not certain given the radiological features, so a biopsy was planned and confirmed the diagnosis of vertebral hemangioma. Preoperative embolization, spinal fusion, and gross-total resection of the extravertebral component of the lesion were performed. This report should raise awareness of the differential diagnosis of dumbbell-shaped spinal tumors and the therapeutic strategies available for aggressive vertebral hemangiomas, a rare lesion that should be managed in a multidisciplinary setting. https://thejns.org/doi/10.3171/CASE24190.

Rotational Latissimus Dorsi Flap for Lateral Repair of Thoracic Cerebrospinal Fluid-Pleural Fistula: Case Report.

Giant calcified thoracic discs are challenging surgical pathologies that tend to be more centrally located and calcified. This complicates the removal process and potentiates the formation of dural defects, resulting in persistent cerebrospinal fluid (CSF) leaks and the formation of pleural fistulas. The typical intervention for this is CSF diversion through external ventricular drain or lumbar drain placement, followed by direct repair. However, if all these measures fail, subsequent salvage techniques have not been described previously. A 45-year-old man with past medical history of obesity (body mass index: 58), hypertension, and type 2 diabetes mellitus presented to the emergency department with thoracic myelopathy symptoms. MR demonstrated a giant calcified thoracic discs at T7-T8 with severe spinal cord compression. Intraoperatively, the disc was found fused to the dura and removal caused a large ventrolateral dural dehiscence. CSF diversion and direct repair were attempted unsuccessfully, so a salvage procedure with a rotational pedicled latissimus dorsi flap was performed. The patient's latissimus dorsi was exposed and resected from attachments, maintaining thoracodorsal blood supply, while removing thoracodorsal innervation. The flap was then rotated into the previous corpectomy site. The dural defect was repaired with a sealant patch, overlayed with a parietal pleural flap and the latissimus dorsi flap. By the patient's last follow-up, he had full functional independence at home. We present a surgical case highlighting the challenges of managing postoperative CSF-pleural fistula occurring after giant calcified thoracic disc removal and the successful use of a novel rotational latissimus dorsi flap to definitively repair the fistula after unsuccessful primary interventions.

Surgical decompression in spinal Paget's disease: illustrative case.

Paget's disease of bone (PDB) is a common bone metabolic pathology in older adults, characterized by mixed osteolytic, osteoblastic, and quiescent periods. Surgical guidelines for PDB involving the spine are not well-defined and are reserved for cases refractory to medical treatments, typically bisphosphonates like zoledronic acid. This case study describes a 52-year-old male with PDB who presented with rapidly progressing myelopathy symptoms refractory to standard medical treatment, warranting surgical decompression. Surgical decompression and fusion, involving laminectomy with partial facetectomies, placement of pedicle screw instrumentation, and posterolateral arthrodesis spanning beyond the pathological segment, was performed. Follow-up visits indicated progressive improvement in symptoms and mobility, and imaging showed stable postsurgical changes with increased sclerosis in the affected vertebrae on a 2-year postsurgical course. This case underscores that PDB of the spine can transition from asymptomatic to significant impairment and demonstrates that surgical intervention can provide effective symptomatic relief in myelopathy secondary to PDB. The case contributes to the growing evidence of the effectiveness of surgical decompression in PDB involving the spine. https://thejns.org/doi/10.3171/CASE24203.

Clinical and surgical outcome in patients with cervical spondylodiscitis-a single-center retrospective case series of 24 patients.

Cervical spondylodiscitis is a rare pathology, with an incidence of 0.5-2.5 per 100,000 population, posing significant potential risks. This type of infection can lead to neurological impairment in up to 29% of patients. Radical surgical debridement of the infected segment, fusion, and an intravenous antibiotic regimen remains the gold standard in most spine centers. This study aimed to analyze the surgical outcome in a tertiary spine center based on disease severity. In this study, we retrospectively included all patients diagnosed with cervical spondylodiscitis and treated at the University Hospital Augsburg between January 2017 and May 2022. We collected and analyzed baseline parameters on clinical presentation with symptoms, laboratory parameters, radiological appearance, and surgical parameters such as type of approach and implant, as well as neurological and radiological outcomes. Descriptive statistics were performed using SPSS, and relevant correlations were examined using the t-test for independent samples and the chi-square test. Twenty-four patients (9%) with cervical spondylodiscitis were identified. Twenty-two (92%) surgically treated patients were subdivided into the complicated discitis group (n = 14, 64%) and the uncomplicated discitis group (n = 8, 36%). Seventeen patients (71%) presented with sepsis on admission, 17 patients (71%) were diagnosed with epidural abscess on primary imaging, and 5 patients (21%) had more than one discitis lesion at a distant spinal segment. The presence of epidural abscess was significantly associated with systemic sepsis (OR = 6.2; p = 0.03) and myelopathy symptoms (OR = 14.4; p = 0.00). The most frequently detected specimen was a multisensitive Staphylococcus aureus (10 patients, 42%). Six patients (25%) died after a median of 20 days despite antibiogram-accurate therapy, five of whom were diagnosed with a complicated type of discitis. The follow-up data of 15 patients (63%) revealed permanent neurological damage in 9 patients (38%). Notably, the surgical approach was a significant factor for revision surgery (p = 0.008), as three out of five (60%) ventrodorsal cases with complicated discitis were revised. Cervical spondylodiscitis represents a severe infectious disease that is often associated with permanent neurological damage or a fatal outcome, despite adequate surgical and antibiotic treatments. Complicated types of discitis may require a more challenging surgical and clinical course.

A Rare Case of an Adult with Spinal Cord Injury Without Neuroimaging Abnormality (SCIWONA)

BackgroundSpinal cord injury without radiographic abnormality (SCIWORA) is defined as having clinical symptoms of traumatic myelopathy with no radiographic or computed tomographic features of spinal fracture or instability. An abnormal finding, such as a fracture, subluxation, or abnormal intersegmental motion at the level of the spinal cord injury, excludes SCIWORA as the diagnosis. Prevalence of SCIWORA is highest among children younger than 8 years, and is a diagnosis seen primarily in children, owing to anatomic differences that put children at more risk of this condition. In more recent years, with the increasing use of magnetic resonance imaging in patients with suspected spinal cord injury, a new term, spinal cord injury without neuroimaging abnormality (SCIWONA) has been suggested as a more specific way to describe cases of SCIWORA that have negative neuroimaging. Case ReportHere we describe a case of a woman who presented with symptoms consistent with a spinal cord injury after a traumatic fall. Her presentation and imaging were consistent with SCIWONA. The patient subsequently had rapid and complete recovery of her neurologic function. Why Should an Emergency Physician Be Aware of This? Early recognition of SCIWONA and subsequent medical management is imperative for improved outcomes for these patients. Operative treatment is rare and typically only necessary in patients with consistent spinal cord instability.

Evidence-based commentary on the diagnosis, management, and further research of degenerative cervical spinal cord compression in the absence of clinical symptoms of myelopathy.

Degenerative cervical myelopathy (DCM) represents the final consequence of a series of degenerative changes in the cervical spine, resulting in cervical spinal canal stenosis and mechanical stress on the cervical spinal cord. This process leads to subsequent pathophysiological processes in the spinal cord tissues. The primary mechanism of injury is degenerative compression of the cervical spinal cord, detectable by magnetic resonance imaging (MRI), serving as a hallmark for diagnosing DCM. However, the relative resilience of the cervical spinal cord to mechanical compression leads to clinical-radiological discordance, i.e., some individuals may exhibit MRI findings of DCC without the clinical signs and symptoms of myelopathy. This degenerative compression of the cervical spinal cord without clinical signs of myelopathy, potentially serving as a precursor to the development of DCM, remains a somewhat controversial topic. In this review article, we elaborate on and provide commentary on the terminology, epidemiology, natural course, diagnosis, predictive value, risks, and practical management of this condition-all of which are subjects of ongoing debate.

Transarterial Embolization of Intracranial Dural Arteriovenous Fistulas Cognard Type V With Direct Drainage Into the Perimedullary Veins: Case Report and Literature Review.

Cognard type V fistula (CVF) is a rare type of dural arteriovenous fistula characterized by spinal perimedullary venous drainage. Owing to the lack of pathognomonic findings, misdiagnosis is common. Patients often undergo multiple spinal angiograms negative for spinal vascular malformations. Digital subtraction angiography is the gold standard diagnostic tool. The preferred treatment option is endovascular management with embolization through a transarterial, transvenous, or combined approach. Other options include open surgery, stereotactic radiosurgery, or a combination of both. The patient from case # 1 presented with progressive weakness and hypoesthesia in the bilateral lower extremities, with urinary and bowel incontinence. The DSA identified a CVF fed by the meningohypophyseal trunk and a draining perimedullary vein. Embolization with 0.1 ccs of Onyx-18 was performed with complete fistula occlusion. The patient from case # 2 developed bilateral lower extremity weakness, diffuse numbness, and urinary incontinence. The DSA showed a CVF fed by tributaries from the ascending pharyngeal artery and posterior meningeal artery branches of the V3 segment, draining into a perimedullary vein. Embolization with 0.3 cc of Onyx-18 was performed with 100% occlusion of the fistula. A 1-year follow-up angiogram confirmed complete fistula occlusion. Both patients consented to the procedure. Even if a patient only presents symptoms of myelopathy, CVF should be considered. Herein, we present 2 cases of CVF with direct drainage into the perimedullary veins which presented exclusively with myelopathy syndrome and describe treatment with trasarterial embolization with Onyx.

Epidural angioleiomyoma: an extraordinary cause of compressive myelopathy-MRI findings with histopathological correlation.

Angioleiomyomas are benign mesenchymal tumors usually located in the limbs, with anecdotal reports in the spine. We present an atypical case of an epidural spine angioleiomyoma presenting with compressive myelopathy symptoms. The diagnosis was suggested based on MRI findings, and subsequently confirmed histopathologically. This is the first known occurrence of pure spinal epidural angioleiomyoma as a source of compressive myelopathy. The imaging presentation, especially the 'dark reticular sign' on MRI, was crucial in suggesting the diagnosis despite the atypical location CONCLUSION: This report serves to raise awareness among clinicians and radiologists about including angioleiomyoma in differential diagnoses for spinal epidural lesions with indicative MRI features. The favorable outcome aftersurgical intervention underscores the necessity of swift and accurate diagnosis followed by appropriate treatment for such uncommon spinal tumors.

Diffusion tensor imaging in differentiation of spinal cord lesions

Background Spinal lesions sometimes remain insufficiently visualized by ‘conventional’ magnetic resonance imaging techniques; indeed very often the lesions seen on T2 weighted images do not completely display the effects of pathology on the long tracts. Diffusion imaging, which enables the imaging of molecular water motion, has been applied recently to spinal cord diseases Aim The purpose of this study was to assess the role of Diffusion tensor imaging in in differentiation between different spinal cord lesions Patients &amp; methods This prospective study included 30 patients with myelopathy symptoms. All patients were subjected to full history taking, clinical examination, magnetic resonance imaging and diffusion tensor imaging MRI. Results The mean FA values at the site of the lesion was significantly lower than the normal appearing spinal cord in inflammation/demyelination, compressive myelopathy and traumatic spinal cord injury groups while the mean apparent diffusion coefficient values at the site of the lesions was significantly higher than the normal appearing spinal cord in inflammation/demyelination group. FA was sensitive than apparent diffusion coefficient in the detection of the spinal cord abnormalities with a sensitivity of 90% versus 60% respectively. Conclusion Diffusion tensor imaging with its quantitative indices is a non-invasive tool that is used in functional assessment of normal and pathologic spinal cord white matter, giving detailed information about different pathology and helping early management.

362 Enhanced Measures to Quantify Gait and Balance Impairment in Degenerative Cervical Myelopathy: A Prospective Cohort Study

INTRODUCTION: Gait and balance impairment are among the cardinal symptoms of Degenerative Cervical Myelopathy, however, utilizing objective measurements of these functions is highly challenging. METHODS: A prospective cross-sectional cohort study with manual and quantitative gait/balance testing using a Protokinetics Zeno Walkway electronic pressure mat (self/fast-paced, tandem gait/stance, Romberg, one foot standing). RESULTS: 95 DCM and 78 healthy subjects were included. For quantitave gait assesment, Velocity (p = 4.56x 10-8, 3.39x10-7), Gait Variability Index (p = 1.788x10-8, p = 0.00169), and stability ratio, single stance time/ double stance time, (p = 4.167x10^-7, p = 1.438x10^-5) were significantly different between groups for both self and fast-paced gait assessments, respectively. Balance was assessed by the variability of the center of pressure (COP). The standard deviation variability of COP in both the X (p = 0.00171) and Y directions (p = 0.000104) and cadence (p = 0.00175) were significant for tandem gait, walking heel-to-toe. Standing on either the Left or Right foot also showed a difference in the variability of COP in both directions X (p = 4.21x10^-7 Left Foot, p = 8.27x10^-7 Right Foot) and Y (p = 6.64x10^-4 Left Foot, p = 1.32x10^-4 Right Foot). On, manual assesment, DCM patients scored significantly worse in all parameters such as self-paced (p = 5.54x10^-2), fast-paced (p = 6.28x10^-2), tandem gait (p = 3.60x10^-8), Romberg eyes open (p = 1.58x10^-2), Romberg eyes closed (p = 1.90x10^-2), L foot stance (p = 6.78x10^-6), R foot stance (2.1x10^-6), and tandem stance (p = 8.83x10^-5). CONCLUSIONS: Quantitative parameters from an electronic pressure mat can be used to assess gait and balance impairment with high sensitivity and strong correlation with subjective measures. Manual scoring of tandem gait, standing on one foot, and tandem stance also provided robust differences and can be easily adopted into routine assessment of DCM patients.

Advanced Technique of 360° Decompression for Thoracic Spondylotic Myelopathy Using the Biportal Endoscopic Posterior Approach

Objective: Biportal endoscopic surgery was developed to treat degenerative pathologies that cause myelopathy. Thoracic disc herniation accelerates myelopathy at the level of thoracic stenosis caused by ossification of the ligamentum flavum (OLF). This study describes a feasible surgical technique for the biportal endoscopic posterior approach for removing the thoracic OLF and herniated disc that cause thoracic myelopathy.Methods: Bilateral laminar thinning was performed while preserving the midline and contralateral bony structures. The thoracic OLF was thinned and cut at the bony drilled edge using a diamond drill. The OLF was elevated and removed using an en bloc technique after epidural dissection. The herniated disc was removed through the space created after medial facetectomy. All the procedures were performed without neural injury.Results: Postoperatively, the neurological symptoms of thoracic myelopathy improved, as did the upper back and chest wall pain.Conclusion: We successfully treated double-crushing lesions of the thoracic herniated disc and OLF using biportal endoscopy. In biportal endoscopic surgery, drills and instruments can be smoothly used in the narrow spinal canal of the upper thoracic vertebrae. The biportal endoscopic posterior thoracic approach may be an attractive surgical option for treating thoracic myelopathy caused by combined degenerative pathologies.

Adhesive arachnoiditis, subarachnoid hemorrhage, and intradural extramedullary thoracic cavernoma: illustrative case.

Spinal arachnoiditis can result from various factors, including spinal subarachnoid hemorrhage (sSAH). In this paper, the authors describe a case of intradural extramedullary cavernoma with an initial presentation of subarachnoid hemorrhage leading to multilevel spinal arachnoiditis to discuss the pathophysiology and optimal treatment strategy. Spinal intradural extramedullary cavernoma manifesting with sSAH is a rare clinical presentation; therefore, there is no clear strategy for the management of sSAH. Spinal arachnoiditis is a result of chronic inflammation of the pia arachnoid layer due to hematomyelia. No effective treatment that interrupts this inflammatory cascade and would also prevent the development of spinal arachnoiditis has been described to date. Lumbar drainage could aid in sSAH management, relieve spinal cord compression, and restore the normal spinal cerebrospinal fluid circulation gradient. It could help to clear the blood degradation products rapidly and prevent early inflammatory arachnoiditis development. Mini-invasive intrathecal endoscopic adhesiolysis appears to be a reasonable approach for reducing the risk of aggravating spinal arachnoiditis with a mechanical-surgical stimulus. Whether a conservative approach should be applied in these patients with mild myelopathy symptoms is still debatable.

Neurofibroma of C2 root

Background: Intra and extradural neurofibromas of C2 root is a challenging pathology, usually with indolent evolution, that is why the onset symptoms are neurologic deficit just like upper cervical myelopathy symptoms and explains the late diagnosis of giant tumours with severe spinal cord compression with involvement and distortion of great vessels anatomy. These facts make surgeries more difficult. The follow-up of this type of surgery must be very close because CSF fistula can often occur. Case description: The present article reports a series of three cases of neurofibromas, two of them are giant dumbbell-shaped C2 neurofibromas and the third one is a case of neurofibromatosis type 1 of C2 roots bilaterally, C3 root unilateral with unusual postoperative course. Dural reconstruction was necessary in all cases. Conclusions: The patients in this series were very symptomatic with good recovery. The surgical procedures were challenging, total tumour removal was possible, and the reconstruction of dural defects was needed in all cases. In the case of NF1, the postoperative period was practically just the follow-up of complications and addressing them. This fact stresses the importance of meticulous preoperative planning and close follow-up. Postoperative quality of life was better than preoperative in all the cases. The purpose of the surgical treatment is the decompression of the spinal cord, tumour removal and prophylaxis of CSF fistula by closing the dural defects. Overall, the surgical C2 root neurofibromas resection is a safe procedure and is associated with good clinical outcomes.

Ayurvedic Management of Cervical Myelopathy

Cervical Myelopathy is a condition causing compression of the spinal cord at the cervical level of the spinal cord. It is mostly due to degenerative cervical spondylosis and is hence called Cervical Spondylotic Myelopathy. The spinal cord may directly experience compressive and ischemic dysfunction as a result of age-related spondylotic alterations. A 63-year-old male with complaints of gradually progressive weakness in the arms and hands along with numbness, tingling sensation, neck stiffness and pain around the neck region for the last 10 years came to the OPD of our hospital. The management offered by contemporary medicine is not satisfactory. Cervical myelopathy and Greevastambha can be co-related in this case, based on signs and symptoms. This case report demonstrates how the clinical and radiological symptoms of cervical spondylotic myelopathy were alleviated by an Ayurvedic intervention. To confirm these results and incorporate Ayurveda into conventional medicine for spinal cord injuries, more investigation and controlled trials are necessary.

Don’t pin it all on a stereotype

Hypercalcemia is one of the most frequently encountered problems in endocrinology OPD. Although the evaluation may not always be straightforward in all scenarios. Common factors affecting calcium levels such as dehydration, improper sample collection, and vitamin D supplementation may mask a serious underlying disorder. Here, we discuss a case of an elderly female who had symptoms of myelopathy and hypercalcemia whose etiology was initially attributed to excessive supplementation of calcium, vitamin D, and age- related bone changes; had another serious underlying calcium metabolism disorder.