This retrospective case series of prospective data aims to describe the transaxillary approach fo... more This retrospective case series of prospective data aims to describe the transaxillary approach for the treatment of upper thoracic spine pathology. Various surgical techniques and approaches have been reported across the literature to address upper thoracic spine pathology, including the cervicothoracic approach, anterior transsternal approach, posterolateral approach, supraclavicular approach, and lateral parascapular approaches. These techniques are invasive. A minimally invasive, less morbid, and direct access approach to the pathology of the upper thoracic spine has not been reported in the literature. Patients with pathology affecting the first thoracic vertebra up to the sixth thoracic vertebra were classified into the upper thoracic spine group. Patients with pathology below the sixth thoracic vertebra were excluded. Patients not having a minimum follow-up of 12 months were also excluded. The study analyzed 18 patients. The mean preoperative modified Japanese Orthopedic Association score was 7.2±1.44, which improved to 10.16±1.2 (p<0.05). The majority (14/18) of the patients had an excellent outcome. Three patients had good outcomes, and one patient had a fair outcome. Five cases of intraoperative dural leak were recorded, and one patient had postoperative neurological deficit. The transaxillary approach is a safe, viable, muscle-sparing, and minimally invasive approach for ventral pathologies of the upper thoracic spine.
Study Design: Prospective Comparative Study Objective:This study aims to compare the functional o... more Study Design: Prospective Comparative Study Objective:This study aims to compare the functional outcomes of Robotic-assisted rehabilitation by Lokomat system Vs. Conventional rehabilitation in patients with Dorsolumbar complete spinal cord injury. Methods: 15 patients with Dorsolumbar spinal cord injury with ASIA A neurology were allocated to robotic rehabilitation and 15 patients to conventional rehabilitation after an operative procedure. Pre-rehabilitation parameters were noted in terms of ASIA Neurology, Motor, and sensory function scores, WISCI II score (Walking Index in Spinal Cord Injury score), LEMS (Lower Extremity Motor Score), SCIM III score (Spinal Cord Independence Measure III score), AO Spine PROST (AO Patient Reported Outcome Spine Trauma), McGill QOL score (Mc Gill Quality Of Life score), VAS score (Visual Analogue Scale) for pain and Modified Ashworth scale for spasticity in lower limbs. Results: On comparing of robotic group to conventional group there was a statistically significant improvement in group in terms of Motor score, WISCI II score, SCIM III score, AO PROST score, Mc GILL QOL score, Max velocity, and Step length. While LEMS score, ASIA neurology, VAS score, Sensory score, and Modified Ashworth scale for spasticity were not statically significant while comparing between two groups. Conclusion: Robot-assisted rehabilitation is superior than conventional rehabilitation in Spinal Cord Injury patients. Variations in results found in the literature for robotic assisted training are probably a result of factors such as differences in type and severity of lesion, time of onset to entry in rehab the devices used, application of the interventions and control interventions. Level of Evidence: III
W e read with interest Dr Kotter et al’s article on laminectomy with fusion versus laminectomy al... more W e read with interest Dr Kotter et al’s article on laminectomy with fusion versus laminectomy alone for degenerative cervical myelopathy (DCM). We commend their use of a multicenter database with validated outcome measures. Overall, they support a rationale for laminectomy plus fusion for DCM rather than laminectomy alone. We emphasize caution in the interpretation of their findings. DCM patients are a heterogenous group subject to multiple confounding variables with only 22 patients in the laminectomy group versus 186 in the laminectomy and fusion group. Thus, findings are not generalizable with no power calculations to detect a proportional statistical difference. Broad inclusion criteria limit generalizability with no informationonsymptom duration, radiological cord compression, and extent of cervical deformity. There are few baseline variables for a multicenter study, omission of systemic confounding variables, no data on center case volume and stratification. Significant selection bias exists secondary to approach, number of levels and, the decision to fuse varying hugely among the surgical community. Only a standardized randomized controlled trial can truly address this question. Ultimately, one cannot infer based on the presented difference in outcome measures, is secondary to ‘‘impeding dynamic movement of the spinal cord’’ in patients undergoing fusion.
Journal of clinical orthopaedics and trauma, Apr 1, 2021
Background Though spine trauma contributes to great functional, psychological, and economic loss,... more Background Though spine trauma contributes to great functional, psychological, and economic loss, research regarding the demographic profile of patients according to different regions of our country are lacking.This study aims to identify the demographic pattern and clinical profile of patients with spinal fracture in the Sub-Himalayan region. Method Patients with acute or subacute spine trauma presenting within 8weeks and involving fracture of cervical, dorsal, or lumbar vertebra, from July 2017 to December 2019 were included prospectively. Patients with osteoporotic or metastatic collapse, isolated transverse or spinous process fracture, penetrating trauma or ballistic injuries were excluded. Results Out of 280 enrolled patients, 180 were males and 100 were females. The maximum number of spine trauma patients was in 16-30 years age group. The most common mechanism of injury was fall from height (FFH, 42.5%)> road traffic accident (RTA, 38.6%). RTA was more common among males and FFH among females (p < 0.0001). Most common location of injury was at thoracolumbar junction (D10-L2) (37.5%) followed by cervical spine (25.3%). 58.2% of patients had AO type A facture morphology followed by AO types C (36.1%) and AO type B (5.7%). Spinal Cord Injury (SCI) was seen in 82.1% spine trauma patients with statistically significant association with male gender (p- 0.045). Complete paralysis was seen maximum in patients with cervical spine injury (67.3%, p < 0.0001). Complete neurological deficit (ASIA grade A) was seen maximum in AO type C fracture morphology (74.25%, p < 0.001) followed by AO type A4 (29.6%). Seasonal distribution showed increased incidence during summer and monsoon season. Conclusion Young aged males in age group of 16-30 yrs were most commonly affected with fall from height as the most common mechanism of trauma. Association was found between gender and mechanism of injury (RTA in males and FFH in females). Most common vertebral injury level was thoracolumbar junction. AO type A was the most common fracture morphology. SCI seen in 82.1% of spine trauma. Statistically significant association was found between Complete SCI with Location of Injury (Cervical) and Fracture morphology (AO type C).
Abstract Background Protrusion, extrusion and sequestrated discs are common types of disc herniat... more Abstract Background Protrusion, extrusion and sequestrated discs are common types of disc herniation. Protrusion is the variant with intact annulus. Sometimes nucleus pulposus may break through inner layers of the annulus and extrude to lie between the outer and inner layers of the annulus fibers. Such herniation may be called as subannular herniation. The endoscopic approaches are an attractive option in younger population as they are minimally invasive, highly efficient and offer early rehabilitation, early functional recovery and improved quality of life. We report one such case where a challenging herniated subannular nucleus pulposus was treated by outside-in inter-annular Transforaminal endoscopic disc surgery (TELD). Case Report: A 17-year-old female presented to our clinic with insidious onset, progressive low back ache and right leg pain of 3 months duration. The pain increased in intensity as the time elapsed and the Visual Analogue Score (VAS) on presentation was VAS- 5 (Back) and VAS-7 (right Leg). These symptoms were also associated with reduced sensations over the right L5 dermatomal distribution and perianal hypo-aesthesia. There was weakness in bilateral great toe dorsiflexion and mild urinary symptoms. Magnetic resonance imaging (MRI) of the Lumbar spine showed a herniated subannular Disc at L4-L5 level with a large central component compressing the thecal sac and traversing nerve root. The patient underwent Mobile Outside-in Interannular Transforaminal Endoscopic Lumbar Discectomy (TELD). Patient’s symptoms improved significantly after surgery and visual analogue score improved to, VAS Back – 1 and VAS Leg – 0. At six months follow up, the neurology was normal. Conclusion Mobile outside-in, Interannular Transforaminal Endoscopic Lumbar Discectomy (TELD) is an effective, minimally-invasive option to treat sub annular herniated nucleus pulposus.
Introduction: Malignant bone tumors of the spine are extremely rare with an incidence of 0.05% of... more Introduction: Malignant bone tumors of the spine are extremely rare with an incidence of 0.05% of primary neoplasms. Solitary plasmacytoma of the vertebra accounts for about 30% of the total within this group. Case presentation: A 23-year-old female presented to spine clinic, with complaints of low back pain, deformity in lower back, and difficulty in walking for 3 months duration. Radiological investigations revealed destruction of L3 vertebra with soft-tissue mass around it. USG-guided biopsy from the lesion was suggestive of plasma cell dyscrasia. Routine blood investigations showed no abnormality. Urine myeloma profile and immunoelectrophoresis were done which were within normal limit and ruled out multiple myeloma. Due to the profound neurological deficit and existing instability, the patient underwent decompression, resection of tumor, anterior column reconstruction with cage, and instrumented posterior and posterolateral fusion (360° fusion) from L1-L5, before radiotherapy. The patient was subjected to 23 cycles of intensity-modulated radiotherapy and is doing good on subsequent follow-ups with good fusion. Conclusion: Solitary plasmacytoma of vertebra when associated with neurological deficit and/or instability should be treated with spinal stabilization surgery followed by radiotherapy to achieve good and overall predictable outcomes.
Journal of Craniovertebral Junction and Spine, 2016
Epidural injection of steroid is given for back pain resistant to other conservative management. ... more Epidural injection of steroid is given for back pain resistant to other conservative management. Normal saline (NS) is used as diluent in 80 mg methylprednisolone and a local anesthetic. Due to a similar looking ampoule of NS and potassium chloride (KCl), there is a probability of accidental use of KCl instead of NS. We present a case of a 50-year-old male patient having low back ache refractory to other conservative treatments. Epidural injection of steroid was given, but accidently KCl was mixed with methylprednisolone instead of NS. He developed severe cramps in the lower limbs, pruritus, and sweating, and finally paraplegia. Electrocardiography and blood showed features suggestive of hyperkalemia. He was given calcium gluconate and potassium chelating agent along with supportive measures. The patient recovered within 8 h. It is concluded that calcium gluconate and potassium chelating agent can be used if accidentally KCl is injected in epidural space.
Introduction: The management of heel pad avulsion injuries has been challenging because of the pr... more Introduction: The management of heel pad avulsion injuries has been challenging because of the precarious blood supply. The difficulties get compounded when it is associated with tendo-achilles rupture and calcaneal fracture. Here, it is a description of a case with the above features managed with a unique technique. Case report: A 63-year-old woman presented to casualty with injury to right ankle after a road traffic accident. On clinical and radiological examination, there was avulsion of heel pad with calcaneal tuberosity fracture and tendo-achilles rupture. It was managed with debridement of the wound, repair of tendo-achilles, and fixation of calcaneal tuberosity and heel pad. The functional outcome was assessed in terms of the ability of the patient to return to painless barefoot weight bearing. The uniqueness of this method is the combined use of suture material (Ethibond) and stainless steel (cannulated cancellous screws [CCS]), by tying the Ethibond from tendo-achilles to the head of CCS rather than bone. When the CCS were tightened, two things were achieved; one being the reduction of the fracture and the second to bring a good apposition of tendo-achilles with the calcaneum. As this method worked on tension band principle and Ethibond was used instead of stainless steel wire, if no objections, this technique can be called as "soft tension band technique." Conclusion: This case report illustrates a method of preserving heel pad when it is viable along with definitive treatment of associated soft tissue and bony injuries by a simple technique. This method has described the fixation of open fracture of calcaneal tuberosity with tendo-achilles rupture with heel pad avulsion in one sitting with excellent clinical results.
Over the years, a number of authors have used different working definitions of instability in tub... more Over the years, a number of authors have used different working definitions of instability in tuberculosis of the spine (TB spine). However, no clear consensus exists to define instability in TB spine. The current systematic review addresses the question 'What defines instability in TB spine'? A comprehensive medical literature search was carried out to identify all the studies which defined instability in the setting of spinal TB. The extracted data included the clinical, X-ray and CT or MRI-based definitions. The current review identified lesser age, junctional region of the spine, mechanical pain and 'instability catch', kyphotic deformity above 40 degrees, pan-vertebral or bilateral facetal involvement and multifocal contiguous disease involving more than three vertebrae as predictors for spinal instability in the dorso-lumbar spine. Cervical kyphosis more than 30 degrees and facetal or pan-vertebral involvement were found to be the factors used to define instability in subaxial cervical spine. With respect to C1-C2 TB spine, migration of the tip of the odontoid above the McRae or McGregor line or anterior translation of C1 over C2 were considered as determinants for instability. Although definitive conclusions could not be drawn due to lack of adequate evidence, the authors identified factors which may contribute towards instability in TB spine.
Background: Iatrogenic neurological injury resulting during surgical intervention is a devastatin... more Background: Iatrogenic neurological injury resulting during surgical intervention is a devastating complication not only for patient but also for the operating surgeon. Even with best efforts, the risk remains approximately 5%. Aims: This study aims to study the role of intraoperative neuromonitoring (IONM) in non-deformed spine surgeries and to find out the sensitivity and specificity. Settings and Design: Tertiary health-care centre. Retrospective study with data of the patients operated from January 2019 to January 2020 was reviewed and evaluated. Materials and Methods: Patients with spinal fractures, spondylodiscitis, bony tumours of spine and degenerative spinal disorders without neurological deficit were included. The patients with spinal deformity and with prior neurological deficits were excluded. Group A: the patients with no IONM signal drop during procedure, Group B: the patients who experienced significant drop in signal during surgery. Statistical Analysis Used: Data entry-MS Excel, Data analysis-SPSS 23.0 version for windows, descriptive statistics-mean ± numerical variable, null hypothesis-paired test-two sample for mean (<0.05 = significant). Results: Fifty-nine patients were included. Of 59, 50 patients had no significant drop, and 9 patients had permanent drop in signals. The mean blood loss in Group A was 735 ± 442.1 ml and was 978.9 ± 829 ml in Group B (P = 0.006). There was no signal drop in 39 patients. The sensitivity and specificity according to the above data in our series was 60% (confidence interval [CI] = 0.613–0.586) and 88% (CI = 0.891–0.886). Conclusions: IONM is fairly sensitive and very specific for detecting intraoperative neural compromise. There is significant correlation between the blood loss in the surgery and signal drop.
International Journal of Research in Orthopaedics, Feb 23, 2021
Fractures of the thoracic and lumbar vertebrae are quite common injuries among polytrauma patient... more Fractures of the thoracic and lumbar vertebrae are quite common injuries among polytrauma patients, and nearly one-third of those patients have concomitant neural structure injury and variable neurologic deficit. 1 Almost 60% of spinal fractures occur within the thoracolumbar region, with 17% being burst fracture. 2,3 These injuries are painful and may impact quality of life resulting in prolong absence from work and chronic pain; thus, having significant socioeconomic impact furthermore. 4 These injuries are usually resulting of high energy trauma like motorized vehicle accidents or falls from height and more common in men. Elderly people also are in danger for these fractures, because of weakened bone from osteoporosis. 5
Study design Meta-analysis. Objective To compare the clinical and radiological outcomes in patien... more Study design Meta-analysis. Objective To compare the clinical and radiological outcomes in patients with Adolescent Idiopathic scoliosis (AIS) treated by selective thoracic fusion (STF) with lowest instrumented vertebra (LIV) at touched vertebra (TV) vs stable vertebra (SV). Methods The databases PubMed, Embase and Google Scholar were searched until November 2020.Studies which had Lenke type 1 curves and Lenke type 2 curves in adolescent population treated by STF and which reported pre- and post-operative curve characteristics including correction percentage and complications were included. Studies which did not report the LIV selection, curve correction percentages and whose full text could not be acquired were excluded. Results Eight studies were included for analysis of which seven were found to be retrospective studies (level III evidence) and one was prospective study (level II evidence) each. Overall proportional meta-analysis found no significant difference in correction rate, total srs-22 scores, and complication rates. Conclusion The evaluation of SV group and TV group as LIV for selective thoracic fusions in AIS reveals a comparable outcome in terms of curve correction, patient satisfaction scores and complication rates. The TV can be chosen safely as the LIV especially in type A and B Lenke 1&amp;2 curves, as it saves more motion segments when compared to SV.
Background: Posterolateral decompression and debridement in patients with TB spine led to defect ... more Background: Posterolateral decompression and debridement in patients with TB spine led to defect in the anterior column which makes the spinal column unstable, thus making anterior column reconstruction an important step in surgical management. Objective: Through the study, authors sought to answer the following questions: 1) What are the differences in clinical outcomes between patients with TB spine undergoing anterior column reconstruction using titanium mesh cage versus PEEK cage? 2) What are the differences in radiological outcomes between these two groups of patients? Methods: This is a retrospective comparative study including patients with TB spine undergoing surgical management. The included subjects were divided into groups A and B depending on the implantation of PEEK or titanium mesh cage respectively for anterior column reconstruction. Outcome criteria analyzed included clinical criteria like VAS and ODI scores, radiological criteria like kyphosis correction, loss of kyphosis at follow-up, cage subsidence, and bony fusion on a 2D CT scan. Results: The study population included 14 patients in Group A and 15 patients in Group B. Improvement in VAS and ODI scores was comparable between groups. There was no significant difference in radiological outcome measures between the two groups, however, two patients from group B showed implant-related complications needing revision. All patients showed good bony fusion at the final follow-up. Conclusion: PEEK and titanium cages have comparable clinico-radiological outcomes for anterior column reconstruction in patients with active TB spine. Its advantages for being radiolucent and its ease of use may make it a choice of implant.
Background: Identifying the risk factors for the neurological deficit in spine tuberculosis would... more Background: Identifying the risk factors for the neurological deficit in spine tuberculosis would help surgeons in deciding on early surgery, thus reducing the morbidity related to neurological deficit. The main objective of our study was to predict the risk of neurological deficit in patients with spinal tuberculosis (TB). Methods: The demographic, clinical, radiological (X-ray and MRI) data of 105 patients with active spine TB were retrospectively analyzed. Patients were divided into two groupswith a neurological deficit (n = 52) as Group A and those without deficit (n = 53) as Group B. Univariate and multivariate logistic regression analysis was used to predict the risk factors for the neurological deficit. Results: The mean age of the patients was 38.1 years. The most common location of disease was dorsal region (35.2%). Paradiscal (77%) was the most common type of involvement. A statistically significant difference (p < 0.05) was noted in the location of disease, presence of cord compression, kyphosis, cord oedema, loss of CSF anterior to the cord, and degree of canal compromise or canal encroachment between two groups. Multivariate analysis revealed kyphosis > 30°(OR-3.92, CI-1.21-12.7, p-0.023), canal encroachment > 50% (OR-7.34, CI-2.32-23.17, p-0.001), and cord oedema (OR-11.93, CI-1.24-114.05, p-0.03) as independent risk factors for predicting the risk of neurological deficit. Conclusion: Kyphosis > 30°, cord oedema, and canal encroachment (>50%) significantly predicted neurological deficit in patients with spine TB. Early surgery should be considered with all these risk factors to prevent a neurological deficit.
The aim of the study was to objectively review the variability in the prevailing treatment protoc... more The aim of the study was to objectively review the variability in the prevailing treatment protocols and surgical decision making in the management of patients with spinal tuberculosis (TB) among spine surgeons with expertise in spinal TB across the country. Overview of Literature: A lack of good-quality evidence, ambiguities in the national spinal TB guidelines, and the demand for early rehabilitation and a better quality of life in patients with spinal TB has led to the emergence of various gray zones in the management of spinal TB. Methods: Seventeen fellowship-trained spinal TB experts representing different geographical regions of India completed an online survey consisting of questions pertaining to the conservative management of spinal TB (antitubercular therapy) and 30 clinical case vignettes including a wide spectrum of presentations of spinal TB with no or minimal neurological deficit. The variability in the responses for questions and case wise variability with respect to surgical decision making was assessed using the index of qualitative variation (IQV). The average tendency to operate (TTO) was calculated for various groups of respondents. Results: High variability was observed in all questions regarding conservative spinal TB management (IQV > 0.8). Among the 30 case vignettes, 14 were found to have high variability with respect to surgical decision making (IQV > 0.8). With respect to levels of fixation, all but two cases had poor or slight agreement. Younger age and practice in a government or tertiary care teaching hospital were factors associated with a higher TTO. Conclusions: Significant variability was detected in treatment practices for the management of spinal TB among experts. Most of the case vignettes were found to have significant heterogeneity with respect to surgical decision making, which reflects a significant lack of consensus and lacunae in literature.
This retrospective case series of prospective data aims to describe the transaxillary approach fo... more This retrospective case series of prospective data aims to describe the transaxillary approach for the treatment of upper thoracic spine pathology. Various surgical techniques and approaches have been reported across the literature to address upper thoracic spine pathology, including the cervicothoracic approach, anterior transsternal approach, posterolateral approach, supraclavicular approach, and lateral parascapular approaches. These techniques are invasive. A minimally invasive, less morbid, and direct access approach to the pathology of the upper thoracic spine has not been reported in the literature. Patients with pathology affecting the first thoracic vertebra up to the sixth thoracic vertebra were classified into the upper thoracic spine group. Patients with pathology below the sixth thoracic vertebra were excluded. Patients not having a minimum follow-up of 12 months were also excluded. The study analyzed 18 patients. The mean preoperative modified Japanese Orthopedic Association score was 7.2±1.44, which improved to 10.16±1.2 (p<0.05). The majority (14/18) of the patients had an excellent outcome. Three patients had good outcomes, and one patient had a fair outcome. Five cases of intraoperative dural leak were recorded, and one patient had postoperative neurological deficit. The transaxillary approach is a safe, viable, muscle-sparing, and minimally invasive approach for ventral pathologies of the upper thoracic spine.
Study Design: Prospective Comparative Study Objective:This study aims to compare the functional o... more Study Design: Prospective Comparative Study Objective:This study aims to compare the functional outcomes of Robotic-assisted rehabilitation by Lokomat system Vs. Conventional rehabilitation in patients with Dorsolumbar complete spinal cord injury. Methods: 15 patients with Dorsolumbar spinal cord injury with ASIA A neurology were allocated to robotic rehabilitation and 15 patients to conventional rehabilitation after an operative procedure. Pre-rehabilitation parameters were noted in terms of ASIA Neurology, Motor, and sensory function scores, WISCI II score (Walking Index in Spinal Cord Injury score), LEMS (Lower Extremity Motor Score), SCIM III score (Spinal Cord Independence Measure III score), AO Spine PROST (AO Patient Reported Outcome Spine Trauma), McGill QOL score (Mc Gill Quality Of Life score), VAS score (Visual Analogue Scale) for pain and Modified Ashworth scale for spasticity in lower limbs. Results: On comparing of robotic group to conventional group there was a statistically significant improvement in group in terms of Motor score, WISCI II score, SCIM III score, AO PROST score, Mc GILL QOL score, Max velocity, and Step length. While LEMS score, ASIA neurology, VAS score, Sensory score, and Modified Ashworth scale for spasticity were not statically significant while comparing between two groups. Conclusion: Robot-assisted rehabilitation is superior than conventional rehabilitation in Spinal Cord Injury patients. Variations in results found in the literature for robotic assisted training are probably a result of factors such as differences in type and severity of lesion, time of onset to entry in rehab the devices used, application of the interventions and control interventions. Level of Evidence: III
W e read with interest Dr Kotter et al’s article on laminectomy with fusion versus laminectomy al... more W e read with interest Dr Kotter et al’s article on laminectomy with fusion versus laminectomy alone for degenerative cervical myelopathy (DCM). We commend their use of a multicenter database with validated outcome measures. Overall, they support a rationale for laminectomy plus fusion for DCM rather than laminectomy alone. We emphasize caution in the interpretation of their findings. DCM patients are a heterogenous group subject to multiple confounding variables with only 22 patients in the laminectomy group versus 186 in the laminectomy and fusion group. Thus, findings are not generalizable with no power calculations to detect a proportional statistical difference. Broad inclusion criteria limit generalizability with no informationonsymptom duration, radiological cord compression, and extent of cervical deformity. There are few baseline variables for a multicenter study, omission of systemic confounding variables, no data on center case volume and stratification. Significant selection bias exists secondary to approach, number of levels and, the decision to fuse varying hugely among the surgical community. Only a standardized randomized controlled trial can truly address this question. Ultimately, one cannot infer based on the presented difference in outcome measures, is secondary to ‘‘impeding dynamic movement of the spinal cord’’ in patients undergoing fusion.
Journal of clinical orthopaedics and trauma, Apr 1, 2021
Background Though spine trauma contributes to great functional, psychological, and economic loss,... more Background Though spine trauma contributes to great functional, psychological, and economic loss, research regarding the demographic profile of patients according to different regions of our country are lacking.This study aims to identify the demographic pattern and clinical profile of patients with spinal fracture in the Sub-Himalayan region. Method Patients with acute or subacute spine trauma presenting within 8weeks and involving fracture of cervical, dorsal, or lumbar vertebra, from July 2017 to December 2019 were included prospectively. Patients with osteoporotic or metastatic collapse, isolated transverse or spinous process fracture, penetrating trauma or ballistic injuries were excluded. Results Out of 280 enrolled patients, 180 were males and 100 were females. The maximum number of spine trauma patients was in 16-30 years age group. The most common mechanism of injury was fall from height (FFH, 42.5%)> road traffic accident (RTA, 38.6%). RTA was more common among males and FFH among females (p < 0.0001). Most common location of injury was at thoracolumbar junction (D10-L2) (37.5%) followed by cervical spine (25.3%). 58.2% of patients had AO type A facture morphology followed by AO types C (36.1%) and AO type B (5.7%). Spinal Cord Injury (SCI) was seen in 82.1% spine trauma patients with statistically significant association with male gender (p- 0.045). Complete paralysis was seen maximum in patients with cervical spine injury (67.3%, p < 0.0001). Complete neurological deficit (ASIA grade A) was seen maximum in AO type C fracture morphology (74.25%, p < 0.001) followed by AO type A4 (29.6%). Seasonal distribution showed increased incidence during summer and monsoon season. Conclusion Young aged males in age group of 16-30 yrs were most commonly affected with fall from height as the most common mechanism of trauma. Association was found between gender and mechanism of injury (RTA in males and FFH in females). Most common vertebral injury level was thoracolumbar junction. AO type A was the most common fracture morphology. SCI seen in 82.1% of spine trauma. Statistically significant association was found between Complete SCI with Location of Injury (Cervical) and Fracture morphology (AO type C).
Abstract Background Protrusion, extrusion and sequestrated discs are common types of disc herniat... more Abstract Background Protrusion, extrusion and sequestrated discs are common types of disc herniation. Protrusion is the variant with intact annulus. Sometimes nucleus pulposus may break through inner layers of the annulus and extrude to lie between the outer and inner layers of the annulus fibers. Such herniation may be called as subannular herniation. The endoscopic approaches are an attractive option in younger population as they are minimally invasive, highly efficient and offer early rehabilitation, early functional recovery and improved quality of life. We report one such case where a challenging herniated subannular nucleus pulposus was treated by outside-in inter-annular Transforaminal endoscopic disc surgery (TELD). Case Report: A 17-year-old female presented to our clinic with insidious onset, progressive low back ache and right leg pain of 3 months duration. The pain increased in intensity as the time elapsed and the Visual Analogue Score (VAS) on presentation was VAS- 5 (Back) and VAS-7 (right Leg). These symptoms were also associated with reduced sensations over the right L5 dermatomal distribution and perianal hypo-aesthesia. There was weakness in bilateral great toe dorsiflexion and mild urinary symptoms. Magnetic resonance imaging (MRI) of the Lumbar spine showed a herniated subannular Disc at L4-L5 level with a large central component compressing the thecal sac and traversing nerve root. The patient underwent Mobile Outside-in Interannular Transforaminal Endoscopic Lumbar Discectomy (TELD). Patient’s symptoms improved significantly after surgery and visual analogue score improved to, VAS Back – 1 and VAS Leg – 0. At six months follow up, the neurology was normal. Conclusion Mobile outside-in, Interannular Transforaminal Endoscopic Lumbar Discectomy (TELD) is an effective, minimally-invasive option to treat sub annular herniated nucleus pulposus.
Introduction: Malignant bone tumors of the spine are extremely rare with an incidence of 0.05% of... more Introduction: Malignant bone tumors of the spine are extremely rare with an incidence of 0.05% of primary neoplasms. Solitary plasmacytoma of the vertebra accounts for about 30% of the total within this group. Case presentation: A 23-year-old female presented to spine clinic, with complaints of low back pain, deformity in lower back, and difficulty in walking for 3 months duration. Radiological investigations revealed destruction of L3 vertebra with soft-tissue mass around it. USG-guided biopsy from the lesion was suggestive of plasma cell dyscrasia. Routine blood investigations showed no abnormality. Urine myeloma profile and immunoelectrophoresis were done which were within normal limit and ruled out multiple myeloma. Due to the profound neurological deficit and existing instability, the patient underwent decompression, resection of tumor, anterior column reconstruction with cage, and instrumented posterior and posterolateral fusion (360° fusion) from L1-L5, before radiotherapy. The patient was subjected to 23 cycles of intensity-modulated radiotherapy and is doing good on subsequent follow-ups with good fusion. Conclusion: Solitary plasmacytoma of vertebra when associated with neurological deficit and/or instability should be treated with spinal stabilization surgery followed by radiotherapy to achieve good and overall predictable outcomes.
Journal of Craniovertebral Junction and Spine, 2016
Epidural injection of steroid is given for back pain resistant to other conservative management. ... more Epidural injection of steroid is given for back pain resistant to other conservative management. Normal saline (NS) is used as diluent in 80 mg methylprednisolone and a local anesthetic. Due to a similar looking ampoule of NS and potassium chloride (KCl), there is a probability of accidental use of KCl instead of NS. We present a case of a 50-year-old male patient having low back ache refractory to other conservative treatments. Epidural injection of steroid was given, but accidently KCl was mixed with methylprednisolone instead of NS. He developed severe cramps in the lower limbs, pruritus, and sweating, and finally paraplegia. Electrocardiography and blood showed features suggestive of hyperkalemia. He was given calcium gluconate and potassium chelating agent along with supportive measures. The patient recovered within 8 h. It is concluded that calcium gluconate and potassium chelating agent can be used if accidentally KCl is injected in epidural space.
Introduction: The management of heel pad avulsion injuries has been challenging because of the pr... more Introduction: The management of heel pad avulsion injuries has been challenging because of the precarious blood supply. The difficulties get compounded when it is associated with tendo-achilles rupture and calcaneal fracture. Here, it is a description of a case with the above features managed with a unique technique. Case report: A 63-year-old woman presented to casualty with injury to right ankle after a road traffic accident. On clinical and radiological examination, there was avulsion of heel pad with calcaneal tuberosity fracture and tendo-achilles rupture. It was managed with debridement of the wound, repair of tendo-achilles, and fixation of calcaneal tuberosity and heel pad. The functional outcome was assessed in terms of the ability of the patient to return to painless barefoot weight bearing. The uniqueness of this method is the combined use of suture material (Ethibond) and stainless steel (cannulated cancellous screws [CCS]), by tying the Ethibond from tendo-achilles to the head of CCS rather than bone. When the CCS were tightened, two things were achieved; one being the reduction of the fracture and the second to bring a good apposition of tendo-achilles with the calcaneum. As this method worked on tension band principle and Ethibond was used instead of stainless steel wire, if no objections, this technique can be called as "soft tension band technique." Conclusion: This case report illustrates a method of preserving heel pad when it is viable along with definitive treatment of associated soft tissue and bony injuries by a simple technique. This method has described the fixation of open fracture of calcaneal tuberosity with tendo-achilles rupture with heel pad avulsion in one sitting with excellent clinical results.
Over the years, a number of authors have used different working definitions of instability in tub... more Over the years, a number of authors have used different working definitions of instability in tuberculosis of the spine (TB spine). However, no clear consensus exists to define instability in TB spine. The current systematic review addresses the question 'What defines instability in TB spine'? A comprehensive medical literature search was carried out to identify all the studies which defined instability in the setting of spinal TB. The extracted data included the clinical, X-ray and CT or MRI-based definitions. The current review identified lesser age, junctional region of the spine, mechanical pain and 'instability catch', kyphotic deformity above 40 degrees, pan-vertebral or bilateral facetal involvement and multifocal contiguous disease involving more than three vertebrae as predictors for spinal instability in the dorso-lumbar spine. Cervical kyphosis more than 30 degrees and facetal or pan-vertebral involvement were found to be the factors used to define instability in subaxial cervical spine. With respect to C1-C2 TB spine, migration of the tip of the odontoid above the McRae or McGregor line or anterior translation of C1 over C2 were considered as determinants for instability. Although definitive conclusions could not be drawn due to lack of adequate evidence, the authors identified factors which may contribute towards instability in TB spine.
Background: Iatrogenic neurological injury resulting during surgical intervention is a devastatin... more Background: Iatrogenic neurological injury resulting during surgical intervention is a devastating complication not only for patient but also for the operating surgeon. Even with best efforts, the risk remains approximately 5%. Aims: This study aims to study the role of intraoperative neuromonitoring (IONM) in non-deformed spine surgeries and to find out the sensitivity and specificity. Settings and Design: Tertiary health-care centre. Retrospective study with data of the patients operated from January 2019 to January 2020 was reviewed and evaluated. Materials and Methods: Patients with spinal fractures, spondylodiscitis, bony tumours of spine and degenerative spinal disorders without neurological deficit were included. The patients with spinal deformity and with prior neurological deficits were excluded. Group A: the patients with no IONM signal drop during procedure, Group B: the patients who experienced significant drop in signal during surgery. Statistical Analysis Used: Data entry-MS Excel, Data analysis-SPSS 23.0 version for windows, descriptive statistics-mean ± numerical variable, null hypothesis-paired test-two sample for mean (<0.05 = significant). Results: Fifty-nine patients were included. Of 59, 50 patients had no significant drop, and 9 patients had permanent drop in signals. The mean blood loss in Group A was 735 ± 442.1 ml and was 978.9 ± 829 ml in Group B (P = 0.006). There was no signal drop in 39 patients. The sensitivity and specificity according to the above data in our series was 60% (confidence interval [CI] = 0.613–0.586) and 88% (CI = 0.891–0.886). Conclusions: IONM is fairly sensitive and very specific for detecting intraoperative neural compromise. There is significant correlation between the blood loss in the surgery and signal drop.
International Journal of Research in Orthopaedics, Feb 23, 2021
Fractures of the thoracic and lumbar vertebrae are quite common injuries among polytrauma patient... more Fractures of the thoracic and lumbar vertebrae are quite common injuries among polytrauma patients, and nearly one-third of those patients have concomitant neural structure injury and variable neurologic deficit. 1 Almost 60% of spinal fractures occur within the thoracolumbar region, with 17% being burst fracture. 2,3 These injuries are painful and may impact quality of life resulting in prolong absence from work and chronic pain; thus, having significant socioeconomic impact furthermore. 4 These injuries are usually resulting of high energy trauma like motorized vehicle accidents or falls from height and more common in men. Elderly people also are in danger for these fractures, because of weakened bone from osteoporosis. 5
Study design Meta-analysis. Objective To compare the clinical and radiological outcomes in patien... more Study design Meta-analysis. Objective To compare the clinical and radiological outcomes in patients with Adolescent Idiopathic scoliosis (AIS) treated by selective thoracic fusion (STF) with lowest instrumented vertebra (LIV) at touched vertebra (TV) vs stable vertebra (SV). Methods The databases PubMed, Embase and Google Scholar were searched until November 2020.Studies which had Lenke type 1 curves and Lenke type 2 curves in adolescent population treated by STF and which reported pre- and post-operative curve characteristics including correction percentage and complications were included. Studies which did not report the LIV selection, curve correction percentages and whose full text could not be acquired were excluded. Results Eight studies were included for analysis of which seven were found to be retrospective studies (level III evidence) and one was prospective study (level II evidence) each. Overall proportional meta-analysis found no significant difference in correction rate, total srs-22 scores, and complication rates. Conclusion The evaluation of SV group and TV group as LIV for selective thoracic fusions in AIS reveals a comparable outcome in terms of curve correction, patient satisfaction scores and complication rates. The TV can be chosen safely as the LIV especially in type A and B Lenke 1&amp;2 curves, as it saves more motion segments when compared to SV.
Background: Posterolateral decompression and debridement in patients with TB spine led to defect ... more Background: Posterolateral decompression and debridement in patients with TB spine led to defect in the anterior column which makes the spinal column unstable, thus making anterior column reconstruction an important step in surgical management. Objective: Through the study, authors sought to answer the following questions: 1) What are the differences in clinical outcomes between patients with TB spine undergoing anterior column reconstruction using titanium mesh cage versus PEEK cage? 2) What are the differences in radiological outcomes between these two groups of patients? Methods: This is a retrospective comparative study including patients with TB spine undergoing surgical management. The included subjects were divided into groups A and B depending on the implantation of PEEK or titanium mesh cage respectively for anterior column reconstruction. Outcome criteria analyzed included clinical criteria like VAS and ODI scores, radiological criteria like kyphosis correction, loss of kyphosis at follow-up, cage subsidence, and bony fusion on a 2D CT scan. Results: The study population included 14 patients in Group A and 15 patients in Group B. Improvement in VAS and ODI scores was comparable between groups. There was no significant difference in radiological outcome measures between the two groups, however, two patients from group B showed implant-related complications needing revision. All patients showed good bony fusion at the final follow-up. Conclusion: PEEK and titanium cages have comparable clinico-radiological outcomes for anterior column reconstruction in patients with active TB spine. Its advantages for being radiolucent and its ease of use may make it a choice of implant.
Background: Identifying the risk factors for the neurological deficit in spine tuberculosis would... more Background: Identifying the risk factors for the neurological deficit in spine tuberculosis would help surgeons in deciding on early surgery, thus reducing the morbidity related to neurological deficit. The main objective of our study was to predict the risk of neurological deficit in patients with spinal tuberculosis (TB). Methods: The demographic, clinical, radiological (X-ray and MRI) data of 105 patients with active spine TB were retrospectively analyzed. Patients were divided into two groupswith a neurological deficit (n = 52) as Group A and those without deficit (n = 53) as Group B. Univariate and multivariate logistic regression analysis was used to predict the risk factors for the neurological deficit. Results: The mean age of the patients was 38.1 years. The most common location of disease was dorsal region (35.2%). Paradiscal (77%) was the most common type of involvement. A statistically significant difference (p < 0.05) was noted in the location of disease, presence of cord compression, kyphosis, cord oedema, loss of CSF anterior to the cord, and degree of canal compromise or canal encroachment between two groups. Multivariate analysis revealed kyphosis > 30°(OR-3.92, CI-1.21-12.7, p-0.023), canal encroachment > 50% (OR-7.34, CI-2.32-23.17, p-0.001), and cord oedema (OR-11.93, CI-1.24-114.05, p-0.03) as independent risk factors for predicting the risk of neurological deficit. Conclusion: Kyphosis > 30°, cord oedema, and canal encroachment (>50%) significantly predicted neurological deficit in patients with spine TB. Early surgery should be considered with all these risk factors to prevent a neurological deficit.
The aim of the study was to objectively review the variability in the prevailing treatment protoc... more The aim of the study was to objectively review the variability in the prevailing treatment protocols and surgical decision making in the management of patients with spinal tuberculosis (TB) among spine surgeons with expertise in spinal TB across the country. Overview of Literature: A lack of good-quality evidence, ambiguities in the national spinal TB guidelines, and the demand for early rehabilitation and a better quality of life in patients with spinal TB has led to the emergence of various gray zones in the management of spinal TB. Methods: Seventeen fellowship-trained spinal TB experts representing different geographical regions of India completed an online survey consisting of questions pertaining to the conservative management of spinal TB (antitubercular therapy) and 30 clinical case vignettes including a wide spectrum of presentations of spinal TB with no or minimal neurological deficit. The variability in the responses for questions and case wise variability with respect to surgical decision making was assessed using the index of qualitative variation (IQV). The average tendency to operate (TTO) was calculated for various groups of respondents. Results: High variability was observed in all questions regarding conservative spinal TB management (IQV > 0.8). Among the 30 case vignettes, 14 were found to have high variability with respect to surgical decision making (IQV > 0.8). With respect to levels of fixation, all but two cases had poor or slight agreement. Younger age and practice in a government or tertiary care teaching hospital were factors associated with a higher TTO. Conclusions: Significant variability was detected in treatment practices for the management of spinal TB among experts. Most of the case vignettes were found to have significant heterogeneity with respect to surgical decision making, which reflects a significant lack of consensus and lacunae in literature.
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