Sarcopenia and its effects on outcome of lumbar spine surgeries

PURPOSE

Sarcopenia, defined as progressive impairment of muscle function secondary to loss of skeletal muscle mass, has prevalence of 24-56% in patients > 60 years. Forty-four per cent of elderly patients undergoing orthopaedic surgery are found to be sarcopenic. It is a known risk factor for fall, fractures, disability, increased post-operative morbidity and mortality. If diagnosed pre-operatively, it can help prepare the patient and surgical team to foresee complications and thereby reduce morbidity and mortality. In the present study, we evaluated and correlated sarcopenia with the surgical outcome of operated patients with lumbar spine pathology.

MATERIALS AND METHODS

A prospective, observational study was conducted on 114 patients > 40 years undergoing lumbar spine surgeries, who were studied and followed up for 3 months. They were segregated into 5 groups based on age (40-50 year, 50-60 year, 60-70 year, 70-80 year, and  > 80 year) and were assessed separately. Data on demography, grip strength analysis, 30-s chair stand test, Psoas muscle index (calculated on pre-operative MRI), pre- and post-operative ODI (Oswestry Disability Index) scores at 2 weeks and 3 months, Dindo-Clavien Classification of peri-operative complications, 90-day readmission rates and mortality (if any) were included. Patients were segregated into sarcopenic and non-sarcopenic groups based on the definition and set parameters as per the European Working Group on Sarcopenia in Older People (EWGSOP). A comparative analysis between these groups was performed.

RESULTS

Of 114 patients, there were 18 patients in 40-49 years, 24 in 50-59 years, 33 in 60-69 years, 30 in 70-79 years and 9 in > 80 years age group. Statistically significant difference in peri-operative ODI scores was seen in sarcopenic vs non-sarcopenic patients in all age groups (p < 0.05) except 40-49 years. The results showed that sarcopenic group had higher rate of peri-operative complications, delayed mobilisation, longer stay and mortality compared to non-sarcopenic group.

CONCLUSION

We conclude that sarcopenic patients have poor outcome in lumbar spine surgery compared to those without. So, by diagnosing sarcopenia using tests routinely done as pre-operative requirement, one can reduce radiation exposure and cost of treatment. The management can be revolutionised by predicting those who are at high risk of developing post-operative complications and poor surgical outcomes by mere diagnosis of sarcopenia. This knowledge will benefit both the patients and the surgeons.

A 2-Year Outcomes and Complications of Various Techniques of Lumbar Discectomy: A Multicentric Prospective Study

STUDY DESIGN

Prospective Study.

OBJECTIVES

There are numerous techniques for performing lumbar discectomy, each with its own rationale and stated benefits. The authors set out to evaluate and compare the perioperative variables, results, and complications of each treatment in a group of patients provided by ten hospitals and operated on by experienced surgeons.

METHODS

This prospective study comprised of 591 patients operated between February-2017 to February-2019. The procedures included open discectomy, microdiscectomy, tubular microdiscectomy, interlaminar endoscopic lumbar discectomy, transforaminal endoscopic lumbar discectomy and Destandau techniques with a follow-up of minimum 2 years. VAS (Visual Analogue Score) for back and leg pain, ODI (Oswestry Disability Index), duration of surgery, hospital stay, length of scar, operative blood loss and peri-operative complications were recorded in each group.

RESULTS

Post-operatively, there was a significant improvement in the VAS score for back pain as well as leg pain, and ODI scores spanning all groups, with no significant distinction amongst them. When compared to open procedures (open discectomy and microdiscectomy), minimally invasive surgeries (tubular discectomy, interlaminar endoscopic lumbar discectomy, transforaminal endoscopic lumbar discectomy, and Destandau techniques) reported shorter operative time, duration of hospital stays, better cosmesis, and lower blood loss. Overall, the complication rate was reported to be 8.62%. Complication rates differed slightly across approaches.

CONCLUSION

Minimally invasive surgeries have citable advantages over open approaches in terms of perioperative variables. However, all approaches are successful and provide comparable pain relief with similar functional outcomes at long term follow up.

Development and Validation of MRI Imaging Biomarkers for Prostate Cancer Using Deep Learning

PURPOSE/OBJECTIVE(S)

Given the increasing number of treatment options for patients with localized prostate cancer (PCa), there is a need for biomarkers to aid in risk stratification. Specifically, novel biomarkers can aid in the identification of high-risk phenotypes among similar patients in traditional NCCN risk groupings. One promising area for development is using pre-treatment prostate MRI to identify imaging biomarkers to identify prostate cancer patients at highest risk for recurrence. We hypothesized that deep learning could be leveraged to identify imaging biomarkers of aggressive PCa from pre-treatment prostate MRIs.

MATERIALS/METHODS

Our study included 1,020 patients treated at our institution between 2010-2022. Given pathologic extraprostatic extension (EPE) and seminal vesicle invasion (SVI) are associated with higher risk of treatment failure, we hypothesized that deep learning models which identified radiographic EPE and SVI would provide non-invasive imaging biomarkers associated with PCa prognosis. We trained two separate deep learning models using convolutional neural networks to predict SVI and EPE respectively. The model inputs were T2W prostate MRIs (n = 894) and models consisted of 8 convolutional layers. Dropout, L2 regularization, and data augmentation were used to improve model generalizability and reduce overfitting. Discriminatory ability of each model was measured using AUC on a blinded external test set of 221 patients. To assess the clinical utility of our imaging biomarkers, log-rank tests were used to evaluate biochemical free survival (BFS) for patients classified as high risk to patients classified as low risk. Biochemical failure was defined as post-treatment PSA >0.1 for patients who underwent radical prostatectomy (RP) or PSA >2ng/ml above nadir for patients receiving radiation therapy.

RESULTS

Within our cohort of 1,020 patients the median age was 66 with a median follow up of 4 years. 49.3% (n = 503) underwent RP and 50.7% (n = 517) received EBRT. 4% (n = 41) were low risk, 62.4% (n = 636) were intermediate risk, and 33% (n = 337) were high risk based on NCCN criteria. Deep learning models showed good discriminatory ability for both EPE (AUC 0.66) and SVI (AUC 0.74). Both imaging biomarkers showed prognostic ability to identify high risk prostate phenotypes. Patients deemed high risk based on EPE classifier had worse BFS (median 5 vs 9 years, p<.001). Similarly, patients classified as high risk based on SVI also showed worse BFS (median 5 vs 9 years, p = 0.024). Among intermediate risk patients, EPE biomarker showed an ability to identify high risk phenotypes (median 6 vs 9 years, p = 0.024).

CONCLUSION

Deep learning classifiers of prostate MRIs demonstrated the ability to stratify high-risk prostate cancer phenotypes beyond traditional risk paradigms. Imaging biomarkers represent a non-invasive method to help aid in the personalization of treatment for patients with localized prostate cancer and identify patients who potentially require treatment escalation.

Changes in standing and walking time after multimodal physical rehabilitation in low grade degenerative lumbar spondylolisthesis: a non-randomised pilot study

BACKGROUND

Surgery is often prescribed to patients with significant reduction in standing time (ST) and walking time (WT) due to degenerative lumbar spondylolisthesis (DLS). The efficacy of a multimodal physical rehabilitation protocol (MPRP) in improving ST and WT in patients with DLS is not known.

OBJECTIVE

To investigate the effect of MPRP on ST and WT in patients with DLS and compare the results with similar patients treated with other physiotherapy treatment (OPT) methods.

METHODS

Outcomes including numerical pain rating scale (NPRS) and Oswestry disability index (ODI) scores, ST and WT were compared in patients in the MPRP and OPT groups.

RESULTS

Data from 25 patients in MPRP group and 10 patients in OPT group were analyzed. In the MPRP group, the mean NPRS and ODI scores, ST, and WT improved significantly (p < .0001) after MPRP at a mean follow-up of 328 days. The mean NPRS score was significantly lower (p = .0001); mean ST (p = .03), and mean WT (p = .03) were significantly higher; and the mean NPRS improvement (p < .0001), mean ST improvement (p = .001), and mean WT improvement (p = .008) were significantly higher in MPRP group when compared to the OPT group at final follow-up.

CONCLUSION

Patients with low-grade DLS showed significant improvement in ST and WT after MPRP when compared to similar patients who underwent other physiotherapy treatments. These encouraging results indicate that MPRP can be utilized as a primary treatment option in patients with significantly reduced ST and WT due to DLS.

Prevalence and risk factors of neck pain in spine surgeons - Are we our own patients?

Aim

This survey of spine surgeons aimed to determine the prevalence of neck pain and identify the associated risk factors. The prevalence of neck pain has been reported in various medical sub-specialities including laparoscopy surgeons, dentists, plastic surgeons, ophthalmologist, urologist and orthopaedic surgeons. However, the literature is lacking on prevalence and risk factors for neck pain in spine surgeons.

Methods

A survey questionnaire containing demographic, Neck pain and work practice details was administered to 300 spine surgeons (members of an online group) via text message and e-mail.

Results

One hundred and eighty surgeons responded to the survey (response rate, 60%). Three spine surgeons had previous cervical spine surgeries. The 1-month prevalence rate of neck pain was 74.4% (134/180 surgeons). One hundred and eighteen surgeons (88%) reported only neck pain, 16 surgeons (11.9%) had neck pain with radicular arm pain. Only 20.5% of surgeons used a loupe, 18% of surgeons used a microscope, and 24% of surgeons used operating table height at umbilicus during surgery. There was no significant difference between the mean age (p = 0.65), work experience (p = 0.8), time spent in surgery (p = 0.7), and operating table height preference (p = 0.4) when symptomatic and asymptomatic groups were compared. However, a significantly greater percentage of surgeons had a sedentary lifestyle (p = 0.002) & used loupes as compared to microscopes (p = 0.04) in the symptomatic group. There was significant correlation between the surgeon's lifestyle & use of loupe and the incidence of neck pain.

Conclusion

Spine surgeons have a higher prevalence of neck pain than general populations and surgeons from other specialties. Considering the high prevalence of neck pain, general health, work, and ergonomic guidelines and recommendations must be formulated to help prevent and decrease the burden of neck pain among spine surgeons.

Case Reports: The Perils of an Orthopedic Graduate

The perils of an orthopedic graduate You have just cleared your postgraduate examination in Orthopedics. Moreover, the journey has been tough. You have filtered through the toughest of competitions, made the grade, and passed the mother of all examinations and you can now proudly say that you are a qualified orthopedic surgery Welcome to the next level-overqualified, under employed, and confused It is a sea on uncertainty – you are no longer a student. There is no more set curriculum to follow. No one to tell you what to do you are the boss now – but with no specific work to do From huge sense of achievement, we all instantly move to a phase of diffidence and-There is a lack of clarity on how to move forward. MS Ortho, what now? The options available can be quite easily characterized – 1. Take up the available public Hospital teaching post. This move is toward entering academics, but could also mean procrastinating 2. Sub-specialization – go look for available training options to further your career. Choosing the specialty that you will marry for life, and, in turn, divorce permanently all other options can be confusing and daunting for some. Other postgraduates, who are very sure of what they want, can find it very hard to find the appropriate training center and mentor 3. Start practice as a general orthopod – your meter will be down, and your wheels will start turning immediately, with the collateral risk of ending up being a “small fish in a big pond.” Fortunately, orthopedics are running specialty and most start doing well in practice pretty early 4. Join dads practice-for the lucky few orthokids, though many from this group still choose to specialize 5. Leave the country and figure out what next-at least there is a promise of a job, a steady income, a new lifestyle. All of which is indeed an attractive prospect for the fresh postgraduate. Creating a more organized system for orthopedic postgraduates to help deciding their careers moves and lending the best possible option becomes responsibility of our academic societies It would be absolutely wonderful for these young orthopedic surgeons If all these options could be presented systematically, at counseling sessions – including listing the available resources and methods to get there, and using senior practicing oracademic surgeons as mentors and counselors Videos of our channel would agree that it is time to make this move to help create a fantastic generation of orthopods.

Development of Tuberculosis Spine Instability Score (TSIS): An Evidence-Based and Expert Consensus-Based Content Validation Study Among Spine Surgeons

STUDY DESIGN

An expert-panel consensus-based content validation and case-based clinical validation study.

OBJECTIVE

To develop a novel scoring system for diagnosing instability in tuberculosis (TB) spine using an expert-panel consensus followed by clinical validation for validating the content.

SUMMARY OF BACKGROUND DATA

Currently, diagnosis of instability is primarily experience-based which may lead to considerable variability and misdiagnosis in the hands of a relatively in-experienced spine surgeon. Considering the potential complications this entity entails, a universally accepted scoring criteria is very important for accurate and uniform diagnosis of instability in TB spine.

METHODS

The development of TB spine instability score (TSIS) followed a two-step process, one designing the instrument and the other obtaining judgemental evidence. For judgemental evidence a panel of experts was appointed to make appropriate modifications and content validation for finalizing the scoring instrument. This score was applied on 30 patients of TB spine and receiver operating characteristic (ROC) curves were drawn for sensitivity and specificity analysis.

RESULTS

The comprehensive scoring criteria to diagnose instability in TB spine was approved after three rounds of expert panel discussions with an index of content validation more than 0.75 after final round of panel discussion. On case-based validation after plotting ROC curves, sensitivity and specificity for diagnosing stable and potentially unstable lesions at a cut-off score of 6 was 92.9% and 86.8% respectively whereas for diagnosing potentially unstable and unstable lesions at a cut-off score of 10 was 94.3% and 81.9%, respectively.

CONCLUSION

TSIS is a comprehensive scoring system integrating demographic, anatomical, clinical, and radiological factors aimed at diagnosing instability in TB spine. The classification determines indications for surgical stabilization in patients with TB spine, with no or little neurological deficit.Level of Evidence: 4.

In Scientific Literature, We Trust!

Text books have always been the traditional and definitive seat of learning for us as orthopedic postgraduates. However, as we move forward from our student lives, orthopedic surgeons begin to rely more on more on research papers and journal articles to update new information on their specific fields of interest. It soon becomes the norm for practicing orthopedic surgeons to read interesting articles in popular journals and then intuitively translate their conclusions to information and knowledge which is then transmitted to their junior peer as “standard teaching.” Concurrently, contributing to scientific literature, conducting our own research, and publishing it, has remained a huge attraction for doctors. It not only pushes us up in the academic circuit, but also potentially enhances our career progression In many institutions, it has become mandatory to publish for promotions! As a result over the last few decades, the clamor to have research papers published in journals has multiplied and as a result, the number of journals available to print your research work has also multiplied It is pure demand supply mathematics. But then what happens to quality? The deep question is – does an exponential increase in the published literature, not have an adverse effect on the quality of each publication? And now with a situation where there is some journal on the other available to publish whatever you have written, the deeper question remains – “can we blindly rely on everything we read in scientific journals.” As a logical derivation, from the above discussion, the obvious answer is No! The impact of transferring conclusions – from inadequately conducted research papers which have been published in haste by journals to fill up their pages – as knowledge to young peers, can be far reaching, as you can imagine. As postgraduates, there is little effort made to teach us how to analyze a scientific publication and to look into loopholes and flaws in the research methodology, and determine truly if a paper and its conclusions are worthy we need to inculcate this education quickly, to our peers and of course ourselves – and control this potential side-effect of the publication boom that we are in! Happy reading!

Tuberculosis of the spine in children - does drug resistance affect surgical outcomes?

BACKGROUND CONTEXT

The emergence of drug resistance has complicated the management of spinal tuberculosis (TB). While it is well known that the medical management of drug-resistant spinal TB is more difficult, the surgical outcomes of the same have not been studied sufficiently, particularly in children.

PURPOSE

To analyze the surgical outcomes in a cohort of children treated for spinal TB, and to thus assess whether drug resistant (DR) disease is associated with poorer surgical outcomes.

STUDY DESIGN/SETTING

Retrospective observational study.

PATIENT SAMPLE

All children diagnosed and treated for tuberculous spondylodiscitis at a single center between January 2014 and June 2017.

OUTCOME MEASURES

Surgical outcomes in terms of neurological status and kyphosis angle at final follow-up, and complication rates.

METHODS

Radiographic and clinical data of children treated for spinal TB with minimum two-year follow-up were retrospectively analyzed. Data gathered included age, gender, level of spine affected, number of vertebrae involved, neurology (Frankel grade), microbiological reports, duration and type of anti-tuberculous therapy (ATT), details of Orthopaedic management and complications during treatment. In DR cases, the time from presentation to starting of second-line ATT was also assessed. Radiographs were reviewed to note the pre- and post-operative degree of kyphosis as well as the angle at final follow-up. Patients that developed major complications were compared statistically with those that did not.

RESULTS

Forty-one consecutive children (mean age 8.5 ± 4.2 years, 20 boys, 21 girls) were treated for spinal TB with a mean follow-up of 31.2 ± 6.4 months. Fifteen were managed conservatively, of which only one had DR-TB. Of the 26 managed surgically, 13 were managed with first-line ATT and 13 required second-line ATT. Of this latter group, eight had microbiologically proven drug resistance, whereas five were switched to second-line therapy presumptively because of failure to show an adequate response to first-line regimen. At last follow-up, all children had completed the prescribed course of ATT and had been declared cured. Neurological improvement was seen in all but one patient; and at last follow-up, 18 children were Frankel E, seven were Frankel D, and one was Frankel B. ¹The immediate post-operative Kyphosis angle averaged 24.38° ± 15.21°. However, six children showed a subsequent worsening of kyphosis, and the Kyphosis angle at last follow-up averaged 30.96° ± 23.92°. Five children had major complications requiring revision surgery; complications included wound dehiscence, vertebral collapse, screw pull-out and implant breakage. Significantly higher number of patients in the group with complications had required second-line ATT (p < .05).

CONCLUSIONS

In a cohort of children treated surgically for spinal tuberculosis, a higher complication rate, and thus poor surgical outcomes, were found to be associated with drug resistant disease.

Assessment of pedicle screw malposition in uniplanar versus multiplanar spinal deformities in children

Background

Spinal deformities can either be uniplanar or multiplanar. The current study aims to compare mal-positioned pedicle screw assessment on radiographs versus CT in children <12 years with multiplanar and uniplanar spinal deformities.

Methods

A cohort of 15 children, mean age 10.1 years, who underwent posterior spinal fusion using free-hand pedicle screw insertion for multiplanar (M) or uniplanar (U) deformities with post-operative radiograph and CT evaluation of 154 screws. The outcome measures included the assessment of malpositions detected on plain radiographs versus CT scans in U and M deformities. The overall breaches in post-operative plain radiographs and CT in each group were compared and analyzed by two independent observers.

The mal-positioned screws were graded on extent of cortical breach on CT. Inter and intra-observer variability was calculated with Kappa(k) method. Sensitivity, Specificity and Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were calculated by comparing breaches on radiographs versus CT considered the gold standard.

Results

In total,154 pedicle screws were analyzed, 65 in U group and 89 in M group. There were 23 (14.9%) malpositioned screws identified on plain radiographs and 43 (27.9%) on CT (p = 0.008). There were 17/154 (11.03%) Grade 1 breaches, 16/154 (10.38%) Grade 2 breaches and 10/154(6.49%) Grade III breaches.

Among the 43 CT breaches, 12/65 (18.46%) were in U group, 31/89 (34.83%) were in M group (p = 0.013).The overall Sensitivity, Specificity and PPV of plain radiographs compared to CT in detecting malpositions were 32.56%, 91.89% and 60.87% respectively.

Conclusions

There was a significant discrepancy in identification of pedicle screw malposition based on plain radiographic versus CT based assessment, more so in multiplanar deformities. The ability to detect a breach on plain radiographs is lesser in multiplanar versus uniplanar deformities.

Cervical myelopathy in a child with Sprengel shoulder and Klippel-Feil syndrome

PURPOSE

Sprengel shoulder, Klippel-Feil syndrome and congenital scoliosis are associated conditions. Cervical myelopathy in a child due to a concomitant omovertebral bar causing posterior cord compression and a hypermobile cervical disc protrusion adjacent to fused cervical segments causing anterior compression at the same level is very rare. We report the presentation, findings, surgical management and results of treatment in such a child.

METHODS

A 9-year-old girl with Sprengel shoulder presented with cervical myelopathy (Frankel D). Imaging revealed a bony omovertebral bar connected to the left scapula compressing the spinal cord posteriorly through a lamina defect at C5 resulting in significant cervical stenosis. A hypermobile disc protrusion adjacent to congenitally fused segments resulted in anterior compression at the same level. She was treated surgically with cervical laminectomy and instrumented fusion, excision of the omovertebral bar and modified Woodward procedure for the left Sprengel shoulder.

RESULTS

At 2 year follow-up, she had improved neurologically (Frankel E) and there was improved shoulder symmetry and abduction. MRI showed resolution of cervical stenosis. Although there was no significant progression of congenital scoliosis, it will need to be monitored.

CONCLUSIONS

Cervical myelopathy due to an omovertebral bar and cervical disc protrusion in a child with Klippel-Feil syndrome and Sprengel shoulder is a rare presentation and can be treated with a single posterior approach addressing both pathologies.

Management of Metastatic Spine and Hip Alveolar Soft Part Sarcoma: Case Report and Review of Literature

Alveolar soft part sarcoma (ASPS) is a rare soft tissue tumor. Primary or metastatic involvement of the spine is unusual in ASPS. In most case, it is refractory to chemotherapy and radiation. Surgical resection is the most effective intervention. We report the case of a 38-year-old female having ASPS along with metastatic spine and hip involvement treated surgically as a single-stage operation, which is the first of its kind approach to our knowledge. We present the case of a 38-year-old female with simultaneous L4 pathological fracture with symptomatic lumbar canal stenosis without focal neurology and pathological fracture of neck of femur of left hip, secondary to metastatic ASPS. Since both conditions were contributing equally to her disability and demanded early intervention, they were treated simultaneously with intralesional excision of the tumor and posterior stabilization of the spine and left hip proximal femur resection and replaced it with proximal femur endoprosthesis as a single-stage operation. Postoperatively, she had significant relief of radiculopathy and left hip pain. She was mobilized out of bed on the postoperative day 1 and was discharged from hospital on the postoperative day 6. She was given chemotherapy drug sunitib postoperative. At her last follow-up, 20 months' postoperative, she was asymptomatic and was independent in terms of activities of daily living. Metastatic ASPS of the spine and hip is a rare clinical entity. Simultaneous surgical treatment of the spine and hip pathology is technically demanding. If the conditions demands, as in our case, both of them can be managed safely in a single-stage with good midterm outcome.

Assessment of Outcomes of Spine Surgery in Indian Athletes Involved in High-End Contact Sports

STUDY DESIGN

This study was a retrospective analysis.

PURPOSE

This study aimed to analyze the functional outcome following spinal surgery in elite athletes using return-to-play criteria.

OVERVIEW OF LITERATURE

Spinal ailments are relatively common in athletes and are bound to increase due to the ever-growing popularity of contact sports. An elite athlete is highly motivated to make a rapid recovery and return to full participation in sports. Although the criteria for diagnosis and surgical treatment of various spinal disorders in athletes have been well defined in the literature, there is no clear definition about the factors determining the return to play in athletes.

METHODS

This study was a retrospective analysis of the data of 10 elite athletes who underwent spinal surgery for symptomatic degenerative disorder of the spine. Eight patients underwent lumbar spine surgery (two patients of microdiscectomy and six patients of fusion), and the remaining two patients underwent cervical spine surgery (one each anterior cervical discectomy and fusion and anterior cervical disc replacement). Outcome measures were investigated using return-to-training and return-to-sports criteria, as indicated by the length of time between surgery and return to competitive sports as parameters.

RESULTS

Of the 10 patients, eight were males and two were females. The average age of the patients at the time of surgery was 32.4 years (range, 25-41 years). All patients returned to active participation of their sports. The average time for return to training was 7.3 weeks (range, 3-12 weeks). The average time for return to sports was 45.6 weeks (range, 36-72 weeks), and the average follow-up period was 59 months (range, 27-120 months).

CONCLUSIONS

Spine surgery in an elite athlete involved in contact sports is safe and effective. Currently, there is a lack of standardized guidelines for return to sports after spine injuries. An athlete needs to be symptom-free, with full range of motion and full strength before returning to sports.

Validation Study of Rajasekaran's Kyphosis Classification System: Do We Clearly Understand Single- and Two-Column Deficiencies?

Study Design

Multicenter validation study.

Purpose

To evaluate the inter-rater reliability of Rajasekaran’s kyphosis classification through a multicenter validation study.

Overview of Literature

The classification of kyphosis, developed by Rajasekaran, incorporates factors related to curve characteristics, including column deficiency, disc mobility, curve magnitude, and osteotomy requirements. Although the classification offers significant benefits in determining prognosis and management decisions, it has not been subjected to multicenter validation.

Methods

A total of 30 sets of images, including plain radiographs, computed tomography scans, and magnetic resonance imaging scans, were randomly selected from our hospital patient database. All patients had undergone deformity correction surgery for kyphosis. Twelve spine surgeons from the Asia-Pacific region (six different countries) independently evaluated and classified the deformity types and proposed their surgical recommendations. This information was then compared with standard deformity classification and surgical recommendations.

Results

The kappa coefficients for the classification were as follows: 0.88 for type 1A, 0.78 for type 1B, 0.50 for type 2B, 0.40 for type 3A, 0.63 for type 3B, and 0.86 for type 3C deformities. The overall kappa coefficient for the classification was 0.68. Regarding the repeatability of osteotomy recommendations, kappa values were the highest for Ponte’s (Schwab type 2) osteotomy (kappa 0.8). Kappa values for other osteotomy recommendations were 0.52 for pedicle subtraction/disc-bone osteotomy (Schwab type 3/4), 0.42 for vertebral column resection (VCR, type 5), and 0.30 for multilevel VCRs (type 6).

Conclusions

Excellent accuracy was found for types 1A, 1B, and 3C deformities (ends of spectrum). There was more variation among surgeons in differentiating between one-column (types 2A and 2B) and two-column (types 3A and 3B) deficiencies, as surgeons often failed to recognize the radiological signs of posterior column failure. This failure to identify column deficiencies can potentially alter kyphosis management. There was excellent consensus among surgeons in the recommendation of type 2 osteotomy; however, some variation was observed in their choice for other osteotomies.

Does Three-Dimensional Printed Patient-Specific Templates Add Benefit in Revision Surgeries for Complex Pediatric Kyphoscoliosis Deformity with Sublaminar Wires in Situ? A Clinical Study

STUDY DESIGN

Case-control study.

PURPOSE

To evaluate the accuracy of three-dimensional (3D) printed patient-specific templates (PSTs) for placement of pedicle screws (PAs) in patients undergoing revision surgeries for complex kyphoscoliosis deformity with sublaminar wires in situ.

OVERVIEW OF LITERATURE

Revision kyphoscoliosis correction surgery in pediatric patients is a challenging task for the treating surgeon. In patients with sublaminar wires in situ, the native anatomical landmarks are obscured, thus making the freehand screw placement technique a highly specialized task. Hence, the concept of using PSTs for insertion of PAs in such surgeries is always intriguing and attractive.

METHODS

Five consecutive patients undergoing revision deformity correction with sublaminar wires in situ were included in this study. Patients were divided in two groups based on the technique of PA insertion. A total of 91 PAs were inserted using either a freehand technique (group A) or 3D printed templates (group B) (34 vs. 57). The placement of PAs was classified according to a postoperative computed tomography scan using Neo's classification. Perforation beyond class 2 (>2 mm) was termed as a misplaced screw. The average time required for the insertion of screws was also noted.

RESULTS

Mean age, surgical time, and blood loss were recorded. The change in mean Cobb's angle in both groups was also recorded. The difference in rates of misplaced screws was noted in group A and group B (36.21% vs. 2.56%); however, the mean number of misplaced PAs per patient in group A and group B was statistically insignificant (6.5±3.54 vs. 4.67±1.53, p =0.4641). The mean time required to insert a single PA was also statistically insignificant (120±28.28 vs. 90±30 seconds, p =0.3456).

CONCLUSIONS

Although 3D printed PSTs help to avoid the misplacement of PAs in revision deformity correction surgeries with sublaminar wires in situ, the mean number of misplaced screws per patient using this technique was found to be statistically insignificant when compared with the freehand technique in this study.

Profile of osteoarticular tuberculosis in children

OBJECTIVE

To determine clinical profile of osteoarticular tuberculosis (TB) in children.

METHODS

Cross-sectional analysis from 2007 to 2013. All patients diagnosed with bone TB, spinal TB or TB abscesses were included.

RESULTS

Out of 1318 children with TB, 39 (2.96%) had osteoarticular TB, of which 16 (42%) had osteomyelitis, 8 (20.5%) had spinal involvement, 7 (17.9%) had TB synovitis, 2 (5.1%) had psoas abscess and 6 (15.4%) had abscesses. The mean age of presentation was 7.1 ± 3.5 years (range 2-14 years). Of the 33 cases in which a culture was done, 25 (64%) showed a positive culture. Drug sensitivity tests were done in 21 patients of which 10 (47.6%) tested were drug resistant, of which 4 (36.4%) were multidrug resistant (MDR), 2 (18.2%) were extensively drug resistant (XDR), 3 were pre-XDR (27.3%) and 1 was polyresistant (9.1%). Nine (23.1%) patients had TB in the past with a treatment duration of 8.3 ± 5.3 months. Contact with a TB patient had occurred in 10 (25.6%) cases. Associated pulmonary TB were seen in 6 (15.39%) and TB meningitis were seen in 1 (2.6%) patients. Surgical intervention was needed in 11 (28.2%) patients of which 5 (45.5%) underwent curettage, drainage was done in 1 (9.1%), arthrotomy in 4 (36.4%) and spinal surgery in 1 (9.1%) patient.

CONCLUSION

Drug resistant osteoarticular TB is an emerging problem in children.

A Technical Note on Making Patient-Specific Pedicle Screw Templates for Revision Pediatric Kyphoscoliosis Surgery with Sublaminar Wires In Situ

Introduction:

Revision deformity correction surgery of a pediatric spine, especially with sublaminar Soacing between wires in situ, is a daunting task for patient as well as treating physician. Obscured native anatomy in the presence of sublaminar wires poses a staunch intraoperative challenge for a surgeon for safe placement of pedicle screws so as to avoid neurological and vascular injury. In revision surgeries with previous implants, it’ is challenging, especially due to metal artifacts in imaging, bone loss due to previous surgery. In this note, we describe the technique of making making three-dimensional (3D)-printed patient-specific templates for safe placement of pedicle screws in pediatric patients undergoing revision kyphoscoliosis surgery with sublaminar wires in situ.

Case Report:

A 12-year-old female presented to the clinic with a history of early-onset scoliosis, for which she underwent deformity correction surgery with spinal rectangle loop and sublaminar wires 4 years ago. At presentation, she had decompensated with increase in deformity and failed implant. She underwent revision deformity correction surgery with pedicle screws. 3D-printed patient-specific pedicle screw templates were useful in this patient for appropriate pedicle screw placement, as patient had obscured native anatomy due to fusion mass and in situ sublaminar wires.

Conclusion:

3D-printed patient-specific pedicle screw templates are very useful in revision pediatric deformity correction surgeries, especially when the obscured native bony anatomy makes free-hand insertion of pedicle screw unsafe.

Autostabilization of neglected high-grade fracture-dislocation in the cervical spine

Neglected cervical spine trauma is rare with very few case series reported in literature. There are no clear guidelines for its treatment. If operative treatment is sought, the role of skull traction, type of approach (anterior only, posterior only, or combined), sequence of surgery, type of instrumentation, etc., have to be considered. Hence, the treatment is challenging. Autostabilization has been described in the natural history of degenerative lumbar spondylolisthesis. As a result, many patients are treated nonoperatively, obviating need of surgery. We report two cases of neglected/untreated fracture–dislocation at subaxial cervical spine. They presented with exertional neck pain. Computed tomography scan showed bony fusion at involved level. The patient was treated nonsurgically with favorable outcome at long-term follow-up. Our cases depict autostabilization in a case of neglected traumatic cervical spine injury, which is never been reported. Such patients do well with nonsurgical treatment, thus obviating need for extensive deformity correction.

Cervical Kyphosis

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

Role of Frailty Scoring in the Assessment of Perioperative Mortality in Surgical Management of Tuberculous Spondylodiscitis in the Elderly

STUDY DESIGN

Retrospective study.

OBJECTIVES

Treatment of spinal tuberculosis in the elderly involves consideration of compromised physiology, which often poses a clinical challenge to the surgeons to balance surgical safety versus deteriorating function. Frailty scoring has been reported as an effective tool to predict mortality and morbidity in cardiovascular surgery and recently in hip fractures. Its use in spinal surgery is scarcely reported.

METHODS

We included elderly patients operated for spinal tuberculosis. Demographic, clinical and radiological profile with operative details of instrumentation, blood loss, surgical duration and mortality were noted. Modified frailty score (MFS) was calculated for each patient. There were 26 patients (males 9, females 17) with a mean age of 73.2 years. The patients were divided into those with 30-day postoperative mortality (M) and those who survived (S). The null hypothesis was that the MFS was comparable in both the groups.

RESULTS

The M group had 5 patients (19.2%) and the S group consisted of 21 patients. There was no statistical difference between the groups with regard to mean age, sex, number of medical comorbidities, ASA (American Society of Anesthesiologists) grade, Frankel grade C or worse, blood loss, and operative time. The mean MFS in M group was 5 and in S group was 1.8, which was statistically significant (P < .001).

CONCLUSIONS

Higher MFS is associated with postoperative 30-day mortality in the elderly patients with spinal tuberculosis undergoing surgery. It can be used as a guide to predict 30-day postoperative mortality in these patients.

Outcomes of Various Treatment Modalities for Lumbar Spinal Ailments in Elite Athletes: A Literature Review

Lumbar spinal injuries are common in elite athletes, who can present with a spectrum of ailments ranging from lumbar strain to prolapsed intervertebral discs. Sequelae can include neurological impairment and lumbar instability among other possible outcomes. This group of patients is unique in terms of their clinicoradiological presentation and treatment modalities. The primary goals of treatment are a rapid return to play and prevention of recurrence, thus prolonging the athlete’s professional career. Treatment modalities can range from activity restriction to nerve root blocks and surgery. A successful treatment outcome is based on timely diagnosis, treatment suiting the demands of the particular sport, and early rehabilitation. A multidisciplinary team approach involving the coach, rehabilitation specialist, pain management specialist, and spine surgeon helps in planning appropriate treatment. In this article, we review special considerations in the elite athletic population with lumbar spinal ailments as well as the outcomes of various treatment modalities.

Cervical Gibbectomy for Rigid, Rounded Kyphosis in Pediatric Patient: Surgical Planning with Technical Note

OBJECTIVES

Cervical kyphosis surgery poses a significant challenge to spine surgeons. Etiologies of cervical kyphosis are many, each having its own outcome and treatment challenges. Irrespective of the etiology, the treating physician should consider all options fully to improve function and prevent neurologic worsening. We outline management principles and decision making in the case of a rigid, rounded kyphosis of the cervical spine and highlight the technique of an internal gibbectomy procedure, which has never been reported in the cervical spine.

METHODS

We report a case of Ewing sarcoma of the cervical spine that presented with progressive myelopathy symptoms. The patient was operated on multiple times (anterior and posterior) and presented to us with rigid, rounded global kyphosis of the cervical spine. We performed internal gibbectomy from a posterior approach and decompressed the neural tissue.

RESULTS

The patient had a satisfactory recovery in myelopathy symptoms, and the modified Japanese Orthopaedic Association score improved at subsequent follow-ups. There was no recurrence at 2-year follow-up.

CONCLUSIONS

Internal gibbectomy can be a treatment option in rigid, rounded kyphosis in which the primary goal of surgery is neural decompression.

Buckling Collapse of Midcervical Spine Secondary to Neurofibromatosis

Buckling collapse is the term typically used to describe severe kyphosis >100 degrees, characteristically seen in thoracolumbar tuberculosis. Neurofibromatosis is rarely associated with severe cervical kyphosis. Dystrophic changes in vertebra make surgical correction and fusion challenging. Single-stage cervical osteotomies (e.g., pedicle subtraction osteotomy, vertebral column resection) are commonly done in cervicothoracic junction. However, it is technically challenging and associated with high risk of vertebral artery injury, neural injury, etc. when performed in higher cervical spine. Hence in our case we did a staged procedure performing circumferential osteotomy for buckling kyphosis in the midcervical spine. Because it involved midcervical spine and there was no chin-to-chest deformity, we preferred the anterior-posterior-anterior sequence.

The Role of Steroids in a Child with Spinal Pre-Extensively Drug-Resistant Tuberculosis

There has been a rise in the number of reported cases of drug-resistant tuberculosis (TB) in children in the recent past. Beneficial effects of steroids in the treatment of spine TB on standard antituberculous therapy are known. However, the role of steroids in patients with spinal drug-resistant TB is not established. We report on a 10-year-old girl with pre-extensively drug resistant (XDR) spinal TB and the effect of steroids in drug resistant TB.

Current Concepts - Congenital Scoliosis

Background:

Congenital scoliosis is one of the ‘difficult to treat’ scenarios which a spine surgeon has to face. Multiple factors including the age of child at presentation, no definite pattern of deformity and associated anomalies hinder the execution of the ideal treatment plan. All patients of congenital scoliosis need to be investigated in detail. X rays and MRI of spine is usually ordered first. Screening investigations to rule out VACTERL (Visceral, Anorectal, Cardiac, Tracheo-esophageal fistula, Renal and Lung) abnormalities are required. They are cardiac echocardiography and ultrasonography of abdomen and pelvis. CT scan is required to understand the complex deformity and is helpful in surgical planning.

Methods:

A comprehensive medical literature review was done to understand the current surgical and non surgical treatment options available. An attempt was made to specifically study limitations and advantages of each procedure.

Results:

The treatment of congenital scoliosis differs with respect to the age of presentation. In adults with curves more than 50 degrees or spinal imbalance the preferred treatment is osteotomy and correction. In children the goals are different and treatment strategy has to be varied according to the age of patient. A single or two level hemivertebra can easily be treated with hemivertebra excision and short segment fusion. However, more than 3 levels or multiple fused ribs and chest wall abnormalities require a guided growth procedure to prevent thoracic insufficiency syndrome. The goal of management in childhood is to allow guided spine growth till the child reaches 10 - 12 years of age, when a definitive fusion can be done. The current research needs to be directed more at the prevention and understanding the etiology of the disease. Till that time, diagnosing the disease early and treating it before the sequels set in, is of paramount importance.

Conclusion:

The primary aim of treatment of congenital scoliosis is to allow the expansion of chest and abdominal cavity, while keeping the deformity under control. Various methods can be categorized into definitive (hemivertebrectomy) or preventive (guided growth). Casting, Growth rods, Convex Epiphysiodesis are all guided growth measures. The guided growth procedure either ‘corrects the deformity’ or will have to be converted to a final fusion surgery once the child completes the spinal growth which is preferably done around 10 - 12 years of age. Future directions should aim at genetic counselling and early detection.

Current Concepts in Pediatric Cervical Spine Trauma

Background:

Pediatric spinal trauma is rare and challenging entity. Although cervical spine is commonly affected, it is often missed on routine imaging investigations. Therefore better understanding of growing spine and its patho-physiology is crucial.

Methods:

Articles related to pediatric cervical trauma were searched on Pubmed and other online research data banks. We have summarized unique anatomy of pediatric spine, investigations followed by common injury patterns, their diagnostic challenges and management.

Results:

Immature spine follows typical injury patterns, so thorough knowledge of its presentation should be known. Primary physicians should be able to perform initial assessment based on clinical examination and investigations for early diagnosis. High index of suspicion and strategic approach leads to early diagnosis and prevents further morbidity and mortality.

Conclusion:

Spinal injuries in children are rare and typical. They are often missed and can have fatal consequences. Thorough understanding of pediatric anatomy and injury patterns helps in early diagnosis.

Mycobacteria Intracellulare Spondylodiscitis Presenting as Progressive Consecutive Vertebral Sclerosis: A Case Report

INTRODUCTION

Non-tuberculous mycobacteria (NTM) are slow-growing organisms affecting both immunocompromised and immunocompetent patients. As compared to tuberculosis, they pose formidable challenge in successful management beginning with diagnosis extending through its treatment.

CASE REPORT

Our case highlights unusual spinal presentation of NTM, intricacies in diagnosis, and successful management.

CONCLUSION

As the prevalence of NTM is rising, it is important as clinicians to understand unique aspects which differ from tuberculosis for appropriate and successful treatment.

Spinal Mucormycosis

Spinal mucormycosis is a rare and fatal condition. High degree of suspicion is required for early diagnosis and treatment.

Isolated Mucormycotic Spondylodiscitis of Lumbar Spine-A Rare Case Report

INTRODUCTION

Mucormycosis is life threatening infection rarely affecting musculoskeletal system and spinal involvement is extremely rare with only two cases reported in English literature.

CASE REPORT

We present this rare case of spondylodiscitis with lumbar vertebral osteomyelitis due to mucormycosis in a patient with chronic kidney disease on haemodialysis diagnosed by CT guided biopsy and highlight its clinico -radiological presentation and management principles.

CONCLUSION

Thus, as the incidence of Mucorales infection increase due to increase in patients with predisposing factors, the unusual sites of affection increase. Treating clinician should have a high vigilance in patients with predisposing factors. Although there is dramatic improvement in the treatment modalities of mucormycosis, still the mortality is high. Early diagnosis is important to prevent dissemination and timely intervention in order to reduce morbidity and mortality. A well equipped multidisciplinary approach for clinico-radiological assessment and management is necessary.

Posterior approach in thoracolumbar tuberculosis: a clinical and radiological review of 67 operated cases

(1) To present the indications of single stage all posterior surgery in thoracic and lumbar tuberculosis. (2) To evaluate the results of single stage all posterior surgery. We analysed 67 patients who underwent single stage all posterior surgery with follow-up of 31.37 months. We performed the following operative procedures depending upon level and case requirements. (Group A) Instrumentation alone for instability. (Group B) Transpedicular decompression and instrumentation for neurological compression in thoracic and thoracolumbar spine. (Group C) Transforaminal approach for access to anterior column in lumbar spine in addition to posterior instrumentation. (Group D) Pedicle subtraction osteotomy and instrumentation for deformity correction. (Group E) Posterior decompression alone for isolated posterior epidural compression. (Group F) Reconstruction of anterior column by all posterior approach. Thirty-eight had neurological deficit whereas 29 were Frankel E. In 12 cases, anterior reconstruction was done. In the remaining 55 cases, we relied on vertebral reconstitution under chemotherapy. Operative time was 150.5 min and blood loss was 514.18 ml. Of 38 patients with deficit, 34 improved. There was radiological fusion in all patients. Pre- and post-operative Cobb's measurements were 9.95 and 8.1, respectively, in thoracic and thoracolumbar spine and -9.39 and -11.42, respectively, in lumbar spine. Of 55 cases where anterior reconstruction was not done, only 3 had progression of Cobb's >10°. Posterior approach can achieve adequate decompression of offending middle column and if required, even anterior reconstruction. Posterior approach is versatile, with many surgical options depending on the level and case requirements.

Surgical patterns in osteoporotic vertebral compression fractures

PURPOSE

To report morphological patterns of osteoporotic vertebral compression fractures (OVCFs) presenting for surgery. To describe surgical options based on fracture pattern. To evaluate clinical and radiological outcome.

METHODS

Forty consecutively operated OVCFs nonunion patients were retrospectively studied. We define four patterns of OVCFs that needed surgical intervention. Group 1 mini open vertebroplasty (N = 10) no neurologic deficits and kyphotic deformity, but with intravertebral instability and significant radiological spinal canal compromise. Group 2 with neurologic deficits (N = 24) (2A)-transpedicular decompression (TPD) with instrumentation (N = 14). Fracture morphology similar to (1) and localized kyphosis <30° (2B)-pedicle subtraction osteotomy (PSO) with instrumentation (N = 10). Fracture morphology similar to (1) and local kyphosis >30°. Group 3 posterolateral decompression with interbody reconstruction (N = 06) endplate(s) destroyed, with instability at discovertebral junction, with neurologic deficit. Average follow-up was 34 months. VAS, ODI and Cobb angle were recorded at 3, 6, 12 months and yearly.

RESULTS

There was significant improvement in the clinical (VAS and ODI) scores and radiologic outcome in each group at last follow-up. 30 patients out of 40, had neurologic deficits (Frankel's grade C = 16, Frankel's grade D = 14). The motor power gradually improved to Frankel's grade E. Average duration of surgery was 97 min. Average blood loss was 610 ml.

CONCLUSION

Different surgical techniques were used to suit different fracture patterns, with good clinical and radiological results. This could be a step forward in devising an algorithm to surgical treatment of OVCF nonunions.

Postvertebroplasty instability

Vertebroplasty provides excellent pain relief and functional restoration for osteoporotic fractures. Short-term complications such as cement leak and embolism are well described. Incident fractures are the only well-reported long-term complications. The authors describe the cases of 5 patients who presented with back pain caused by instability or worsening neurological status 13 months (range 8–17 months) after vertebroplasty. They further classify this postvertebroplasty instability into intervertebral instability and intravertebral instability, depending on the apex of abnormal mobility.

One patient presented with cement migration and progressive collapse of the augmented vertebral body. Another patient presented with an additional fracture. Both cases were classified as intravertebral instability. The cases of 3 other patients presenting with adjacent endplate erosion, vacuum disc phenomenon, and bridging osteophyte formation were classified as having intervertebral instability.

Long-term effect of cements on the augmented vertebral body and adjacent endplates and discs is a cause for concern. Vertebroplasty acts as a mechanical stabilizer and provides structural support but does not bring about union. Micromotion has been shown to persist for years after vertebroplasty. This study describes persistent instability after vertebroplasty in a series of 5 cases. The authors propose that postvertebroplasty instability occurs due to collapse of soft osteoporotic bone and endplates around cement. All 3 cases of intervertebral instability were associated with an intradiscal cement leak. With increased longevity and higher functional demands of the geriatric population, the durability of this “rock (cement) between cushions (of osteoporotic bone)” arrangement (as seen in vertebroplasty) will be increasingly challenged.

Drug resistance patterns in 111 cases of drug-resistant tuberculosis spine

PURPOSE

We report the largest study conducted till date of drug resistant tuberculosis in spine analyzing the drug susceptibility patterns in 111 cases of proven drug resistance.

METHODS

An observed cross-sectional study was conducted. Six-hundred and eighty-six patients with positive cultures underwent sensitivity testing to 13 commonly used anti-tubercular drugs using BACTEC MGIT-960 system.

RESULTS

Females (60.3%) outnumbered males (39.6%). Only three patients (2.7%) were found HIV positive, and none of these had AIDS. Forty-four (39.6%) patients had taken AKT in the past for some form of tuberculosis. Eight (7.2%) patients had history of treatment default. The drug sensitivity testing revealed 87 (78.3%) cases of multi drug resistance (resistance to both isoniazid and rifampicin) and 3 (2.7%) cases of XDR-TB spine. Of the individual drugs, widespread resistance was present to both isoniazid (92.7%) and rifampicin (81.9%), followed by streptomycin (69.3%). Least resistance was found to kanamycin, amikacin and capreomycin.

CONCLUSION

It is recommended to do routine biopsy, culture and drug sensitivity testing in all patients of tuberculosis spine to guide selection of appropriate second-line drugs when required. In cases of non availability of drug susceptibility testing despite repeated attempts, it is suggested to use data from large series such as this to plan best empirical chemotherapy protocol.

Visual loss after spine surgery

Incidence of perioperative visual loss ranges from 0.06% to 0.2% with the most common cause as ischemic optic neuropathy. We report one-year follow up of a 50-years-old hypertensive housewife who underwent lumbar decompression and fusion for degenerative scoliosis, but woke up with painless unilateral visual loss. Fundus examination was normal. Her visual acuity improved from initial finger counting close to face to finger counting at 3 m at 1 year. Identification of high risk patients may help in appropriate preoperative counselling, prevention and early recognition of this devastating complication.

Role of 'low cost Indian implants' in our practice: our experience with 1,572 pedicle screws

PURPOSE

As Indian spine surgeons, we have to choose between 'foreign implants' and 'Indian implants'. An Indian four pedicle screw rod construct costs 330 US dollars (one-third that of a similar foreign construct). About 60% of patients cannot afford expensive foreign implants. There is little written data evaluating how these Indian implants fare. The purpose of our study was to evaluate implant failure rate with Indian implants and compare it to foreign implants.

METHODS

We analysed results of 1,572 titanium pedicle screws used in 239 patients with a minimum 1-year follow-up. Patients were divided into Indian and foreign implant groups. Radiological failures were classified as (1) surgery and disease failure, (2) bone failure and (3) implant failure. The null hypothesis was that there is no difference between implant failure rate for Indian and foreign implants.

RESULTS

A total of 128 (53.56%) of patients could not afford foreign implants. We used 679 foreign and 893 Indian pedicle screws. In foreign implant group, there was a single incident of implant failure (0.15%). In Indian implant group, there were five such incidents (0.56%).

CONCLUSIONS

(1) Rate of failure for 'low cost' Indian implants is very low (approximately 1 implant complication for every 200 screws). (2) There is no statistically significant difference in failure rates for Indian implants and foreign implants (P-value = 0.2438). We recommend that Indian implants are a safe and viable option to make spine surgery cost effective in the Indian scenario.

Giant cell tumor of the spine: A review of 9 surgical interventions in 6 cases

BACKGROUND

Giant cell tumor (GCT) of the spine is uncommon but most aggressive benign tumor of the spine with unpredictable outcome. We present our observation on six cases of GCT of the spine. We treated six patients with giant cell tumors (GCT) of the spine between 1993 and 2006. A total of nine surgical interventions were carried out. Four interventions were carried out in patients presented as 'new' cases, while five on recurrences from past GCT resections. All presented with cord compression and neurological deficits of varying grades. All patients also presented with clinical as well as radiological instability. Preoperative tissue diagnosis was available only in the five recurrences (tissue from the old resection). Posterior only (n=2), anterior only (n=4) and single-stage back and front (n=3) surgeries were carried out depending on the nature of the tumor.

RESULTS

Overall results were satisfactory, as all patients were symptom-free postoperatively. Two out of our four new patients had tumor recurrence and both needed repeat resection. Both have been disease-free at last follow-up.

CONCLUSION

Surgical intervention is mandatory. Close follow up is needed for early diagnosis of recurrences.

Measuring change in arm hand skilled performance in persons with a cervical spinal cord injury: responsiveness of the Van Lieshout Test

OBJECTIVES

To asses whether the Van Lieshout Test (VLT) is responsive to measure changes in arm hand skilled performance (AHSP) over time during active rehabilitation in persons with cervical spinal cord injury (C-SCI) and in different subgroups of persons with C-SCI according to lesion completeness and to lesion level.

STUDY DESIGN

Longitudinal cohort study.

SETTING

Spinal Cord Injury Units in eight rehabilitation centres across the Netherlands.

METHODS

In the present study, data from a national SCI cohort study are used. Data from the VLT, the Grasp Release Test (GRT), the Functional Independence Measure (FIM) and the Quadriplegia Index of Function (QIF) were recorded at three moments during active rehabilitation: at the start of active rehabilitation (t1), 3 months after t1 (t2) and at discharge (t3). Data have been analysed using three responsiveness measures, that is, the standardized response mean, the effect size and comparison of test scores measured at different times.

RESULTS

The VLT is responsive for the intervals t1-3, t1-2 and t2-3. The VLT can be used to measure changes in AHSP in persons with a C-SCI with an American Spinal Injury Association Impairment Scale (AIS) A or B score or an AIS C or D score, as well as in persons with a C3-C6 lesion or a C7-T1 lesion. The responsiveness of the VLT is significantly correlated to the GRT, but not to the FIM and the QIF.

CONCLUSION

The VLT is responsive in measuring changes in AHSP during rehabilitation in persons with C-SCI.

Rectus femoris surface myoelectric signal cross-talk during static contractions

The clinical application of EMG requires that the recorded signal is representative of the muscle of interest and is not contaminated with signals from adjacent muscles. Some authors report that surface EMG is not suitable for obtaining information on a single muscle but rather reflects muscle group function [J. Perry, C.S. Easterday, D.J. Antonelli, Surface versus intramuscular electrodes for electromyography of superficial and deep muscles. Physical Therapy 61 (1981) 7-15]. Other authors report however, that surface EMG is adequate to determine individual muscle function, once guidelines pertaining to data acquisition are followed [D.A. Winter, A.J. Fuglevand, S.E. Archer. Cross-talk in surface electromyography: theoretical and practical estimates. Journal of Electromyography and Kinesiology 4 (1994) 15-26]. The aim of this study was to determine whether surface EMG was suitable for monitoring rectus femoris (RF) activity during static contractions. Five healthy subjects, having given written informed consent, participated in this trial. Surface and fine wire EMG from the rectus femoris and the vastus lateralis (VL) muscles were recorded simultaneously during a protocol of static contractions consisting of knee extensions and hip flexions. Ratios were used to quantify the relationship between the surface EMG amplitude value and the fine wire EMG amplitude value for the same contraction. The results showed that hip flexion contractions elicited RF activation only and that knee extension contractions elicited fine wire activity in VL only. When the relationship between RF surface and RF fine wire electrodes was compared for hip flexion and knee extension contractions, it was observed that for all subjects, there was a tendency for increased RF surface activity in the absence of RF fine wire activity during knee extensions. It was concluded that the activity recorded by the RF surface electrode arrangement during knee extension consisted of EMG from the vastii, i.e., cross-talk and that vastus intermedius was the most likely origin of the erroneous signal. Therefore it is concluded that for accurate EMG information from RF, fine wire electrodes are necessary during a range of static contractions.

Results of nonsurgical treatment of thoracic spinal tuberculosis in adults

BACKGROUND

The indications for surgery in spinal tuberculosis have been controversial, and more so recently, in the era of renewed understanding of the concept of multi-drug-resistant tuberculosis along with newer modalities of spinal instrumentation. Indications for surgery need to be redefined in this context.

PURPOSE

To assess the efficacy and results of nonsurgical treatment in thoracic spinal tuberculosis in adult patients, and redefine indications for surgery.

STUDY DESIGN

We present a retrospective analysis of 70 adults with thoracic spinal tuberculosis, with varying presentations, including abscesses and neurological deficits, seen at our spine clinic, in a period between August 1998 and August 2000, treated largely nonsurgically, with rewarding results.

METHODS

A retrospective study was made of 70 adult patients with thoracic spinal tuberculosis presenting at our spine clinic, between August 1998 and August 2000. All patients were subjected to medical management, unless there were specific indications for surgery, as per our protocol, wherein absolute indications of surgery in adults included advanced neurological deficit (less than Grade 3 by 5, by the 5-point grading system of the Medical Research Council), neurology worsening while on antituberculous chemotherapy, diagnosis in doubt on clinicoradiological evaluation and significant kyphosis (greater than 40 degrees) on presentation. Clinical and radiological assessment of results was made by an independent observer, at a mean follow up of 40 months.

RESULTS

Forty-four patients presented with abscesses, 21 of which were epidural. Seven had neurological signs of cord compression on clinical examination at presentation. Over 98% of our patients (69 of 70) were successfully treated conservatively, and none of these had any residual instability, radiculopathy or neurological compromise. Seventy-four percent had excellent to good results, with no mechanical residues of the disease, and 23% had residual kyphosis, which was clinically obvious, but biomechanically irrelevant.

CONCLUSIONS

We think that tuberculous spondylodiscitis in adults can be well managed conservatively in a vast majority of cases, and indications for surgery are few and specific.

Is rectus femoris really a part of quadriceps? Assessment of rectus femoris function during gait in able-bodied adults

There is conflicting evidence as to the precise activation pattern of the rectus femoris (RF) muscle during gait in able-bodied subjects. The aim of this study was to determine precise activation pattern of RF during gait in a healthy adult population. Surface and fine wire EMG from RF and vastus lateralis (VL) were recorded simultaneously at different walking speeds in five able-bodied subjects. The results of fine wire EMG showed that, at normal walking speed, RF was active only during the stance-to-swing transition. At faster speeds, increased levels of RF activity were seen during the same transition period. At the fastest speed, there was some activity during terminal stance, in addition to that at stance-to-swing transition, that could be attributed to rapid hip extension and thereby a rapid stretch of RF. However, the RF surface EMG signal was found to exhibit a bi-phasic pattern whilst walking at all different self-selected speeds. A burst of EMG activity recorded at initial contact on the surface signal but not on fine wire EMG, was due to cross-talk from vastus intermedius (VI). A close similarity was observed between the surface EMG patterns of VL and RF. VL surface and fine wire EMG profiles were identical for all the self-selected speeds with a main peak of activity beginning in terminal swing and ceasing in mid-stance. We conclude that RF is active only during stance-to-swing transition and the activity during swing-to-stance transition, as described in the literature, is very probably due to cross-talk.

A feasibility study of remote consultation to determine suitability for surgery in stroke rehabilitation

We studied knowledge transfer for the determination of the suitability of stroke patients for a specialist surgical procedure (split anterior tibial tendon transfer). Gait analysis data from patients at a general hospital were discussed with an expert in another country using personal computers, an ISDN connection (128 kbit/s) and TCP/IP-based communication tools. The key issue was whether the staff in the general hospital became better able to determine suitability for surgery. Twelve patients were studied. In three of the first four cases the advice of the remote expert changed the plan for surgery. After that the treatment plans did not change after consultation. After eight cases the local clinicians did not need to ask for further advice. There was a rapid increase in skill in determining suitability for surgery. The experience and skills of the local clinicians were thought to increase more rapidly than would have been the case without the consultations with a remote expert.

Application of a dual channel peroneal nerve stimulator in a patient with a "central" drop foot

Dropped foot is a common mobility problem amongst patients after a cerebro vascular accident. The condition arises from paresis of the muscles that control the foot movement during the swing phase of gait. If the abnormal movement is not compensated for, it results in a significant decrease in the mobility and hence quality of life. Compensation for the drop foot can be achieved through the application of functional electrical stimulation. To date, in the clinical environment, the stimulation has been applied through electrodes placed on the skin over the common peroneal nerve, and using a single channel implant device. It is well known that with these techniques it is difficult to establish a balanced response of the foot. An implantable dual channel system for stimulation of the deep and superficial peroneal nerve has now been developed for patients with a drop foot following a stroke. By stimulation of the two branches of the common peroneal nerve separately it is possible to achieve a precisely balanced dorsal flexion and eversion of the foot. Stimulation occurs via small bipolar electrodes which are placed subepineural. After successful tests on animals we have now started the two channel peroneal nerve stimulator implantation in patients. The preliminary results of the first implants are presented.

Lumbar and lumbosacral tuberculous spondylodiscitis in adults

We have reviewed, retrospectively, 66 adult patients who were treated for lumbar or lumbosacral tuberculosis. A total of 45 had a paravertebral or epidural abscess, 24 had clinical instability and 18 presented with a radiculopathy, of which six also had a motor deficit. The diagnosis was usually made on clinical and radiological grounds and they were followed up until there were clinical and radiological signs of full recovery.

Conservative treatment with antituberculous drugs was successful in 55 patients (83%). None had persistent instability, radiculopathy or neurological compromise. We feel that tuberculous spondylodiscitis, especially in the lumbar spine, can usually be satisfactorily managed conservatively and that there are few indications for surgical treatment.

Lumbar and lumbosacral tuberculous spondylodiscitis in adults. Redefining the indications for surgery

We have reviewed, retrospectively, 66 adult patients who were treated for lumbar or lumbosacral tuberculosis. A total of 45 had a paravertebral or epidural abscess, 24 had clinical instability and 18 presented with a radiculopathy, of which six also had a motor deficit. The diagnosis was usually made on clinical and radiological grounds and they were followed up until there were clinical and radiological signs of full recovery. Conservative treatment with antituberculous drugs was successful in 55 patients (83%). None had persistent instability, radiculopathy or neurological compromise. We feel that tuberculous spondylodiscitis, especially in the lumbar spine, can usually be satisfactorily managed conservatively and that there are few indications for surgical treatment.

Sacral anterior root stimulation for bladder control: clinical results

The Brindley bladder stimulator delivers intermittent stimulation to the anterior sacral roots. The stimulus parameters can be adjusted and set specifically for individuals. Its primary purpose is to improve bladder emptying, thereby to eliminate urinary infection and to preserve kidney function. It also assists in defecation and enables male patients to have a sustained full erection. In our unit so far 38 patients with a complete spinal cord lesion have received a Brindley bladder stimulator implant. One patient died 2 weeks after the surgery due to pulmonary embolism. Two other patients died due to unrelated causes during the follow up period. They used their implants for less than 1 year. Results relating to these 2 patients and the remaining 35 patients who regularly use their implant are presented. The follow-up period ranged from 3 months to 12 years. Residual urine volumes are substantially reduced in all patients; in 24 patients the residual urine volume is less than 30 ml. All patients have increased bladder capacity. Thirty-one patients are continent. Out of 33 males 29 can achieve a sustained full erection using the stimulator. Twenty-seven patients use the implant for bowel function. The following complications were encountered: (1.) Cerebro-spinal fluid collection occurred around the implant in 3 patients during the post-operative period; (2.) Receiver failure occurred in 3 patients. A successful replacement with a new receiver block was carried out in these cases. It is concluded that the use of a bladder stimulator in selected patients gives long term favourable results.