Purpose: Pneumocephalus is an uncommon but serious complication of spinal surgery and its management and pathophysiology is not widely recognized. Incidence of symptomatic tension pneumocephalus secondary to posterior spinal arthrodesis is unknown. We describe a case of symptomatic tension pneumocephalus in the postoperative period of lumbar arthrodesis surgery, causes, risk factors, treatment and a review of the literature about this uncommon complication.

Methods: The clinical findings, radiological studies (Magnetic resonance imaging and CT scan), and treatment were presented.

Results: We report a rare case of a 41 year old woman with diagnosis of L3-L4, L4- L5 discopathy and left discal herniation L4-L5. A posterior spinal arthrodesis L3-L5, L3-L4 and L4-L5 discectomies and release of the left L5 root, was performed without apparent complications. 24 hours after surgery the patient developed generalized headache, neck stiffness, and dysarthria. MRI and CT scan revealed a huge pneumocephalus in the subarachnoid space, predominantly in the left frontal lobe without midline shift, which originates in the lumbar spinal canal. Treatment: The patient was treated conservatively, featuring 72 hours from progressive neurological improvement, up to clinical and radiological normalization after 7 days.

Conclusions: Pneumocephalus is a rare but potentially serious complication of spine surgery related in most cases with inadvertent dural tear during surgery. Most collections are small, behave benign, and respond to conservative therapy. In the majority of patients with pneumocephalus, a conservative approach consisting of bedrest, hyperhydration, analgesics, sedatives, and antiemetics is adequate, and symptoms resolve in a few weeks. In the present case with inadvartent CSF fistula, the vacuum drainage system predisposed the patient to pneumocephalus. A high degree of suspicion is needed to make the diagnosis, prompt treatment, and remedy of the source of air to prevent unwanted morbidity and mortality.

Cavernous malformations, also termed “cavernous hemangiomas,” “cavernous angiomas,” and “cavernomas”, terms that may carry different histological variations, are benign developmental anomalies composed of endothelium lined vascular channels. They are found throughout the Central Nervous System, but rarely occur in the spine. Spinal cavernous hemangiomas are vascular malformations with a reported incidence of 5% to 12% of all spinal vascular abnormalities. Approximately 3% of spinal cavernous hemangiomas are intradural, usually with an intramedullary location. Epidural cavernous hemangioma of the spine, account for approximately 4% of these vascular epidural lesions.

Hemangiopericytoma is a very rare and aggressive tumor that originates from pericytes of Zimmermann. Spinal hemangiopericytoma is a rare neoplasm that behaves similar to intracranial hemangiopericytoma, with approximately 140 cases being reported in the literature. We report a case of recurrent hemangiopericytoma of dorsal spine in a 55-year-old women treated with surgery for 3 times, with liver metastasis. Gross total resection, if possible, is the first choice of treatment. Radiation therapy or chemotherapy may be indicated, especially in cases with high-grade lesions or tumors with unresectable.

A retrospective review of 70 consecutive lumbar degenerative surgical cases in which intraoperative fluoroscopic imaging was compared with immediate postoperative radiographs using a novel vertebral grid-coordinate system. Same-hospitalization postoperative standing lumbar AP and lateral radiographs do not appear to be cost-effective or to provide additional clinically relevant information when intraoperative fluoroscopy is utilized.

The incidence of atlantoaxial rotatory subluxation is fairly uncommon; however it is more common to be encountered in the pediatric population. It is usually seen in children after a retropharyngeal inflammation or after a minor trauma. Children have unique anatomical features such as inherent ligamentous laxity and shallower and more horizontally oriented facet joints that allow greater freedom of motion especially at the C1-2 joint making them prone to atlantoaxial subluxation. If recognized early it can be successfully managed nonsurgically before chronic inflammatory changes affect the ligaments and joint structure of the C1-2 complex. However, it is unclear in the literature if inpatient admission is necessary for treatment. Here we present a case of atlantoaxial rotatory subluxation in a child caused by forcefully throwing a ball that was successfully reduced and subsequently discharge from the pediatric emergency department all in the same visit.

Background: To analyse use of monopolar diathermy stimulation of pedicle screws in order to improve breach detection.

Methods: Prospective single-blind study. Patients with preoperative neurological deficit excluded. Pedicle screws inserted freehand into thoracic and lumbar spine. Monopolar diathermy in “cutting” mode at half the strength used for actual cutting purpose was used to stimulate the tap in situ, followed by stimulation of the screw if satisfactory. Elicitation of twitching of local paraspinal muscles and/ or lower limb muscles was considered a positive response, suggestive of pedicle breach. Appropriate revision of screw track was done accordingly. Intraoperative C-arm imaging and postoperative CT scan [blinded evaluation] was done for further verification in all cases. Meticulous clinical assessment was done in the immediate postoperative period to rule out any kind of neurological deterioration.

Results: Seventy-eight consecutive patients undergoing surgical stabilization for varied indications such as trauma [n=15], spondylolisthesis [n=53], spinal infection [n=4] and spinal deformity [n=6] were included in the study. Mean age was 42.3+12.3 years. 468 pedicle screws were inserted. Eleven true positive and three false positive cases were noted. Nine false negative cases were detected on postoperative CT. These breaches were however, <2 mm and asymptomatic. Considering this, this method demonstrated sensitivity, specificity, positive predictive value and negative predictive value of 97.63%, 100%, 100% and 21.43%, respectively. No patient had any adverse effect related to the diathermy stimulation.

Conclusions and Clinical Relevance: Diathermy stimulation of pedicle screws inserted into spine in conjunction with screw track probing and intraoperative C-arm imaging is a viable option to improve accuracy of screw placement, particularly in a setup where no other advanced electrophysiological tests exist.