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Study Design: Retrospective case series.Purpose: This study aimed to examine the efficacy of composite grip strength as a marker of surgical outcome in patients with moderate to severe degenerative cervical myelopathy.Overview of Literature: Degenerative cervical myelopathy causes loss of dexterity, muscle strength, and sensations in the hand. The impact of surgical management on improvement in composite grip strength has received scant attention.Methods: This retrospective study was performed on degenerative cervical myelopathy patients with a complete composite grip strength assessment between January 2013 to January 2019. The Biometrics E-link hand kit was used for the assessment. The following parameters were measured: maximum grip strength, sustained grip strength, three-jaw pinch, maximum key pinch, and sustained key pinch. The pre- and postoperative functional status was assessed using the Nurick grade and the modified Japanese Orthopaedic Association (mJOA) score.Results: A total of 40 patients were included in the study. The mean patient age was 51.9 years. The mean preoperative Nurick grade was 3.5 and the mJOA score was 10.9. The anterior approach was used in 25 patients, and the posterior approach was used in 15 patients. Four patients developed complications. Degenerative cervical myelopathy resulted in decreased handgrip and pinch strength as compared to normative Indian data. There was a significant improvement in the postoperative composite grip strength for all five parameters. There was no differential improvement between the anterior and posterior surgical groups. The improvement in the composite grip strength correlated with the improvement in functional scores.Conclusions: Composite grip strength analysis is an objective method for assessing the impact of degenerative cervical myelopathy on grip strength and monitoring the postoperative improvement. Decompressive surgery resulted in global improvement in all the parameters of composite grip strength.

Study Design: Prospective cohort study.Purpose: To evaluate the association between nutritional parameters related to postoperative surgical site infections and duration of hospital stay and intensive care unit (ICU) stay in patients undergoing major spine surgery.Overview of Literature: Malnutrition is highly prevalent in surgical patients. Malnourished patients are considered to be at higher risk for postoperative morbidity and mortality due to impaired wound healing, delayed inflammation, impaired fibroblast proliferation, and collagen synthesis. Decreased lymphocyte count also impairs the ability of the immune system to eradicate or prevent infection, which predisposes these patients to infections. However, this association between malnutrition and postoperative morbidity is not consistent across studies, thus necessitating further investigation.Methods: The values of serum albumin, prealbumin, total lymphocyte counts, and transferrin were documented preoperatively and postoperatively on day 5 for all patients undergoing major spine surgery (surgery involving instrumentation of at least three motion segments). In addition, patients’ surgical wound healing status, duration of hospital stay, and duration of ICU stay in the postoperative period were documented. Finally, the statistical correlation between the nutritional markers and these complications was determined.Results: Low postoperative prealbumin levels was significantly associated with increased complication rates. ICU stay demonstrated a statistically significant association with low postoperative albumin, prealbumin, and transferrin levels. Similarly, we observed that low postoperative albumin and prealbumin levels could significantly predict the need for prolonged hospital stay in patients undergoing major spine surgery.Conclusions: The magnitude of the decrease in nutritional status due to surgery with respect to albumin and prealbumin levels is a significant (p

Study Design: Retrospective case series.Purpose: This study aimed to analyze how the sagittal spinopelvic alignment is influenced by an attempted surgical reduction of the L5–S1 segment in patients with high-grade spondylolisthesis (HGS).Overview of Literature: Conventional treatment strategies stress the importance of achieving fusion across the lumbosacral junction in patients with HGS. The role of reduction in this subset of patients is controversial.Methods: This is a retrospective case series of 35 patients with Meyerding grades III, IV, or V spondylolisthesis who underwent surgical treatment in our institution. Before and after surgery, we took standing lateral radiographs from L1 vertebra to pelvis, including the femoral heads, and measured the slip grade, pelvic incidence, sacral slope, pelvic tilt, lumbosacral angle, and lumbar lordosis. Patients were subdivided into “balanced” and “unbalanced” pelvis groups. To determine the effect and correlation of reduction on these spinopelvic parameters, we statistically compared the pre- and postoperative measurements.Results: The average follow-up was 9 months (range, 3–169 months). Slip grade improved from an average 74.0%±13.2% to 30.0%±14.0% (p

STUDY DESIGN Retrospective case series. PURPOSE The aim of the study is to report the clinical characteristics, early diagnosis, management, and outcome of children with multidrug-resistant (MDR) tubercular spondylodiscitis and to assess the early detection of rifampicin resistance using the Xpert MTB/ RIF assay. OVERVIEW OF LITERATURE MDR tuberculosis is on the rise, especially in developing countries. The incidence rate of MDR has been reported as 8.9% in children. METHODS A retrospective study of children aged

Study design Retrospective case series. Purpose The aim of this study was to analyze functional and radiological outcomes in patients with culture-negative pyogenic vertebral osteomyelitis (PVO). Overview of literature There were only few literature available for these group of patients. Methods Patients with biopsy-positive but culture-negative PVO were included. We analyzed records for data on demography, comorbidities, coexisting infections, neurological status, prior antibiotic therapy, pre- and postoperative erythrocyte sedimentation rate, C-reactive protein levels, and Oswestry Disability Index, and Japanese Orthopedics Association scores. Results Sixty-one patients were included, of which data of 45 patients were available for follow-up. The patients were predominantly males (71%), with a mean age of 53.2 years. Seventy-seven percent patients had comorbidities. Echocardiography, blood culture, and urine culture were performed on 8%, 24%, and 18% of patients, respectively. Thirty-one percent patients had neurological deficits. Computed tomography-guided biopsy was performed on 67% patients. Fifty-two percent patients were treated surgically, and 48% were treated non-surgically. Nineteen percent patients were treated according to the results of cultures from other foci, and the rest were treated empirically. For the initial 2 weeks, all patients were treated with intravenous antibiotics empirically or based on culture from other foci. This treatment was followed by 10 weeks of oral cloxacillin/cephalexin for gram-positive organisms or ciprofloxacin for gram-negative organisms. The mean follow-up time was 18 months (range, 12-120 months). All patients had improvement in Japanese Orthopedics Association, Oswestry Disability Index, and Visual Analog Scale scores (p Conclusions Treatment with empirical antibiotics for 12 weeks with watchful clinical and radiological follow-up yields good resolution of the disease. Further multicenter clinical research needs to be performed for obtaining an algorithmic treatment plan for these patients.

Study DesignCadaveric biomechanical study.PurposeWe compared the “skipped segment screw” (SSS) construct with the conventional “all segment screw” (ASS) construct for cervical spine fixation in six degrees of freedom in terms of the range of motion (ROM).Overview of LiteratureCurrently, no clear guidelines are available in the literature for the configuration of lateral mass (LM) screwrod fixation for cervical spine stabilization. Most surgeons tend to insert screws bilaterally at all segments from C3 to C6 with the assumption that implants at every level will provide maximum stability.MethodsSix porcine cervical spine specimens were harvested from fresh 6–9-month-old pigs. Each specimen was sequentially tested in the following order: intact uninstrumented (UIS), SSS (LM screws in C3, C5, and C7 bilaterally), and ASS (LM screws in C3–C7 bilaterally). Biomechanical testing was performed with a force of 2 Nm in six degrees of freedom and 3D motion tracking was performed.ResultsThe two-tailed paired t-test was used for statistical analysis. There was a significant decrease in ROM in instrumented specimens compared with that in UIS specimens in all six degrees of motion (pConclusionsBecause both configurations provide comparable stability under physiological loading, we provide a biomechanical basis for the use of SSS configuration owing to its potential clinical advantages, such as relatively less bulk of implants within a small operative field, relative ease of manipulating the rod into position, shorter surgical time, less blood loss, lower risk of screw-related complications, less implant-related costs, and most importantly, no compromise in the required stability needed until fusion.

This study aims to assess the accuracy of the Xpert MTB/RIF assay in the diagnosis of tubercular spondylodiscitis and to identify its role in detecting Rifampicin resistance in patients with infective spondylodiscitis. A retrospective study including 348 patients suspected to have infective spondylodiscitis was done. Tissue/pus samples obtained were sent for culture, histopathology and Xpert MTB/RIF assay. All patients who were confirmed to have tubercular spondylodiscitis and those patients who were suspected on clinico-radiological basis were also treated with anti-tuberculous chemotherapy for a period of 9 months. The efficacy of the Xpert MTB/RIF assay was assessed in terms of sensitivity and specificity when compared to culture, histopathology, and Composite reference standard (CRS). During this study period of 24 months, a total of 348 patients were treated for infective spondylodiscitis. 254 patients were treated for tuberculosis following a smear positivity, culture positivity, and histopathology report or empirically based on clinico-radiological findings. The sensitivity and specificity of the Xpert MTB/RIF assay when compared to culture were 88.4 and 63.7%, respectively. When compared to both culture and histopathology reports it was 80.9 and 80.6%. The sensitivity and specificity of the Xpert MTB/RIF assay when compared to composite reference standard were 71.2 and 100%, respectively. The sensitivity of the assay to detect Rifampicin resistance was 100%. The prevalence of Rifampicin resistance was 5.1%. This study recommends Xpert MTB/RIF assay for early detection of Mycobacterium tubercular spondylodiscitis and Rifampicin resistance.

Study Design Retrospective clinical analysis. Purpose To delineate the clinical presentation of melioidosis in the spine and to create awareness among healthcare professionals, particularly spine surgeons, regarding the diagnosis and treatment of melioidotic spondylitis. Overview of Literature Melioidosis is an emerging disease, particularly in developing countries, associated with a high mortality rate. Its causative pathogen, Burkholderia pseudomallei, has been labeled as a bio-terrorism agent. Methods We performed a retrospective analysis of patients who were culture positive for B. pseudomallei. Assessment of patients was performed using clinical, radiological, and blood parameters. Clinical measures included pain, neurological deficit, and return to work. Radiological measures included plain radiography of the spine and magnetic resonance imaging. Blood tests included erythrocyte sedimentation rate and C-reactive protein levels. Results Four patients having melioidosis with spondylitis were evaluated. All of them had diabetes mellitus; three had multiple abscesses which required incision and drainage. Their clinical spectrum was similar to that of tuberculous spondylitis; all had back pain and radiology revealed infective spondylodiscitis with prevertebral and paravertebral collections with psoas abscess. Three patients underwent ultrasound-guided drainage of the psoas abscess and one had aspiration of the subcutaneous abscess. Bacteriological cultures showed presence of B. pseudomallei, and histopathology showed non-caseating granulomatous inflammation. All patients were treated with intravenous Ceftazidime for 2 weeks, followed by oral bactrim double strength and Doxycycline for 20 weeks. All patients improved with treatment and were healed at follow up. Conclusions Melioidosis presents with a clinical spectrum similar to that of tuberculosis. A diagnosis of melioidotic spondylitis should be considered, particularly in patients with diabetes with neutrophilic leukocytosis and clinical-radiological features suggestive of infective spondylodiscitis. Bacteriological culture and histopathology helps in differentiating the two conditions. Health education for healthcare professionals is important for correctly diagnosing this disease.

OBJECTIVE There has been a transition from long- to short-segment instrumentation for unstable burst fractures to preserve motion segments. Circumferential fixation allows a stable short-segment construct, but the associated morbidity and complications are high. Posterior short-segment fixation spanning one level above and below the fractured vertebra has led to clinical failures. Augmentation of this method by including the fractured level in the posterior instrumentation has given promising clinical results. The purpose of this study is to compare the biomechanical stability of short-segment posterior fixation including the fractured level (SSPI) to circumferential fixation in thoracolumbar burst fractures. METHODS An unstable burst fracture was created in 10 fresh-frozen bovine thoracolumbar spine specimens, which were grouped into a Group A and a Group B. Group A specimens were instrumented with SSPI and Group B with circumferential fixation. Biomechanical characteristics including range of motion (ROM) and load-displacement curves were recorded for the intact and instrumented specimens using Universal Testing Device and stereophotogrammetry. RESULTS In Group A, ROM in flexion, extension, lateral flexion, and axial rotation was reduced by 46.9%, 52%, 49.3%, and 45.5%, respectively, compared with 58.1%, 46.5%, 66.6%, and 32.6% in Group B. Stiffness of the construct was increased by 77.8%, 59.8%, 67.8%, and 258.9% in flexion, extension, lateral flexion, and axial rotation, respectively, in Group A compared with 80.6%, 56.1%, 82.6%, and 121.2% in Group B; no statistical difference between the two groups was observed. CONCLUSIONS SSPI has comparable stiffness to that of circumferential fixation.

Purpose: The purpose of the study was to determine the rate and predictors of return to work (RTW) after surgery for cervical spondylotic myelopathy (CSM). Overview of Literature: RTW is arguably the most important outcome following spine surgery from a patient’s perspective. But, to the best of our knowledge, there have been no reports in the English literature describing RTW among patients undergoing surgery for moderate-to-severe CSM. Materials and Methods: We included adult patients with CSM with Nurick grade ≥ 3 who underwent surgery. They were divided into two groups: those who returned to work within 6 months (group 1) and those who did not (group 2) and their outcomes were analyzed. Results: A total of 34 patients were included in the study. Baseline characteristics were comparable between the groups. Only 18 (52.9%) patients returned to work by 6 months. The nature of work had a statistically significant association with RTW by 6 months (P = 0.005) with failure to RTW specifically seen in manual laborers. Age, body mass index, symptom duration, pre-operative absenteeism, smoking, diabetes mellitus, number of levels operated, surgical approach, and post-operative complications did not have significant association with RTW. Better functional outcomes were seen in patients who returned to work as calculated using Nurick grade (P = 0.000) and modified Japanese Orthopedic Association score (P = 0.001). All the patients who returned to work and 75% of the patients who did not RTW were satisfied with the outcome of surgery (P = 0.039). Conclusion: In spite of functional improvement, CSM was associated with poor RTW with manual laborers being the most vulnerable group. This study will help surgeons modulate patient expectations as well as provide a platform for counseling them.

Degenerative spondylolisthesis is one of the commonest spinal pathologies encountered in the aging population. The clinical presentation of degenerative spondylolisthesis can be highly variable, and a large proportion of patients can be managed non-operatively. Operative treatment is reserved for patients with activity limiting disability. Decompression alone can be offered to patients with no radiological or clinical evidence of segmental instability. Fusion procedures have shown high rates of clinical success, although long-term effects such as adjacent segment degeneration have spurred the evolution of non-fusion technologies. These newer options have shown evidence of motion preservation, although long-term clinical benefits have yet to be confirmed.

Study design Retrospective study. Purpose To report the prevalence of patients with multidrug-resistant (MDR) tubercular spondylodiscitis and their outcomes. Additionally, to assess the role of Xpert MTB/RIF assay in early detection of MDR tuberculosis. Overview of literature MDR tuberculosis is increasing globally. The World Health Organization (WHO) has strongly recommended Xpert MTB/RIF assay for early detection of tuberculosis. Methods From 2006 to 2015, a retrospective study was conducted on patients treated for MDR tuberculosis of the spine. Only patients whose diagnosis was confirmed using either culture and/or the Xpert MTB/RIF assay were included. Diagnostic method, treatment regimen, time taken to initiate second-line antituberculosis treatment (ATT), drug-related complications, and cost of medications were analyzed. All patients with MDR were treated according to the WHO recommendations for 2 years. The outcome parameters analyzed included clinical, biochemical, and radiological criteria to assess healing status. Results From 2006 to 2015, a total of 730 patients were treated for tubercular spondylodiscitis. Of those, 36 had MDR tubercular spondylitis (prevalence, 4.9%), and three had extremely drug resistant tubercular spondylitis (prevalence, 0.4%). In this study, 30 patients, with a mean age of 29 years and a mean post-treatment follow-up of 24 months, were enrolled. The majority (77%) had secondary MDR, 17 (56%) underwent surgery, and 26 (87%) completed treatment for 2 years and were healed. Drug-related complications (33%) included ototoxicity, hypothyroidism, and hyperpigmentation of the skin. The average time taken for initiation of second line ATT for MDR patients with Xpert MTB/RIF assay as the diagnostic tool was 18 days, when compared to patients for whom the assay was not available which was 243 days. Conclusions The prevalence of MDR tubercular spondylodiscitis was 4.9%. In total, 87% of patients were healed with adequate treatment. The sensitivity and specificity of the Xpert MTB/RIF assay to detect MDR was 100% and 92.3%, respectively.

To present the case of a patient with Munchausen’s syndrome who underwent multiple surgeries in the spine before the diagnosis was made and, therefore, to highlight the importance of this obscure condition that can result in unnecessary surgical treatment. A 44-year-old businesswoman presented with multiple episodes of low back pain and weakness in both lower limbs over past 11 years. Past history consisted of multiple hospitalizations, and three surgeries on her lumbar spine at different hospitals, with dramatic improvement in symptoms being reported each time after surgery. Clinical examination showed inconsistent and nonspecific neurological findings. Imaging studies like X-rays, magnetic resonance imaging, and all neurophysiological studies were within normal limits. Multi-disciplinary evaluation by a team of orthopedicians, neurologist and psychiatrist and rehabilitation specialists diagnosed it as ‘Munchausen syndrome’. Only one report of this fictitious disease in spine was found in review of literature (Association AP, Diagnostic and statistical manual of mental disorders: DSM-IV-TR®, 2003). A history of multiple surgical interventions at multiple hospitals, often followed by dramatic improvement and then relapse, should trigger a suspicion of Munchausen syndrome, particularly in the scenario of normal imaging studies. Diagnosing this rare condition in spine is key to avoid unnecessary surgery.

STUDY DESIGN: Non-concurrent prospective study. PURPOSE: To determine the functional outcome after open 'fragment' discectomy for recurrent lumbar disc herniation, and to analyze the factors that may affect the outcome. OVERVIEW OF LITERATURE: Literature search revealed only four studies where the factors affecting the outcome of a revision surgery for recurrent disc herniation have been evaluated. None of these studies analyzed for diabetes, disc degeneration and facet arthropathy. We have analyzed these features, in addition to the demographic and clinical factors. METHODS: Thirty-four patients who underwent the procedure were followed up for an average period of 27.1 months. The Japanese Orthopaedic Association (JOA) score and Oswestry disability index (ODI) were used to assess the functional outcome. Age, gender, smoking, diabetic status, duration of recurrent symptoms, the side of leg pain, level and type of disc herniation, degree of disc degeneration on magnetic resonance imaging, and facet joint arthritis before first and second surgeries, were analyzed as factors affecting the outcome. RESULTS: The average Hirabayashi improvement in JOA was 56.4%. The mean preoperative ODI was 74.5% and the mean ODI at final follow-up was 32.2%, the difference being statistically significant (p

A series of 12 patients in our centre following single level instrumented posterior lumbar interbody fusion at L4-L5 developed unexplainable motor weakness in the proximal lumbar nerve roots (L2, L3) and numbness of the whole limb, a clinical picture resembling lumbar plexopathy. Even though lumbar plexopathy has been reported following gynaecological procedures and in transpsoas interbody fusion surgeries, there is no literature reporting this complication following conventional instrumented posterior lumbar interbody fusions.Retrospective observational study.To find the possible mechanism of development of lumbar plexopathy in patients who underwent posterior lumbar interbody fusion surgeries in our centre.We analyzed retrospectively the medical records, electrophysiological reports of the patients, literatures on the anatomy of lumbar plexus and other literature reporting similar complications. We also dissected lumbar plexus of three cadavers and simulated surgical technique on them to find the mechanism of development of this unusual complication.We found injury to lumbar plexus that probably occurred intraoperatively with Hohmann's retractor that was used for retraction of the paraspinal muscles. This theory was favoured by many clinical factors and further confirmed by cadaveric dissections.We conclude that surgical technique with improper use of Hohmann's retractor causes traction and compression injury to the lumbar plexus resulting in this complication. We propose proper technique of insertion of Hohmann's retractor and also recommend use of modified Hohmann's retractor with shorter tips for spinal procedures to prevent such complication.

Extension injuries of the cervical spine can result in a wide spectrum of clinical presentations. The very young as well as the elderly population may be uniquely predisposed to this group of injuries. Radiographic signs are often subtle, and therefore, a high index of suspicion followed by careful clinical examination and appropriate radiological evaluation are mandatory to minimize the danger of missing the diagnosis. Accurately identifying specific radiological injury patterns can ensure that appropriate treatment measures are promptly instituted, thereby potentially promoting the chances of recovery.

Pseudomeningocele is an extradural cerebrospinal fluid collection arising from a dural defect, that may be congenital, traumatic, or more commonly as a result of postoperative complication. Majority of the postoperative pseudomeningoceles occurring after lumbar spine surgeries are small and resolve spontaneously. However, large pseudomeningoceles are rare and spontaneous resolution of such pseudomeningoceles has not been described. We report four cases of postoperative large lumbar pseudomeningoceles that presented as asymptomatic soft fluctuant swelling over the back which resolved spontaneously. We also reviewed the related literatures and operative records of these patients to find the possible mechanism of occurrence, their management, prevention, and reasons for spontaneous resolution. We conclude that nonoperative management under close observation can be employed for asymptomatic postoperative large lumbar pseudomeningoceles. Surgical exploration and repair should be reserved for symptomatic cases presenting with clinical features of intracranial hypotension, worsening neurology, external fistula or infection, thereby avoiding morbidity and potential complications associated with surgical treatment.

Ganglion cysts of the knee are extremely uncommon. They usually cause non-specific symptoms and do not produce classical signs. Advances in imaging techniques as well as widespread use of arthroscopy have made detection of these cysts easier, and most can be treated arthroscopically. Ganglion cysts arising within the infrapatellar fat pad are even more uncommon. We report a case of a young lady with a giant intra-articular ganglion within the infrapatellar fat pad that was treated by open excision.

Study design Retrospective analysis of radiological images. Purpose To determine the prevalence of lumbosacral transition vertebra (LSTV) and to study its significance with respect to clinically significant spinal symptoms, disc degeneration and herniation. Overview of literature LSTV is the most common congenital anomaly of the lumbosacral spine. The prevalence has been debated to vary between 7% and 30%, and its relationship to back pain, disc degeneration and herniation has also not been established. Methods The study involved examining the radiological images of 3 groups of patients. Group A consisted of kidney urinary bladder (KUB) X-rays of patients attending urology outpatient clinic. Group B consisted of X-rays with or without magnetic resonance images (MRIs) of patients at-tending a spine outpatient clinic, and group C consisted of X-rays and MRI of patients who had undergone surgery for lumbar disc herniation. One thousand patients meeting the inclusion criteria were selected to be in each group. LSTV was classified by Castellvi's classification and disc degeneration was assessed by Pfirrmann's grading on MRI scans. Results The prevalence of LSTV among urology outpatients, spine outpatients and discectomy patients was 8.1%, 14%, and 16.9% respectively. LSTV patients showed a higher Pfirrmann's grade of degeneration of the last mobile disc. Results were found to be significant statistically. Conclusions The prevalence of LSTV in spinal outpatients and discectomy patients was significantly higher as compared to those attending the urology outpatient clinic. There was a definite causal relationship between the transitional vertebra and the degeneration of the disc immediately cephalad to it.

Osteochondromas are the most common benign tumors of the bone. They mostly arise from the appendicular skeleton and present clinically in the second or third decade of life. Ostechondromas arising from the subaxial cervical spine and presenting after the 5th decade of life are extremely rare. We report a 52-year-old male patient who presented with numbness and subjective weakness of left upper and lower limbs and neck pain, and had lobulated bony hard fixed swelling in the right lower cervical paraspinal region. Radiological images revealed a bony swelling arising from C4 and C5 lamina with a cartilaginous cap and intraspinal extension. Excision biopsy with stabilisation of the spine was performed. Histopathalogical examination of the specimen confirmed the diagnosis of osteochondroma. We conclude surgical excision of such rare tumors, including the cartilaginous cap as well as the intraspinal component can reliably produce a good clinical outcome.

Gorham's disease is a rare disorder characterized by clinical and radiological disappearance of bone by proliferation of non-neoplastic vascular tissue. The disease was first reported by Jackson in 1838 in a boneless arm. The disease was then described in detail in 1955 by Gorham and Stout. Since then, about 200 cases have been reported in the literature, with only about 28 cases involving the spine. We report 2 cases of Gorham's disease involving the spine and review related literature to gain more understanding about this rare disease.