Clinical and Radiological Outcomes after Reducing Adult Lytic High-Grade Spondylolisthesis Using a Hybrid Technique: Combination of Percutaneous Pedicle Screws with Midline Microscopic Transforaminal Decompression

STUDY DESIGN

Retrospective study.

PURPOSE

To analyze the results and effectiveness of percutaneous screws (PS) with midline microscopic transforaminal decompression (MTFD) technique in reducing adult stiff lytic high-grade spondylolisthesis (HGSL) and compare it with the conventional technique.

OVERVIEW OF LITERATURE

Pedicle screw cannulation and segmental kyphosis negotiation are surgical challenges in HGSL. Open reduction is the preferred approach. PS have the advantage of optimized trajectory and minimized soft tissue exposure. The role of minimally invasive surgery in HGSL remains unknown. We propose a hybrid technique combining PS with MTFD for lytic HGSL.

METHODS

This study included 25 patients with adult lytic HGSL (Meyerding grade III and IV) operated using a hybrid technique from 2012 to 2015. Data were compared with retrospective data on conventional open reduction (n=23) operated from 2000 to 2015. The minimum follow-up was 5 years. Clinical outcomes were assessed using the Visual Analog Scale (VAS) score and modified Oswestry Disability Index (m-ODI). The spinopelvic and perioperative parameters were recorded. The inter-body fusion and adjacent segment degeneration (ASD) were assessed on radiographs at the final follow-up.

RESULTS

The average age in the MTFD and open groups was 45.84±12.70 years (nine males and 16 females) and 49.26±13.33 years (eight males and 15 females), respectively. Further, 22 and three patients in the MTFD group and 19 and four in the open group had grade III and IV listhesis, respectively. The MTFD group demonstrated less operative time, blood loss, and hospital stays than the open group. Significant improvements were observed in VAS and m-ODI in subsequent follow-ups in both groups. The MTFD group fared better at 3 months but outcomes were comparable at the final follow-up. Both techniques were equally effective in restoring spinopelvic parameters. The incidence of ASD is comparable.

CONCLUSIONS

The technique was proven effective in reducing HGSL. The long-term clinical and radiological outcomes were favorable and comparable with the conventional approach.

Ventriculoperitoneal Shunt Malfunction, a Rare Cause of Paraplegia after Kyphosis Correction: A Case Report and Literature Review

Ventriculoperitoneal shunt (VPS) malfunction after kyphosis surgery in 12-year boy caused a sudden hydrocephalus which increased cerebrospinal fluid pressure within the spinal cord and decreased cord perfusion. Spinal cord at apex of deformity was vulnerable to ischemia which caused paraplegia. The ischemic event was reversible after re-insertion of the VPS.

Study Design.

Case report and literature review.

Objective.

The aim of this study was to report a rare case of hydrocephalus due to ventriculoperitoneal shunt (VPS) malfunction following kyphosis correction that resulted in paraplegia in the postoperative period. The available English literature to explain the possible cause of paraplegia is reviewed.

Summary of Background Data.

Twelve-year male child presented with a severe dorsal kyphoscoliosis deformity with spastic paraparesis since 4 months. The lower extremities had grade-2 power and spasticity. The sensation was reduced below D9. The deep tendon reflexes were exaggerated with ankle clonus. Bowel-bladder had urgency and frequency. The radiographs and CT showed D6-7 hemi-vertebra with complex kyphoscoliosis deformity. magnetic resonance imaging showed a stretching cord at D6-7 due to 92° angular kyphosis. The somatosensory evoked potential showed posterior column involvement. The VPS was placed for hydrocephalus at 4 months of age. The shunt remained functioned throughout childhood.

Methods.

He underwent posterior vertebral column resection and kyphosis correction surgery. Postoperative CNS function was normal. Neurology was status quo. After 20 hours, the boy appeared irritable, confused with a headache and repetitive vomiting (Glasgow coma scale: 7-8/15). Computed tomography brain showed dilated both ventricles with left shunt in situ. Immediate re-shunting was done from right side. The CNS status improved dramatically and regained consciousness. Neurology deteriorated to grade-0 with increased spasticity and further decreased sensation below D9. The spinal causes (hematoma, implant malposition, syrinx) were ruled out.

Results.

Delayed neurological recovery was seen at 6th week after shunt surgery. The Rapid motor march was observed and became independent ambulatory at 12th week. At 6 months, he improved up-to grade4 power with grade 2 spasticity which maintained at 2 years.

Conclusion.

VPS blockage caused a sudden hydrocephalus which increased CSF pressure within the spinal cord and decreased cord perfusion. Spinal cord at apex of deformity was vulnerable to ischemia which caused paraplegia.

Level of Evidence: 5

A Modified Posterior Approach for Decompression of a Multiloculated Atlanto-axial Cyst With Myelopathy

STUDY DESIGN

Case report.

OBJECTIVE

To describe a modified posterior approach for decompression and excision of a multiloculated atlanto-axial cyst.

SUMMARY OF BACKGROUND DATA

Atlanto-axial cyst with myelopathy is rare. A direct decompression through anterior approach or an indirect decompression through posterior approach has been proposed. We report a rare multiloculated large C1-C2 cyst extending down to C3 body with myelopathy that created a dilemma in choice of approach. A modified posterior approach was adopted for decompression.

METHODS

A 72-year-old lady, known case of Rheumatoid arthritis, presented with cervical myelopathy which was rapidly progressive since 2 months being her to wheel chair bound. She had clumsiness of gait and bilateral grip weakness. Both upper and lower extremities had nonfunctional power (medical research council scale grade 2). Deep tendon reflexes were exaggerated. Sensation was reduced in trunk and both extremities. Magnetic resonance imaging and computed tomography scan showed a large multiloculated cyst compressing spinal cord. Here author used modified posterior approach from the right side to access the cyst. The C2 ganglion excision, vertebral artery isolation, and resection of the pars allowed an approach similar to transforaminal decompression in the lumbar spine. A large antero-lateral epidural part of the cyst was excised. The retro-dental cyst was decompressed by puncturing cyst. Biopsy confirmed a synovial cyst.

RESULT

The patient showed rapid neurological recovery after surgery. Postoperative magnetic resonance imaging at 3 months showed complete resolution of cyst. At 2-year follow-up, there was a complete neurological recovery with residual spasticity.

CONCLUSION

A customized posterior approach allowed near total excision of a rare multiloculated large C1-2 cyst extending to the C3 body. This allowed visualisation anterior to the spinal cord without undue retraction that saved an additional anterior decompression.

LEVEL OF EVIDENCE

5.

Intradural tumor and concomitant disc herniation of cervical spine

We report a rare patient of a simultaneous extradural and intradural compression of the cervical spinal cord due to co-existent intervertebral disc herniation and an intradural schwannoma at the same level. The intradural lesion was missed resulting in recurrence of myelopathy after a surprisingly complete functional recovery following anterior cervical discectomy. Retrospectively, it was noted that the initial cord swelling noticed was tumor being masked by the compression produced by the herniated disc. A contrast magnetic resonance imaging scan is important in differentiating intradural tumors of the spinal cord. A high index of suspicion is often successful in unmasking both the pathologies.

Surgical approach to cervical spondylotic myelopathy on the basis of radiological patterns of compression: prospective analysis of 129 cases

This is a prospective analysis of 129 patients operated for cervical spondylotic myelopathy (CSM). Paucity of prospective data on surgical management of CSM, especially multilevel CSM (MCM), makes surgical decision making difficult. The objectives of the study were (1) to identify radiological patterns of cord compression (POC), and (2) to propose a surgical protocol based on POC and determine its efficacy. Average follow-up period was 2.8 years. Following POCs were identified: POC I: one or two levels of anterior cord compression. POC II: one or two levels of anterior and posterior compression. POC III: three levels of anterior compression. POC III variant: similar to POC III, associated with significant medical morbidity. POC IV: three or more levels of anterior compression in a developmentally narrow canal or with multiple posterior compressions. POC IV variant: similar to POC IV with one or two levels, being more significant than the others. POC V: three or more levels of compression in a kyphotic spine. Anterior decompression and reconstruction was chosen for POC I, II and III. Posterior decompression was chosen in POC III variant because they had more incidences of preoperative morbidity, in spite of being radiologically similar to POC III. Posterior surgery was also performed for POC IV and IV variant. For POC IV variant a targeted anterior decompression was considered after posterior decompression. The difference in the mJOA score before and after surgery for patients in each POC group was statistically significant. Anterior surgery in MCM had better result (mJOA = 15.9) versus posterior surgery (mJOA = 14.96), the difference being statistically significant. No major graft-related complications occurred in multilevel groups. The better surgical outcome of anterior surgery in MCM may make a significant difference in surgical outcome in younger and fitter patients like those of POC III whose expectations out of surgery are more. Judicious choice of anterior or posterior approach should be made after individualizing each case.

Conus medullaris syndrome due to an intradural disc herniation: a case report

A 70-year-old male patient developed acute paraplegia due to conus medullaris compression secondary to extrusion of D12-L1 disc. After negative epidural examination intraoperatively, a durotomy was performed and an intradural disc fragment was excised. Patient did not regain ambulatory status at two-year follow-up. Intraoperative finding of negative extradural compression, tense swollen dura and CSF leak from ventral dura should alert the surgeon for the possibility of intradural disc herniation. A routine preoperative MRI is misleading and a high index of suspicion helps to avoid a missed diagnosis.

Role of transarticular screw fixation in tuberculous atlanto-axial instability

Prospective study of 27 consecutive cases of tuberculous atlanto-axial instability operated between 1998 and 2003. Early surgical stabilization of tuberculous atlanto-axial instability has gained popularity. This is largely due to success of chemotherapy in rapid control of infection. Although selective atlanto-axial fusion techniques are advocated in other indications, their role in tuberculosis remains confined to atlanto-axial wiring techniques that are mechanically unsound. The role of three-point rigid fixation using trans-articular screws (TAS) remains unclear. The objectives of this study are: (1) To define the role of trans-articular screws in tuberculous atlanto-axial instability based on radiological criteria. (2) To attempt to separate patients that can be treated by selective atlanto-axial fixation as against the standard occipito-cervical fusion (OCF). (3) Compare the clinical and radiological outcome parameters between the two groups. Twenty-seven consecutive patients of tuberculous atlanto-axial instability were operated between 1998 and 2003. The pattern of articular surface destruction and the reducibility of the atlanto-axial complex were assessed on plain radiographs and MRI. The reducibility of the C1-C2 joint was graded as reducible, partially reducible and irreducible. Pattern of the C1-C2 articular mass destruction was grouped as minimal, moderate and severe. The patients were divided into two surgical groups based on radiological findings and were treated with TAS (n=11) and OCF (n=16) fusion. The three-point fixation provided by the TAS allowed early brace free mobilization by 3 months with fusion rate of 100%. Fusion occurred in 83.16% in the OCF group. Implant failure occurred in two patients who underwent OCF. The patient satisfaction rate in the TAS group and the OCF group was 90.90 and 62.50%, respectively. Results in 27 consecutive patients demonstrate improved patient fusion and satisfaction rates in the TAS group. Judicious selection of patients for TAS fixation is possible with relatively few complications in tuberculosis of the atlanto-axial complex. This, however, requires a thorough understanding of the MRI pattern of involvement of the atlanto-axial complex that is difficult in non-endemic areas.

Nonfunctioning islet cell tumor presenting with ascites and portal hypertension

Nonfunctioning islet cell tumors commonly cause no symptoms. A 22-year-old woman presented with lump in the left hypochondrium, refractory high-protein ascites and evidence of left-sided portal hypertension. At exploratory laparotomy, a 30 cm x 15 cm mass was seen at the splenic hilum, with large collateral vessels around. Distal pancreatectomy with splenectomy was done. Histology of the mass showed malignant islet cell tumor infiltrating the spleen. The patient died in the postoperative period.

Acquisition of Helicobacter pylori infection and reinfection after its eradication are uncommon in Indian adults

BACKGROUND

Eradication of Helicobacter pylori infection is known to decrease the recurrence rate of peptic ulcer disease. Data from India on the acquisition rate of H. pylori infection and reinfection after eradication are scant.

AIM

To study the rates of acquisition of H. pylori infection and of reinfection after eradication in Indian adult patients.

METHODS

We evaluated 116 consecutive patients with dyspepsia undergoing endoscopy. Sixty-four of them were H. pylori-positive on gastric antral biopsy (rapid urease test and histology). Patients diagnosed to have H. pylori infection were treated with a four-drug regimen (omeprazole, bismuth subcitrate, tetracycline, furazolidine) for 2 weeks; those failing H. pylori eradication were treated with a second regimen (lansoprazole, amoxycillin, secnidazole) for one week. Patients who were H. pylori-negative to begin with and those who had successful H. pylori eradication were followed up clinically and endoscopically every 3 months for a median of one year.

RESULTS

Ninety-six patients (50 H. pylori-positive) were available for study; the other 20 were lost to follow up after the first endoscopy. Fifty of the 96 (52%) were H. pylori-positive; four of these 50 patients did not follow up after first treatment. The eradication rate with the four-drug regimen was 89.1% (41/46). Four of the 5 non-responders eradicated H. pylori with the second regimen. At the end of median one year follow-up (range 9-15 months), one of the 45 patients (2.4%) who eradicated the organism developed reinfection; none of the 46 patients who were initially H. pylori-negative acquired new infection.

CONCLUSIONS

The risk of reinfection after eradication is low in Indian subjects at the end of one year. The rate of acquisition of new infection is also low in the adult population.

Giant cell tumour of talar body

Giant cell tumour (osteoclastoma) of talar bone is a rare entity and is seen more commonly in the third decade of life. We report this disease entity in a 17-years-old girl. The patient presented with painful swelling of the left ankle with an osteolytic lesion in the talus on conventional radiographs. Intralesional curettage and autologous bone grafting was performed following which patient's pain and swelling disappeared. Complete range of movement at the ankle joint was regained with minimal restriction at the subtalar joint. There is no evidence of relapse at six months follow up.

Evaluation of a new recombinant DNA hepatitis B vaccine (Shanvac-B)

We assessed the efficacy and safety of Shanvac-B, a new recombinant hepatitis B vaccine developed in India. Eighty-one healthy volunteers (75 women, 6 men; aged 18-40 yr), negative for markers for hepatitis B and HIV, received 20 microg of the vaccine intramuscularly at 0, 1 and 2 months. Forty-three (53%) seroconverted at one month after dose 1; of these, 26% were seroprotected (anti-HBs> 10 mIU/mL). Seroprotection at one month after doses 2 and 3 was 99% and 100%, respectively. Geometric mean titres of anti-HBs in subjects who seroconverted were 11 (range 2-366), 266 (8-7469) and 2246 (102-23680) mIU/mL, respectively. One subject developed urticarial rash after the second dose; there was no other adverse event. We conclude that this vaccine is safe and efficacious, providing significant protection even after two doses.