Is the morphology of the apical pedicles influenced by apical rotation or the coronal curve magnitude in adolescent idiopathic scoliosis?: a radiographic assessment

INTRODUCTION

Asymmetry in pedicle anatomy is most distinctly noted around the apex of the curve. The correlation of pedicle dysmorphia with apical vertebral rotation (AVR) and coronal Cobb angle (CCA) has not been studied.

OBJECTIVE

To establish whether pedicle dysmorphism is linked to curve magnitude CCA and the AVR in adolescent idiopathic scoliosis (AIS).

METHODOLOGY

Preoperative plain whole spine standing radiographs and non-contrast computed tomography (CT) scans of 25 AIS patients that were operated at a single centre from 2013 to 2019 were retrospectively reviewed by 3 independent co-investigators. CCA was noted on the standing radiograph, whereas the AVR was measured on the axial cuts of CT scan. Pedicle morphometric measurements were performed for apical and periapical pedicles. These included apical vertebra (when present), 2 vertebrae above (U1 and U2) and below (B1 and B2) the apex vertebra/disc. The pedicle morphometric measurements were performed on CT scans. We assessed the transverse pedicle diameter, transverse cancellous channel diameter, sagittal pedicle diameter, pedicle length and pedicle axis length. Correlation tests between various pedicle morphometric measurements, AVR and the curve magnitude (Cobb angle) was performed by the Pearson correlation test.

RESULTS

The apex of the major curve was in the thoracic spine in 20 patients, thoracolumbar in three patients and in the lumbar spine in two patients. The mean Cobb angle was 61.5 ± 9.3° and the mean AVR was 28.4 ± 17.8°. A positive correlation was noted with the AVR for U1 concave pedicle length (r = 0.45, p = 0.03), pedicle axis length of the U2 concave pedicle (r = 0.6, p = 0.04), transverse pedicle diameter of the convex apical vertebrae (r = 0.82, p = 0.00009) and the convex apical transverse pedicle diameter (r = 0.80, p = 0.002). A negative correlation with the AVR was noted for U2 convex pedicle length (r = - 0.51, p = 0009), transverse cancellous channel diameter of the U2 concave pedicle (r = - 0.42, p = 0.04) and apical concave pedicle (r = - 0.78, p = 0.002) and the sagittal pedicle diameter for the convex pedicle of U2 (r = - 0.45, p = 0.03) and apex(r = - 0.59, p = 0.04). The Cobb angle did not show a significant correlation with any of the pedicle measurements at any of the levels on the convex and the concave sides.

CONCLUSION

Pedicle asymmetry and dysmorphism demonstrate a morphometric association with the apical vertebral rotation than the curve magnitude. The pedicle length and the pedicle axis length increase on the concave apical and periapical region with increase in AVR. The transverse cancellous channel diameter significantly decreases on the concave apical region with the increase in AVR. The sagittal pedicle diameter decreases on the convex side with the increase in AVR.

A Prospective Multicenter ≥2 Years Clinical Study of the Active Apex Correction (APC) Technique in Early Onset Scoliosis (EOS) Patients

STUDY DESIGN

prospective multicenter study.

OBJECTIVES

Active apex correction (APC) is posterior tethering technique for correction of early onset scoliosis (EOS) via reverse modulation at the apex. Active apex correction has been increasingly used worldwide. This study aimed to assess short-term outcomes of multicenter study with ≥2 years of APC on spine length, curve correction, complications, unplanned surgeries, and proposed low crankshaft phenomena incidence.

METHODS

Prospective multicenter study including 24 EOS patients treated by APC; involves inserting and compressing pedicle screws on convex side of apex proximal and distal to most wedged vertebra allowing apex modulation according to Hueter-Volkmann law. Excluded patients with <2 years follow-up whom APC was not primary surgery.

RESULTS

Mean age 85.97 ± 32.43 months, 71% congenital scoliosis, mean follow-up 35.54 ± 12.36 months. At final follow-up, statistically significant improvement in Cobbs angle (∆ = 23.96%, P < .0001), spinal length T1-T12 (∆ = 12.83%, P < .0001), T1-L5 (∆ = 13.41%, P < .0001) but not in apical vertebral translation (AVT) albeit clinical improvement (∆ = 7.9%, P = .36) compared to preoperative measurements. Comparing immediate postoperative measurements to >2 years follow-up, statistically significant improvement in spinal length T1-T12 (∆ = 6.03%, P = .0002) and T1-L5 (∆ = 6.26%, P < .0001) but not in Cobbs angle (∆ = 4.93%, P = .3) or AVT (∆ = 14.77%, P = .25). 9 complications requiring 3 unplanned surgeries recorded in all patients including 2 broken rods, 2 adding-on and 4 screw dislodgement.

CONCLUSION

Active apex correction is a novel technique that has been incorporated in several countries as treatment modality for EOS. Short-term outcomes are promising in terms of clinical improvement, complication rates and decreased need for multiple operations or unplanned surgeries.

SOX9 gene shows association with adolescent idiopathic scoliosis predisposition in Northwest Indians

BACKGROUND

Adolescent idiopathic scoliosis (AIS) is a common structural deformity of the spine affecting adolescent individuals globally. The disorder is polygenic and is accompanied by the association of various genetic loci. Genetic studies in Chinese and Japanese populations have shown the association of genetic variants of SOX9 with AIS curve severity. However, no genetic study evaluating the association of SRY-Box Transcription Factor 9 (SOX9) variants with AIS predisposition has been conducted in any Indian population. Thus, we aimed to investigate the association of the genetic variants of the SOX9 along with 0.88 Mb upstream region with AIS susceptibility in the population of Northwest India.

METHODS

In total, 113 AIS cases and 500 non-AIS controls were recruited from the population of Northwest India in the study and screened for 155 genetic variants across the SOX9 gene and 0.88 Mb upstream region of the gene using Global Screening Array-24 v3.0 chip (Illumina). The statistical significance of the Bonferroni threshold was set at 0.000322.

RESULT

The results showed the association of 11 newly identified variants; rs9302936, rs7210997, rs77736349, rs12940821, rs9302937, rs77447012, rs8071904, rs74898711, rs9900249, rs2430514, and rs1042667 with the AIS susceptibility in the studied population. Only one variant, rs2430514, was inversely associated with AIS in the population, while the ten variants were associated with the AIS risk. Moreover, 47 variants clustered in the gene desert region of the SOX9 gene were associated at a p-value ≤ 0.05.

CONCLUSION

The present study is the first to demonstrate the association of SOX9 enhancer locus variants with AIS in any South Asian Indian population. The results are interesting as rs1042667, a 3' untranslated region (UTR) variant in the exon 3 and upstream variants of the SOX9 gene, were associated with AIS susceptibility in the Northwest Indian population. This provides evidence that the variants in the enhancer region of SOX9 might regulate its gene expression, thus leading to AIS pathology and might act as an important gene for AIS susceptibility.

Unmasking the great imitators-noninfectious conditions masquerading as spinal tuberculosis in a developing country: A single-center case series analysis

Background

The diagnosis of spinal tuberculosis often relies on clinical, radiological, and laboratory findings, particularly in resource-constrained settings. However, numerous noninfectious conditions exhibit similar clinical and radiological features to spinal tuberculosis, leading to potential misdiagnosis in the absence of microbiological or histopathological confirmation. This study aims to present a case series from a developing country, highlighting noninfectious conditions that mimic spinal tuberculosis.

Methods

A retrospective analysis was conducted on hospital records and imaging of patients diagnosed with spinal tuberculosis, lacking microbiological or histopathological evidence, and unresponsive to empirical antitubercular treatment. Patients displaying noninfectious conditions resembling spinal tuberculosis upon further investigation were included. Clinical and radiological findings of these patients were thoroughly analyzed.

Results

Among a total of 23 patients observed over a 6-year period (2015-2020), various noninfectious conditions were identified as mimickers of spinal tuberculosis. These conditions included vertebral body haemangioma, ankylosing spondylitis (with or without Andersson lesion), rheumatoid pannus, osteoid osteoma, cystic hygroma, multiple myeloma, vertebral metastasis, malignant small round-cell tumor, pancreatic pseudocyst, esophageal duplication cyst, Modic changes in degenerative disc disease, Paget's disease, and psoas hematoma.

Conclusion

Noninfectious spinal conditions can masquerade as spinal tuberculosis, underscoring the importance of obtaining a definitive tissue diagnosis before initiating antitubercular treatment. Particular attention should be given to features such as central lesions and the absence of soft tissue involvement in suspected cases of spinal tuberculosis, warranting a careful reconsideration of the diagnosis.

SPINE20 recommendations 2023: One Earth, one family, one future WITHOUT spine DISABILITY

Introduction

The purpose is to report on the fourth set of recommendations developed by SPINE20 to advocate for evidence-based spine care globally under the theme of "One Earth, One Family, One Future WITHOUT Spine DISABILITY".

Research question

Not applicable.

Material and methods

Recommendations were developed and refined through two modified Delphi processes with international, multi-professional panels.

Results

Seven recommendations were delivered to the G20 countries calling them to:-establish, prioritize and implement accessible National Spine Care Programs to improve spine care and health outcomes.-eliminate structural barriers to accessing timely rehabilitation for spinal disorders to reduce poverty.-implement cost-effective, evidence-based practice for digital transformation in spine care, to deliver self-management and prevention, evaluate practice and measure outcomes.-monitor and reduce safety lapses in primary care including missed diagnoses of serious spine pathologies and risk factors for spinal disability and chronicity.-develop, implement and evaluate standardization processes for spine care delivery systems tailored to individual and population health needs.-ensure accessible and affordable quality care to persons with spine disorders, injuries and related disabilities throughout the lifespan.-promote and facilitate healthy lifestyle choices (including physical activity, nutrition, smoking cessation) to improve spine wellness and health.

Discussion and conclusion

SPINE20 proposes that focusing on the recommendations would facilitate equitable access to health systems, affordable spine care delivered by a competent healthcare workforce, and education of persons with spine disorders, which will contribute to reducing spine disability, associated poverty, and increase productivity of the G20 nations.

Impact of Bundled Intervention on Outcomes of Patients Undergoing Clean Orthopedic Surgeries With Hardware Implants: Small Prospective Randomized Controlled Trial

Background: Prosthesis-related infections (PRIs) and surgical site infections (SSIs) remain one of the most devastating complications among patients undergoing clean orthopedic surgeries. Prevention strategies are critical to reduce infection rates in orthopedic surgeries. The current study aimed to determine the effectiveness of a set of evidence-based practices (bundled intervention) in reducing the incidence of PRIs and SSIs among patients undergoing clean orthopedic surgeries with hardware implants. Patients and Methods: A prospective, interventional randomized controlled trial was conducted for a period of three years. A total of 597 patients were enrolled, and depending on their Staphylococcus aureus carrier status were categorized into carrier group (n = 98) and non-carrier group (n = 499). Only carrier group patients were analyzed for effectiveness of bundled interventions, after being randomly assigned to two subgroups: interventional carrier group (ICG; n = 50) and non-interventional carrier group (NICG; n = 48). Results: Of the 597 patients, 98 (16.4%) were colonized with Staphylococcus aureus, among whom 9 (19.4%) had methicillin resistance. During follow-up, overall infection rate of 1.1% was observed (PRI, 0.3%; SSI, 0.8%). There was no case of PRI/SSI in the ICG. However, in the NICG, one patient developed SSI because of methicillin-resistant Staphylococcus aureus. An endogenous source of infection was demonstrated by pulsed field gel electrophoresis (PFGE). The SSI rate was higher in the NICG (p = 0.002). In the non-carrier group (n = 499), SSIs/PRIs occurred among 1.2% of the patients, because of organisms other than Staphylococcus aureus. Conclusions: Benefit of bundle intervention approach could be demonstrated. Further studies assessing the effectiveness of the individual components of the bundle can inform clinical practice greatly.

Patient Positioning in Spine Surgery: What Spine Surgeons Should Know?

Spine surgery has advanced tremendously over the last decade. The number of spine surgeries performed each year has also been increasing constantly. Unfortunately, the reporting of position-related complications in spine surgery has also been steadily increasing. These complications not only result in significant morbidity for the patient but also raises the risk of litigation for the surgical and anesthetic teams. Fortunately, most position-related complications are avoidable with basic positioning knowledge. Hence, it is critical to be cautious and take all necessary precautions to avoid position-related complications. We discuss the various position-related complications associated with the prone position, which is the most commonly used position in spine surgery, in this narrative review. We also discuss the various methods for avoiding complications. Furthermore, we briefly discuss less commonly used positions in spine surgery, like the lateral and sitting positions.

Augmenting the Angiogenic Profile and Functionality of Cord Blood Endothelial Colony-Forming Cells by Indirect Priming with Bone-Marrow-Derived Mesenchymal Stromal Cells

Cellular therapy has shown promise as a strategy for the functional restoration of ischemic tissues through promoting vasculogenesis. Therapy with endothelial progenitor cells (EPCs) has shown encouraging results in preclinical studies, but the limited engraftment, inefficient migration, and poor survival of patrolling endothelial progenitor cells at the injured site hinder its clinical utilization. These limitations can, to some extent, be overcome by co-culturing EPCs with mesenchymal stem cells (MSCs). Studies on the improvement in functional capacity of late EPCs, also referred to as endothelial colony-forming cells (ECFCs), when cultured with MSCs have mostly focused on the angiogenic potential, although migration, adhesion, and proliferation potential also determine effective physiological vasculogenesis. Alteration in angiogenic proteins with co-culturing has also not been studied. We co-cultured ECFCs with MSCs via both direct and indirect means, and studied the impact of the resultant contact-mediated and paracrine-mediated impact of MSCs over ECFCs, respectively, on the functional aspects and the angiogenic protein signature of ECFCs. Both directly and indirectly primed ECFCs significantly restored the adhesion and vasculogenic potential of impaired ECFCs, whereas indirectly primed ECFCs showed better proliferation and migratory potential than directly primed ECFCs. Additionally, indirectly primed ECFCs, in their angiogenesis proteomic signature, showed alleviated inflammation, along with the balanced expression of various growth factors and regulators of angiogenesis.

The Third Gender in a Third World Country: Major Concerns and the "AIIMS Initiative"

With a population dividend of around 1.3 billion, India is the largest democracy in the world that encompasses "unity in diversity". The kaleidoscope of the socio-cultural fabric comprises the transgender population too, which has a historical context dating back millennia and also plays a vital role as described in Hindu scriptures. The Indian transgender person's community shows a variety of gender identities and sexual orientations, which is unlikely from the West, forming a culturally unique gender group. In India, transgender persons were recognised as the 'third gender' in 2014. The third gender population of India is marginalised to a great extent in every sector. Often, transgender persons have been the subjects of sociology, psychology, and health issues. There was a dearth of data regarding their major health problems including bone health, which has not been reported in India and elsewhere before this study. Through a prospective cross-sectional study design, we aimed to determine the current health status of transgender persons with a special emphasis on bone health. Descriptive statistics were used for data analysis. The preliminary results of the study show poor bone health in the transgender population of India. The majority of transgender persons have low bone mineral density (BMD) at a much young age, even before the achievement of their peak bone mass. The health status of the transgender population in India is poor overall. Transgender persons have many impediments to optimal healthcare that requires holistic care. This study presents the current health challenges of the transgender population with a special emphasis on their bone health status as 'AIIMS initiative'. This study also shows transgender persons human rights needs to be explicitly discussed. The stakeholders of social policies require an urgent attention to unfold the major concerns encompassing transgender persons.

Surgical Management of Paediatric Thoracolumbar Tuberculosis by a Combination of Anterior and Posterior Versus Posterior Only Approach: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic Review and Meta-analysis.

OBJECTIVES

This systematic review and meta-analysis is aimed to assess effectiveness, safety, clinical, functional and radiological outcome of either combined anteroposterior or posterior-only approach in the surgical management of active tubercular disease of paediatric thoracolumbar spine.

METHODS

A systematic literature search through PubMed, Scopus, Web of Science and Cochrane Library database was performed. Data extraction was undertaken following methodological quality assessment.

RESULTS

9 out of the 182 publications identified, were included for analysis. A total of 247 patients were analysed. Two amongst the 9 studies were retrospective comparative studies evaluating posterior approach with combined anteroposterior approach and were considered for comparative meta-analysis. Blood loss and duration of surgery was significantly higher in the anteroposterior group, as compared to the posterior-only group. There was no significant difference between the 2 groups in terms of post-operative kyphosis angles, final kyphosis angles, number of complications, functional outcome and spinal fusion time. However, all the included studies were non-randomised and retrospective. Only 2 of them had a control group with a high heterogeneity amongst these 2 studies.

CONCLUSION

The inference from the studies included in this review suggests that equivalent results can be achieved with posterior-only approach for thoracolumbar tuberculosis in children as compared to anteroposterior approach, with much lower complexity, reduced blood loss and shorter surgical time. However, due to the high risk of bias and considerable heterogeneity among the studies included, we cannot conclude whether one approach is better than the other.

3D printing in spine care: A review of current applications

3D printing (3DP) has been brought to medical use since the early part of this century- but it has been widely researched on and publicized only in the last few years. Amongst patients with spinal disorders, 3DP has been utilized in various facets of patient care. These include pre-operative aspects - such as patient education, resident training, pre-operative planning and simulations, intra-operative assistance in the form of customized jigs for pedicle screw insertion, patient specific interbody cages and vertebral body substitutes in complex malignancies and spinal infections. It has also been utilized in deformity surgeries and has opened new avenues in minimally invasive spine care. Guidelines have now been drafted by various organizations including the FDA with a prime focus on quality control measures applicable to this new technology. There has been a recent surge in publications supporting the use of 3DP in spinal disorders, reporting an improvement in various aspects of patient care. As the technology spreads out its wings further, more innovations and applications are expected to unfold in the coming years. Considering the rapid advances that 3DP has made, having a basic understanding of this technology is imperative for all spine surgeons. Despite promising preliminary results, there still exist a few pitfalls of the technology which have hindered the universal application of 3DP. Most importantly, there is a dearth of data related to long term outcomes supporting its clinical use. The prohibitive cost of 3D models, the specialized manpower it necessitates and the need for specific instrumentation are major deterrents to widespread use of this technology, particularly in small-scale healthcare setups. With further advancements in technology, the goal must be to make it more accurate and affordable to hospitals and patients so that the benefits of the technology can reach a wider patient population.

Histopathological, Ultrastructural, and Immunohistochemical Findings in Radial Longitudinal Deficiency: A Prospective, Observational Study

PURPOSE

To report the histopathological, electron microscopic, and immunohistochemical findings of tissue samples obtained from patients with radial longitudinal deficiency (RLD) and investigate the contribution of abnormality in soft tissues as a secondary driver of deformity in RLD.

METHODS

Specimens from radial-sided muscles and tendons were obtained at the time of surgery (either radialization or centralization) from 14 patients with 16 limbs affected with Bayne type 3 and type 4 RLD. The specimens were evaluated using light microscopy, electron microscopy, and immunohistochemical examination.

RESULTS

Among the 16 frozen muscle specimens, 6 (37%) showed normal muscle, while 10 (63%) showed the presence of atrophic fibers. The 6 cases with normal muscle showed no abnormality in fiber type distribution. Six patients showed predominance of type 1 muscle fibers. None of the specimens had myofibroblasts; 4 of 16 specimens had mast cells, and 9 of 16 specimens showed the presence of platelet derived growth factor-positive cells. Features of myofibroblasts (the presence of basal lamina, intercellular junctions, or pinocytic vesicles) were not identified in any specimen on electron microscopy.

CONCLUSIONS

The histopathological, electron microscopic, and immunohistochemical findings, in particular the absence of myofibroblasts, in tissue samples obtained from patients with RLD, do not support the assumption of abnormality in soft tissues as a secondary driver of deformity in RLD.

CLINICAL RELEVANCE

This study provides a preliminary insight into a possible role of soft tissues in the development of the deformity in RLD.

Long-term implications of COVID-19 on bone health: pathophysiology and therapeutics

BACKGROUND

SARS-CoV-2 is a highly infectious respiratory virus associated with coronavirus disease (COVID-19). Discoveries in the field revealed that inflammatory conditions exert a negative impact on bone metabolism; however, only limited studies reported the consequences of SARS-CoV-2 infection on skeletal homeostasis. Inflammatory immune cells (T helper-Th17 cells and macrophages) and their signature cytokines such as interleukin (IL)-6, IL-17, and tumor necrosis factor-alpha (TNF-α) are the major contributors to the cytokine storm observed in COVID-19 disease. Our group along with others has proven that an enhanced population of both inflammatory innate (Dendritic cells-DCs, macrophages, etc.) and adaptive (Th1, Th17, etc.) immune cells, along with their signature cytokines (IL-17, TNF-α, IFN-γ, IL-6, etc.), are associated with various inflammatory bone loss conditions. Moreover, several pieces of evidence suggest that SARS-CoV-2 infects various organs of the body via angiotensin-converting enzyme 2 (ACE2) receptors including bone cells (osteoblasts-OBs and osteoclasts-OCs). This evidence thus clearly highlights both the direct and indirect impact of SARS-CoV-2 on the physiological bone remodeling process. Moreover, data from the previous SARS-CoV outbreak in 2002-2004 revealed the long-term negative impact (decreased bone mineral density-BMDs) of these infections on bone health.

METHODOLOGY

We used the keywords "immunopathogenesis of SARS-CoV-2," "SARS-CoV-2 and bone cells," "factors influencing bone health and COVID-19," "GUT microbiota," and "COVID-19 and Bone health" to integrate the topics for making this review article by searching the following electronic databases: PubMed, Google Scholar, and Scopus.

CONCLUSION

Current evidence and reports indicate the direct relation between SARS-CoV-2 infection and bone health and thus warrant future research in this field. It would be imperative to assess the post-COVID-19 fracture risk of SARS-CoV-2-infected individuals by simultaneously monitoring them for bone metabolism/biochemical markers. Importantly, several emerging research suggest that dysbiosis of the gut microbiota-GM (established role in inflammatory bone loss conditions) is further involved in the severity of COVID-19 disease. In the present review, we thus also highlight the importance of dietary interventions including probiotics (modulating dysbiotic GM) as an adjunct therapeutic alternative in the treatment and management of long-term consequences of COVID-19 on bone health.

Enhanced recovery after surgery (ERAS) protocol in spine surgery

Enhanced recovery after surgery (ERAS) protocols are a set of interventions which are carried out in the preoperative and perioperative period. They are aimed to decrease the harmful effects of surgery on the body and help the patient recover better post-surgery. The effectiveness of ERAS has been well established in various other surgical specialities. Earlier spine surgery was thought to be very complex for application of ERAS protocols. However, this has changed over the last decade with (ERAS) protocols gaining widespread popularity in spine surgery. Initial studies involving ERAS in spine surgery were limited to lumbar spine. However, over the years the horizon of ERAS has expanded to include anterior cervical surgeries, spine deformity, spinal tumors and spine surgery in the elderly. ERAS has been shown to reduce the length of hospital stay, overall hospital costs, opioid consumption in perioperative and postoperative period and to lower complication rates in spine surgery. In this narrative review, we discuss various aspects of ERAS in spine surgery including the benefits of ERAS in spine surgery, the various components of preoperative, intraoperative and postoperative measures of ERAS protocol.

Three-column osteotomy by single-stage posterior approach in congenital and post-tubercular kyphosis: a comparison of outcomes

PURPOSE

To compare the clinical, radiological and functional outcomes of three-column osteotomy (3CO) by a single-stage posterior approach in patients with isolated congenital angular kyphosis (CK) and healed post-tubercular kyphosis (PTK).

METHODS

The hospital records of 30 patients with isolated congenital kyphosis (Group CK) and 51 patients with healed post-tubercular kyphosis (Group PTK), operated at a single centre utilizing a 3CO by a single-stage posterior-only approach, were retrospectively analysed. The two groups were compared with respect to selected demographic variables with clinical, radiological and functional outcome measures at a minimum follow-up of 24 months.

RESULTS

Patients in Group CK (median: 13 years, range: 4-30 years) presented earlier than those in Group PTK (median: 16 years, range: 6-45 years). The apex of the deformity was most often located in the thoracic spine in Group PTK, and in the thoracolumbar or lumbar spine in Group CK. The mean operative time (198.2 ± 31.5 min v/s 174.4 ± 34.5; p = 0.01) and estimated blood loss (859.6 ± 312.2 ml v/s 720.8 ± 187.3; p = 0.04) were significantly higher in Group PTK. While the local kyphosis angle was significantly corrected with surgery in both groups, the correction was significantly better in Group CK-this group also had significantly better overall functional (SRS-22r) scores at a follow-up of 24 months (p < 0.05). The overall complication rate (29.4% v/s 23.3%) and neurological complication rate (9.8% v/s 6.6%) were higher in Group PTK. Permanent neurological deterioration occurred in one patient in each group.

CONCLUSION

Patients with PTK have significantly higher age of presentation, higher operative time and higher complication rate as compared to CK. However, good functional outcomes and kyphosis angle correction can be achieved in both the groups with posterior-only three-column osteotomies.

Predictors of Operative Duration in Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis: A Retrospective Cohort Study

BACKGROUND

Accurate prediction of operative duration is necessary for efficient operating room scheduling, minimizing cancellations, shortening waitlists, better risk stratification, and effective preoperative counseling. Prolonged operative duration is also associated with negative patient outcomes. Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) is typically a lengthy surgical procedure with variable operative duration. The purpose of this study is to identify patient-, procedure-, and surgeon-specific variables that influence the operative duration in PSF for AIS and determine its impact on early postoperative outcomes.

METHODS

Hospital records of 150 AIS patients who underwent PSF at a single center were retrospectively reviewed. Various patient-, procedure-, and surgeon-specific variables-deemed to be possibly affecting the operative duration-were analyzed. A multivariate regression model was used to identify independent predictors of operative duration. The association between operative duration and early postoperative outcome measures was determined.

RESULTS

The final model obtained from the multivariate regression analysis included the following factors: experience of the chief surgeon (β = -0.36), Cobb angle of the major structural curve (β = 0.35), number of screws inserted (β = 0.28), coronal deformity angular ratio (β = 0.20), and apical vertebral rotation (β = -0.21 to 0.03). The model could explain 44% of the variability in the operative duration (R ² = 0.44). The operative duration had a significant correlation with estimated blood loss, need for perioperative blood transfusion, and length of hospital stay.

CONCLUSIONS

A set of variables that predict the variability in operative duration during PSF for AIS was identified, with the experience of the chief surgeon and the severity of the curve being the strongest predictors.

CLINICAL RELEVANCE

The results of this study emphasize the need for each hospital and surgical team to identify predictors of operative duration in their setup in order to better anticipate prolonged operative duration.

LEVEL OF EVIDENCE: 3

Understanding Musculoskeletal Disorders Through Next-Generation Sequencing

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An insight into musculoskeletal disorders through advancements in next-generation sequencing (NGS) promises to maximize benefits and improve outcomes through improved genetic diagnosis.

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The primary use of whole exome sequencing (WES) for musculoskeletal disorders is to identify functionally relevant variants.

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The current evidence has shown the superiority of NGS over conventional genotyping for identifying novel and rare genetic variants in patients with musculoskeletal disorders, due to its high throughput and low cost.

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Genes identified in patients with scoliosis, osteoporosis, osteoarthritis, and osteogenesis imperfecta using NGS technologies are listed for further reference.

"Cage in Box" - A modification of AIIMS BOX technique for large gap nonunion in young patients with neglected femur neck fractures

Neck of femur fractures have often been termed as "The Unsolved Fractures", since they have a guarded outcome even after improved understanding of biomechanics and biology of this area. Gap-nonunion is one such dreaded complication of this fracture, especially in younger (<60 years) population, where arthroplasty may not be the best go-to option. We have earlier described "The AIIMS BOX" technique to manage such cases of gap non-union in neglected neck femur fractures [1]. Here we intend to describe a more successful modification of this technique. We operated 7 cases of gap non-union with our new "Cage in Box" strategy and followed these cases for 5 years. 6 patients from this group achieved excellent to good outcomes and only 1 reported a poor outcome. All the patients, except the one with poor outcome, could walk without aid and do activities of daily living independently. 3 patients developed AVN but had no evidence of collapse. 3 patients also developed Coxa vara, but it was significant only in one case. 6/7 patients were able to squat. We describe this method in detail and feel this can be a viable option in the armamentarium of orthopedic surgeons, along with valgus osteotomy, vascularized and non-vascularized fibular strut graft as well as Meyer's Graft, to help them solve this unsolved fracture.

Non-operative treatment for low back pain: A review of evidence and recommendations

Background Low back pain (LBP) is a healthcare problem with high global prevalence, with non-operative management being the first line of treatment in the majority of patients. This literature review summarizes the current evidence for various modalities of non-operative treatment for LBP. Methods We did a literature search to elicit high-quality evidence for non-operative treatment modalities for LBP, including Cochrane Database reviews and systematic reviews or meta-analysis of randomized controlled trials. Only when these were not available for a particular treatment modality, other level 1 studies were included. The quality of evidence was categorized in accordance with the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) method-a globally adopted tool for grading the quality of evidence and making treatment recommendations. Results The treatment modalities that were reviewed included: general measures, medications/pharmacotherapy, exercises, electromagnetic therapies, alternative treatment modalities and interventional therapies. We found that high-quality evidence is lacking for most non-operative treatment modalities for LBP. The majority of interventions have small benefits or are similar to placebo. Conclusion The current evidence for non-operative treatment modalities for LBP is insufficient to draw conclusions or make recommendations to clinicians. High-quality trials are required before widespread use of any treatment modality. Considering that non-operative treatment is usually the first line of therapy for most patients with LBP, it deserves to be the focus of future research in spinal disorders.

Stepped Care Model for Developing Pathways of Screening, Referral, and Brief Intervention for Depression in Pregnancy: A Mixed-Method Study from Development Phase

BACKGROUND

Depression in pregnancy affects nearly one in five women in low- and middle-income countries and is associated with adverse obstetric and neonatal outcome. Burden of morbidity is high, but specialized mental health resources are meager. Effective low intensity psychosocial interventions hold promise to fill the treatment gap for maternal depression. In this paper, we aim to describe the process of development of a stepped care model incorporating screening, providing brief intervention, and referral pathways developed for managing depression in pregnancy in antenatal care health facilities in India.

METHODOLOGY

Using complex intervention development and evaluation method of Medical Research Council, United Kingdom, we searched evidence-based strategies from preexisting manuals, conducted formative research for need assessment and stakeholder engagement, and developed the intervention following an expert review panel. We conducted pilot testing to assess the feasibility and acceptability of intervention supplemented by three focused group discussions.

RESULTS

Manual review identified psychoeducation, empathetic listening, behavior activation, and supportive counseling as important elements. Need assessment revealed huge gap in perinatal mental health knowledge. Nearly 92% of total 272 perinatal women had poor awareness and 35%-70% of total 62 health-care providers had poor knowledge. In qualitative interview, women reported depressive symptoms as a normal part of pregnancy and had poor help seeking, behavior symptoms of depression were more prominent. A stepped care algorithm was developed for screening all expectant mothers in each trimester for depression using Patient Health Questionnaire-9 (PHQ-9). Women with PHQ-9 score >19 or reporting self-harm ideation were urgently referred to psychiatrist. Women with PHQ-9 score 5-19 were given brief intervention for depression in pregnancy intervention by antenatal nurse. The intervention developed consists of three sessions of psychoeducation, relaxation exercise, and mental health promotion, each lasting 20 min and at gap of 2 weeks each. Service providers and mothers reported good acceptability of psychosocial intervention and reported satisfaction with content and delivery of intervention.

CONCLUSION

Low intensity brief psychosocial interventions can be adapted for implementation if relevant stakeholders are engaged at each step right from development of such as screening, intervention pathway to delivery, and effectiveness study.

Diagnostic yield of image-guided biopsy in patients with suspected infectious spondylodiscitis : a prospective study from a tuberculosis-endemic country

AIMS

The aims of this study were to determine the diagnostic yield of image-guided biopsy in providing a final diagnosis in patients with suspected infectious spondylodiscitis, to report the diagnostic accuracy of various microbiological tests and histological examinations in these patients, and to report the epidemiology of infectious spondylodiscitis from a country where tuberculosis (TB) is endemic, including the incidence of drug-resistant TB.

METHODS

A total of 284 patients with clinically and radiologically suspected infectious spondylodiscitis were prospectively recruited into the study. Image-guided biopsy of the vertebral lesion was performed and specimens were sent for various microbiological tests and histological examinations. The final diagnosis was determined using a composite reference standard based on clinical, radiological, serological, microbiological, and histological findings. The overall diagnostic yield of the biopsy, and that for each test, was calculated in light of the final diagnosis.

RESULTS

The final diagnosis was tuberculous spondylodiscitis in 250 patients (88%) and pyogenic spondylodiscitis in 22 (7.8%). Six (2.1%) had a noninfectious condition-mimicking infectious spondylodiscitis, and six (2.1%) had no definite diagnosis and improved without specific treatment. The diagnosis was made by image-guided biopsy in 152 patients (56%) with infectious spondylodiscitis. Biopsy was contributory in identifying 132/250 patients (53%) with tuberculous spondylodiscitis, and 20/22 patients (91%) with pyogenic spondylodiscitis. Histological examination was the most sensitive diagnostic modality, followed by Xpert MTB/RIF assay.

CONCLUSION

Image-guided biopsy has a reasonably high diagnostic yield in patients with suspected infectious spondylodiscitis. A combination of histological examination, Xpert MTB/RIF assay, bacterial culture, and sensitivity provides high diagnostic accuracy in a country in which TB is endemic. Cite this article: Bone Joint J 2022;104-B(1):120-126.

Is 6 months of Antitubercular Chemotherapy as Effective as More Than 6 months Regimen in Spinal Tuberculosis? A Systematic Review and Meta-Analysis

Historically, osteoarticular tuberculosis (TB), including spinal TB, was treated with prolonged course of antitubercular therapy (ATT). Due to various challenges, there has been reluctance to explore the use of short-course ATT in spinal TB. However, with the success of short-course ATT being demonstrated in other forms of extrapulmonary TB, the subject is open for debate again. Therefore, we systematically reviewed various published literature to determine whether short-course treatment regimen (6 months) of ATT provides equivalent results in terms of disease healing as long-course treatment regimen (≥9 months) in the management of spinal TB. Five electronic databases (PubMed, MEDLINE, EMBASE, CENTRAL, and Web of Science) and their reference lists were searched to identify relevant randomized controlled trials with at least 1 year of follow-up that compared short-course with standard-course ATT for treatment of spinal TB. The methodological quality of included studies was assessed, and their data were extracted. A meta-analysis was used to calculate pooled effect sizes and 95% confidence interval (CI). The outcome measure was healed status of the disease at the final follow-up. Of 331 publications identified through literature search, eight publications describing six randomized studies were included. Moreover, 375 of 414 patients (90.58%) who received 6 months of ATT had healed status at their final follow-up compared to 404 of 463 patients (87.26%) who received ≥9 months of ATT. Overall, the healed status of spinal TB was equivalent in patients in both groups (pooled relative risk, 0.98; 95% CI, 0.92-1.04; p =0.439). However, there was considerable heterogeneity among the trials (I2=40.8%, p =0.149). The results suggest that the use of short-course (6 months) chemotherapy may be considered for the treatment of spinal TB in view of the similarity in the healing response achieved compared to treatment regimens of longer duration.

Clinical, radiological and functional outcome of posterior-only three-column osteotomy in healed, post-tubercular kyphotic deformity: a minimum of 2-year follow-up

PURPOSE

To describe clinical, radiological and functional outcomes of patients with post-tubercular healed kyphosis operated by posterior-only three-column osteotomy.

METHODS

The hospital records of 47 patients from a single center, operated for healed, post-tubercular kyphosis were retrospectively analyzed. Deformity correction in all patients was done utilizing a three-column osteotomy by a single-stage, posterior-only approach. Radiological parameters (local kyphosis angle; KA, thoracic kyphosis; TK, lumbar lordosis; LL, pelvic tilt; PT, sacral slope; SS, C7 sagittal vertical axis; C7 SVA, pelvic incidence minus lumbar lordosis; PI-LL), functional scores and clinical details of complications were recorded.

RESULTS

The median age of the study population was 16 years (6-45). The apex of deformity was in thoracic, thoracolumbar and lumbar spine in 22, 19 and 6 cases, respectively. The mean operative time was 197.2 ± 30.5 min and the mean operative blood loss was 701 ± 312 ml. KA (preoperative: 68.2° ± 26.9° v/s postoperative: 29.6° ± 20.3°; p value < 0.0001), C7 SVA (preoperative 20.9 ± 37.9 mm v/s postoperative: 5.5 ± 16.3 mm; p value = 0.005) and TK (preoperative 47.7° ± 33.2° v/s postoperative: 37.8° ± 19.8°; p value = 0.0024) underwent a significant change with surgery. Mean SRS-22r score improved after surgical correction (preoperative: 2.7 ± 0.2 v/s final follow-up: 4 ± 0.2; p < 0.0001) with the maximum improvement occurring in self-image domain. The overall complication rate was 29.7%-including 4 neurological and 10 non-neurological complications. Permanent neurological deterioration was seen in one patient.

CONCLUSION

Three-column osteotomies through posterior-only approach are safe and effective and offer good clinic-radiological and function outcome in post-tubercular kyphotic deformity correction.

Epidemiological Insights from 1,652 Patients with Spinal Tuberculosis Managed at a Single Center: A Retrospective Review of 5-Year Data

Study Design

Retrospective cohort.

Purpose

To report the demographic characteristics, clinico-radiological presentation, laboratory findings, and outcomes of "middlepath" treatment in patients with spinal tuberculosis from a single public healthcare facility in a developing country.

Overview of Literature

Tuberculosis is a global health problem that is endemic in developing countries and undergoing resurgence in developed ones. Spinal tuberculosis can cause disabling back pain, progressive deformity, and neurological involvement. However, there is a lack of large-scale epidemiological studies quantifying the size and severity of the problem of spinal tuberculosis.

Methods

Hospital records of spinal tuberculosis patients treated at a single center over a period of 5 years were retrospectively reviewed. A diagnosis of spinal tuberculosis was based on standard clinical, radiological, microbiological, and histopathological evidence. Patients were treated in accordance with the "middle-path" regimen; surgery was reserved for selective indications.

Results

A total of 1,652 patients were included. Their median age was 32.4 years, with 53% being male. Axial pain (98%) was the most common presenting symptom; 19% of patients had neurological deficit. Lumbar spine (37%) was the most common site of involvement, with a paradiscal pattern (82%) of involvement predominating. Multi-level involvement was seen in 19% of patients; skip lesions were noted in 2.8%. Transpedicular biopsy was performed in 667 patients; at least one tissue test was diagnostic of tuberculosis in 65% of patients. Forty-four patients had drug resistance to rifampicin. Surgery was required in 10.5% of patients. The "middle-path" regimen was associated with high compliance and significant improvements in pain (Visual Analog Scale score) and function (36-Item Short Form Health Survey).

Conclusions

Our findings confirm the widespread prevalence of spinal tuberculosis and describe various epidemiological characteristics of a large sample of spinal tuberculosis patients. Adoption of the "middle-path" regimen is associated with high compliance and favorable outcomes in spinal tuberculosis.

Clinical, radiological, and functional outcomes of posterior-only three-column osteotomy in congenital kyphosis : a minimum of two years' follow-up

AIMS

To describe the clinical, radiological, and functional outcomes in patients with isolated congenital thoracolumbar kyphosis who were treated with three-column osteotomy by posterior-only approach.

METHODS

Hospital records of 27 patients with isolated congenital thoracolumbar kyphosis undergoing surgery at a single centre were retrospectively analyzed. All patients underwent deformity correction which involved a three-column osteotomy by single-stage posterior-only approach. Radiological parameters (local kyphosis angle (KA), thoracic kyphosis (TK), lumbar lordosis (LL), pelvic tilt (PT), sacral slope (SS), C7 sagittal vertical axis (C7 SVA), T1 slope, and pelvic incidence minus lumbar lordosis (PI-LL)), functional scores, and clinical details of complications were recorded.

RESULTS

The mean age of the study population was 13.9 years (SD 6.4). The apex of deformity was in thoracic, thoracolumbar, and lumbar spine in five, 14, and eight patients, respectively. The mean operating time was 178.4 minutes (SD 38.5) and the mean operative blood loss was 701.8 ml (SD 194.4). KA (preoperative mean 70.8° (SD 21.6°) vs final follow-up mean 24.7° (SD 18.9°); p < 0.001) and TK (preoperative mean -1.48° (SD 41.23°) vs final follow-up mean 24.28° (SD 17.29°); p = 0.005) underwent a significant change with surgery. Mean Scoliosis Research Society (SRS-22r) score improved after surgical correction (preoperative mean 3.24 (SD 0.37) vs final follow-up mean 4.28 (SD 0.47); p < 0.001) with maximum improvement in self-image and mental health domains. The overall complication rate was 26%, including two neurological and five non-neurological complications. Permanent neurological deficit was noted in one patient.

CONCLUSION

Deformity correction employing three-column osteotomies by a single-stage posterior-only approach is safe and effective in treating isolated congenital thoracolumbar kyphosis. Cite this article: Bone Joint J 2021;103-B(7):1309-1316.

Regulatory B Cells (Bregs) Inhibit Osteoclastogenesis and Play a Potential Role in Ameliorating Ovariectomy-Induced Bone Loss

Increasing evidence in recent years has suggested that regulatory B cells (Bregs) are one of the crucial modulators in various inflammatory disease conditions. However, no study to date has investigated the significance of Bregs in modulating osteoclastogenesis. To the best of our knowledge, in the present study, we for the first time examined the anti-osteoclastogenic potential of Bregs under in vitro conditions and observed that Bregs suppress RANKL-induced osteoclastogenesis in a dose-dependent manner. We further elucidated the mechanism behind the observed suppression of osteoclasts differentiation via Bregs. Our results clearly suggested that the observed anti-osteoclastogenic property of Bregs is mediated via the production of IL-10 cytokine. Next, we explored whether Bregs have any role in mediating inflammatory bone loss under post-menopausal osteoporotic conditions in ovx mice. Remarkably, our in vivo data clearly suggest that the frequencies of both CD19+IL-10+ Bregs and CD19+CD1dhiCD5+IL-10+ "B10" Bregs were significantly reduced in case of osteoporotic mice model. Moreover, we also found a significant reduction in serum IL-10 cytokine levels in osteoporotic mice, thereby further supporting our observations. Taken together, the present study for the first time establishes the direct role of regulatory B cells in modulating osteoclastogenesis in vitro. Further, our in vivo data suggest that modulations in the percentage of Bregs population along with its reduced potential to produce IL-10 might further exacerbate the observed bone loss in ovx mice.

Awake Spinal Fusion

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Awake spinal fusion (ASF) integrates advancements in surgical techniques and anesthetic modalities with the aim to maximize benefits and improve outcomes from the surgical and anesthetic standpoints.

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ASF employs minimally invasive or endoscopic surgical techniques that are complemented by regional modalities of anesthesia and analgesia.

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The current evidence, albeit limited, has shown better results with ASF in terms of postoperative pain scores, a patient's need for opioids, postoperative hospital length of stay, and rehabilitation compared with the conventional technique of open spinal fusion with the patient under general anesthesia.

Regional Anesthesia for Spine Surgery

Recent advancements in spine surgery anesthesia techniques and pain management has led to a paradigm shift from conventional open spinal procedures to minimally invasive spine surgeries performed on an outpatient basis. Spinal anesthesia and epidural anesthesia alone or in combination with spinal are common regional anesthesia modalities used in spine surgeries. New modalities of regional analgesia have emerged recently including erector spinae and thoracolumbar interfascial plane block, aimed at decreasing perioperative pain and enhancing early recovery in patients undergoing spine surgery. In this narrative review we discuss the characteristics of regional anesthesia including its types, indications, contraindications, benefits, and potential complications along with new modalities of regional analgesia.

Choosing the Distal Fusion Levels in Lenke Type 1 Adolescent Idiopathic Scoliosis: How Do the Existing Classifications and Recommendations Guide Us?

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

(a) To compare the recommendations of Lenke and Peking Union Medical College (PUMC) classifications in choosing distal fusion levels in Lenke 1 adolescent idiopathic scoliosis (AIS) curves and (b) to analyze whether the variability in distal fusion levels influences treatment outcomes.

METHODS

Hospital records of Lenke 1 AIS patients operated for single stage, posterior-only deformity correction were analyzed. Distal fusion levels recommended by Lenke and PUMC classifications were calculated and were compared with the actual distal fusion levels. The study population was divided based on whether the actual distal fusion levels were in agreement, shorter or longer than those recommended by Lenke classification. Subgroup analysis of Lenke 1C curves was done. The groups were compared with regard to the following outcome measures: Cobb angle correction, postoperative sagittal vertical axis, postoperative C7 offset, and Scoliosis Research Society-22r (SRS-22r) score at 24 months.

RESULTS

The distal fusion levels recommended by the 2 classifications were in agreement in 92 of 104 cases. In all the cases with disparity, Lenke classification recommended shorter fusions than the PUMC classification. No statistically significant difference was observed in the outcome measures-whether the actual distal fusion levels were in agreement, shorter, or longer than those recommended by the Lenke classification or whether or not the recommendations for selective fusion of any of these classifications were adhered to.

CONCLUSION

Lenke classification can save fusion levels without compromising on treatment outcomes when compared with PUMC classification. Variability in choice of distal fusion levels is not clinically significant at 24-month follow-up.

Variations in the Number of Thoracic and Lumbar Vertebrae in Patients With Adolescent Idiopathic Scoliosis: A Retrospective, Observational Study

BACKGROUND

Abnormal anatomy is a contributory factor to wrong-level surgery. Variations in the number of vertebrae in populations from different races and geographical regions have been described. A ∼10% prevalence of variations in number of thoracic and lumbar vertebrae in adolescent idiopathic scoliosis (AIS) patients has been previously reported. The objectives of present study were (i) to find out the prevalence of variations in the number of thoracic and lumbar vertebrae and the presence of lumbosacral transitional vertebrae (LSTV) in Indian AIS patients and (ii) to correlate these variations with gender and type of curve.

METHODS

Hospital records and imaging of 198 AIS patients were reviewed retrospectively. A standardized numbering strategy was used to identify the number of thoracic vertebrae, number of lumbar vertebrae, and presence of LSTV. Patients' gender and curve type were correlated with the presence of an abnormal number of thoracic or lumbar vertebrae. Radiology reports and operation notes were reviewed to find out instances when the radiologist or surgeon had identified an abnormal number of vertebrae.

RESULTS

Forty patients (20.2%) with abnormally numbered thoracic or lumbar vertebrae were identified. Twenty patients (10.1%) had abnormally numbered thoracic vertebrae, and 33 patients (16.7%) had abnormally numbered lumbar vertebrae. The prevalence of LSTV was 18.2%. Presence of variations did not correlate with gender or curve type. Radiology reports identified 2/40 patients with variations, whereas operation notes showed 4/40 patients had been correctly identified to have abnormally numbered vertebrae.

CONCLUSIONS

There is high prevalence of variation in the number of thoracic or lumbar vertebrae in AIS patients, with most of those missed being identified by radiologists or surgeons. The patient's preoperative imaging must be scrutinized to identify these patients and take the variation into account to avoid wrong selection of fusion levels.

LEVEL OF EVIDENCE

3.

CLINICAL RELEVANCE

Text. The study raises awareness about possibility of wrong selection in fusion levels due to anatomical variations in surgery for AIS.

COVID-19 infection, inception and immunity: Observations and recommendations in the light of vitamin D?

Responsive immunity plays an important role fighting against infections. Worldwide, Vitamin D deficiency is a major concern not only for musculoskeletal health but also affecting the immunity status in population. Amidst COVID-19 pandemic, it is imperative to establish the role of vitamin D in destruction of pathogens. Vitamin D awareness program at school level might be an effective health governance policy to educate populations for the importance of vitamin D in overall health.

Selective hemivertebrae resection in congenital scoliosis with multiple hemivertebrae

There are no established guidelines regarding the surgical strategy to be adopted in congenital scoliosis with multiple hemivertebrae-decision has to be guided taking into account the contribution of each hemivertebra to the deformity and its growth potential. We describe a case of a 12-year-old woman with congenital scoliosis due to unbalanced multiple hemivertebrae. Preoperative imaging revealed the presence of three hemivertebrae-at D7, D10 and L5. Our surgical strategy was guided by various factors-the morphology of the hemivertebrae, the location, the contribution of each hemivertebra to the deformity and their relationship to each other. Based on this, we performed a selective hemivertebrae resection-completely resecting L5 hemivertebra and performing 'egg-shell' decancellation of D7 hemivertebra and in situ fusion of D10 hemivertebra, yielding satisfactory results. This case report illustrates a rational thought process that can guide a paediatric spinal deformity surgeon in treating scoliosis with multiple hemivertebrae.

Rare case of juvenile ossifying fibroma of the lumbar spine causing vertebra plana

Juvenile ossifying fibroma (JOF) is a rare benign fibro-osseous tumour occurring in craniofacial bones of children and young adults. An 8-year-old girl presented with low back pain since 10 months. Plain radiographs revealed a vertebra plana-like lesion of L3 vertebra. CT scan showed an osteolytic lesion with areas of ground-glass appearance interspersed with bone flecks involving the entire body, pedicles and laminae of L3 with well-circumscribed cortical margins. Biopsy was done-histopathological findings showed cellular fibrous stroma with bony trabeculae-which, on corroboration with clinical and radiological findings noted previously, confirmed the diagnosis of JOF. The patient underwent preoperative angioembolisation, curettage and posterior stabilisation. At follow-up of 15 months, the patient was asymptomatic-imaging revealed residual tumour in pedicles-which however did not progress radiologically. The case raises the importance of including this rare condition as a differential diagnosis in children and reports successful outcome with subtotal resection.

C-spine clearance in poly-trauma patients: A narrative review

The incidence of cervical spine injury in patients with polytrauma is 3.7%. Early identification and management of cervical spine injuries in these patients play a crucial role in preventing secondary cervical spine and cord injuries. C-spine clearance assumes a pivotal role in reducing the morbidity and mortality associated with cervical spine injury. Despite the availability of various validated management algorithms and protocols for C-spine clearance, there are several controversies regarding C-spine clearance, such as the ideal protocol and imaging modality, clearance of obtunded patients and management of patients that lie out of the described protocols and rules. The current article aims to provide a comprehensive review of the relevant literature and address the prevalent controversies.