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   Table of Contents - Current issue
Coverpage
July-December 2018
Volume 1 | Issue 2
Page Nos. 69-150

Online since Thursday, August 2, 2018

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EDITORIAL  

Evidence-based medicine: What does it mean to spine surgeon p. 69
Anil K Jain, Manish Chadha
DOI:10.4103/isj.isj_44_18  
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SYMPOSIUM - SPINAL TRAUMA Top

A review of thoracolumbar spine fracture classification systems p. 71
Parthasarathy Srinivasan
DOI:10.4103/isj.isj_14_18  
Thoracolumbar spine fractures form a significant portion of any spine surgeon's practice. It is important to classify the injuries, which may vary from minor transverse process fractures to unstable fracture–dislocations in order to aid communication, plan management, anticipated outcome, and prognosis. It is imperative that such a classification must be simple, reliable, comprehensive, and reproducible as well as be validated by multiple observers. In spite of having several classification systems in practice, the ideal one remains elusive. This article reviews the history of classification, evolution of the classifications, the relative merits and demerits of each classification, and highlighting the lacunae which the subsequent line of thought intended to fill. Till date, the AOSpine thoracolumbar spine injury severity system is probably the most comprehensive and management-oriented classification after Magerl and Denis.
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Thoracolumbar fractures: Nonsurgical versus surgical treatment p. 79
Gururaj Sangondimath, Kalidutta Das, Kalyan Varma
DOI:10.4103/isj.isj_22_18  
The thoracolumbar (TL) region is a common site of injury after high-energy trauma which can result in significant disability. Despite advances, controversies continue to exist regarding the management of the injury and indications for surgery. This review is aimed to provide an insight into the existing literature on the nonoperative and operative management of TL trauma. Many classifications of spinal fractures have been proposed to guide management. However, there are no high-level studies comparing the outcomes of surgical and conservative management using these classification systems. These classifications have also not been validated by randomized clinical trials. In general, surgical stabilization is indicated for biomechanically unstable fractures such as flexion distraction injuries, unstable burst fractures, and fracture dislocations whereas simple compression fractures are treated conservatively. There is conflicting evidence in trials comparing conservative and surgical management in TL burst fractures with intact neurology. Progressive neurological deficits, significant kyphosis, and significant canal compromise are generally accepted indications for surgery without proper Level 1 or Level 2 evidence.
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Is there a role for anterior augmentation in thoracolumbar burst fractures? p. 86
Wesley H Bronson, Alexander R Vaccaro
DOI:10.4103/isj.isj_10_18  
Both anterior and posterior approaches for thoracolumbar burst fractures are reasonable surgical options. While an anterior approach was previously considered to be the best method to achieve adequate decompression and stabilization, posterior pedicle screw constructs have gained wide acceptance owing to their biomechanical strength and ability to achieve and maintain indirect decompression. We performed a literature review to analyze biomechanical factors and alignment, canal decompression with neurologic outcomes, and perioperative factors related to anterior and posterior approaches. A review of the literature reveals that anterior reconstruction does appear to provide improved resistance to kyphosis compared to posterior stabilization. However, long-segment fixation and the use of fracture-level pedicle screws have demonstrated improved ability to prevent the loss of intraoperative deformity correction. Neither anterior nor posterior approaches have definitively demonstrated superior canal decompression and neurologic outcomes. Perioperative data likely favor a posterior approach regarding the operative time and blood loss. In the end, the data do not obviously favor a single approach, and surgeons should take into consideration the goals of surgery and their comfort performing surgery through either an anterior or posterior approach.
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Thoracolumbar trauma with delayed presentation p. 94
Rishi M Kanna, Ketan Khurjekar
DOI:10.4103/isj.isj_23_18  
Thoracolumbar injuries presenting in a delayed manner are uncommon, and their etiologies are varied ranging from missed injuries, wrong initial management, and delayed presentation for treatment. While improvements in healthcare awareness and delivery systems worldwide have improved the acute management of spinal injuries, the diagnosis and management of delayed spinal injuries remains a challenge to the treating physician regarding intraoperative difficulties, perioperative complications, and subsequent rehabilitation. Sequel of delayed presentation such as neurological deficit, spinal deformity, capsular contractures, muscle wasting, pulmonary and urinary tract infections and pressure sores have a significant bearing on the outcomes of management of delayed spinal trauma. Indications for surgical management include axial pain, neurological deficit, and kyphotic deformity. Management options include anterior corpectomy and fusion, combined anterior posterior surgery, and an all-posterior spinal decompression and deformity correction.
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Fractures in ankylosed spines: Current concepts p. 101
Ramakanth Rao Ilinani, Ajoy Prasad Shetty
DOI:10.4103/isj.isj_19_18  
The incidence of spinal fractures in ankylosing spondylitis (AS) continues to increase despite the improvements in medical treatment. Depleted flexibility and altered biomechanics along with secondary osteoporosis make them more prone to unstable spinal injuries with minor or even unknown trauma. Difficulties in radiological assessment due to associated deformity can often mask the diagnosis. Advanced imaging techniques and screening of the entire spine are required in suspected cases. Surgical treatment is generally indicated because of the inherent instability of these fractures and frequent neurologic deficits. The choice of approach and fixation remains controversial, especially in cervical and cervicothoracic injuries. Whatever be the mode of treatment, the postinjury complication rates remain higher with significant mortality risk in those having associated comorbidities and neurological injury. However, avoidance of injury by adequate preventive measures, a high index of suspicion and appropriate precautions in the perioperative period can result in improved outcomes in these patients. A systematic computerized literature search was performed using Cochrane Database of Systematic Reviews, EMBASE, and PubMed. The publications made over the past 10 years were analyzed. The searches were performed using Medical Subject Headings and the subheadings used were “AS,” “diffuse idiopathic skeletal hyperostosis,” “epidemiology,” “surgery,” “etiology,” “management,” “surgery,” and “therapy.”
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Spinal fracture in polytrauma situation p. 112
Vijay H D Kamath
DOI:10.4103/isj.isj_24_18  
The timing of surgical stabilization of a thoracolumbar spine fracture in a polytrauma situation is controversial. While delayed surgery was considered safe and the norm, over the last few years there is an increasing amount of literature available that supports early stabilization of the spine fracture with good neurological and non-neurological outcomes. Adequate “resuscitation” of the patient prior to surgical intervention is of paramount importance to reduce surgery associated “second hit”. The “spine damage control” approach is a safe and appropriate management strategy in a polytrauma situation. Minimally invasive stabilization follows the principles of “damage control orthopedics” and appears to be a good surgical option.
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REVIEW ARTICLE Top

Surgical management of postoperative infections in spine surgery p. 117
Rohit Amritanand
DOI:10.4103/isj.isj_23_17  
Postoperative infections following spine surgery are a devastating complication. They add to morbidity, financial burden, and poor outcomes for a patient. The reported incidence of surgical site infection is variable and depends on a number of factors. Overall, cases that require extensive soft-tissue dissection, higher blood loss, and prolonged operative time lead on to higher rates of infection. Minimally invasive surgeries (MISS) have demonstrated significantly reduced rates of infection. A high index of suspicion and a stepwise approach is required to diagnose this complication. A thorough clinical examination with appropriate blood and radiological investigations confirms the diagnosis. Identification of the offending microorganism is vital as it will guide targeted antibiotic therapy. Once this is done, a course of appropriate antibiotics should be commenced. Surgical strategies are available to patients who do not respond to medical management or who develop neurological deficits. The aim of surgical management is the clearance of infection, soft-tissue closure, and the restoration of spinal column integrity. This is accomplished through meticulous tissue debridement, fluid lavage, and wound closure. The stability of already placed implant should be assessed and if sound should be retained. In cases where wound closure is a challenge, soft-tissue reconstruction techniques may be required. Other options such as vacuum therapy are available. Finally, each member of the health-care team, including the patient, has an important role to play in order to keep the occurrence of this unwanted complication to the lowest possible level.
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ORIGINAL ARTICLES Top

Intraoperative stress in spine surgery – Surgeon versus assistant p. 122
Maximilian Reinhold, Jonas Kremer, Declan Stewart
DOI:10.4103/isj.isj_1_18  
Background: This study was a prospective observational study to assess the cardiovascular response and effects of mental stress during spine surgery depending on the surgeon's (attending or lead surgeon) versus assistant's (resident) position. Methods: Stress-related cardiovascular parameters were measured during 101 spine surgical procedures of a 40-year-old fellowship-trained spine surgeon with 12 years of practice. A training computer, personal scale, and thermometer were used to record the duration of surgery, heart rate, weight loss, and calorie burn. Results: The average maximum heart rate as an attending surgeon (124 bpm) was significantly higher when compared to the resident's heart rate (99 bpm) (P < 0.05). A higher stress level resulted in an increasingly higher average maximum heart rate according to the complexity of surgery: “easy” (103 bpm, 1 h: 51 min), “moderate” (125 bpm, 2 h: 57 min), and “difficult” (131bpm, 3 h: 56 min). The mean loss of body fluids at an average room temperature of 20.4°C after surgery was −0.82 kg (0 to −2.3 kg). The mean loss of body weight was calculated with −1.12% at the attending versus −0.59% at the resident (P < 0.05). Conclusions: The observed cardiovascular stress levels were similar to those of a moderate-to-intense workout such as cycling. Long-lasting surgeries result in a weight loss equivalent to a mild dehydration ranging from −2% to −5% of body fluids. Increasing dehydration will eventually worsen someone's cognitive-, visual-, and motor skills. Results of this study suggest that the early rehydration and other strategies (two surgeons and staged procedures) are helpful to minimize risks associated with prolonged, complex spine surgeries.
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Postoperative deep wound infection in posterior spinal fixation surgeries: Does it affect the clinicoradiological outcome? - At a minimum follow-up of 2 years p. 128
Saumyajit Basu, Amitava Biswas, Aditya Banta, Tarun Suri, Anil Solanki
DOI:10.4103/isj.isj_29_17  
Background: Incidence of postoperative deep wound infection (PODWI) after lumbar surgery varies from 2.1% to 6.7%.Studies looking into the effect of postoperative infection on functional recovery of the patient have thrown conflicting results. The aim of this study is to evaluate 2-year functional and radiological outcome of patients with PODWI. This was a retrospective, matched cohort study. Materials and Methods: A total of 23 patients developing acute PODWI (<3 months) after instrumented posterior spinal fusion (IPSF) from 2005 to 2013 were treated by debridement along with antibiotics for 6 weeks (3 weeks intravenous and 3 weeks oral). Their preoperative and postoperative (6 months and 2 years) functional scores in the form of Oswestry Disability Index (ODI) and visual analog scale (VAS) were queried from the electronic database. Fusion was assessed at 2 years using radiograph and computed tomography scan. A noninfected control group (CG) was identified matching indication, type and number of levels of fusion, ODI, and Charlson Age-matched Comorbidity Index. Unpaired t-test was used for statistical analysis. Results: Out of 23 patients, 21 underwent posterior spinal fusion, and two had additional anterior surgery. Mean lag time before the diagnosis of infection was 4.7 weeks. Most common pathogenic organism was Staphylococcus aureus. All patients except one had documented fusion at 2-year follow-up. Four patients developed discharging sinuses. Implant removal had to be done in three patients. The mean ODI difference at 6 months from baseline was higher in the CG (33) as compared to infected group (19) (P < 0.001). Difference at 2 years was comparable for the two groups (P = 0.4). No significant difference was found in the VAS scores between the two groups. Small sample size and retrospective nature are the potential limitations of this study. Conclusions: Patients with acute PODWI after IPSF treated appropriately have comparable long-term outcome to patient with noninfected surgery; however, initial short-term worsening in functional status was seen in infected patients. Fusion was a predictable outcome.
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CASE REPORTS Top

Hyperplastic hematopoietic bone marrow of the spine mimicking spinal metastasis: A case report and review of literature p. 135
Wen Loong Paul Yuen, Wenxian Png, Shree Kumar Dinesh, Wee Lim Loo
DOI:10.4103/isj.isj_5_17  
Magnetic resonance imaging (MRI) has a high sensitivity for detecting metastatic bone tumors. However, distinguishing metastasis from benign lesions can be difficult. We report a case of hyperplastic hematopoietic bone marrow of the spine mimicking spinal metastasis. A 73-year-old male presented to the orthopaedic clinic with worsening back pain following a fall. Initial radiographs demonstrated a compression fracture of the T11, L1, and L2 vertebral body. MRI showed multiple scattered hypointense foci within the lumbar spine suspicious for osseous metastases, with old-healed fractures at T11, L1, and L2. Whole spine imaging was then performed demonstrating similar marrow signal abnormality in the cervical and thoracic spine. Initial suspicion for a pathological fracture secondary to bony metastasis was strong. Subsequent screen for malignancy was negative. Open biopsy was done on the T4 vertebra, and the histopathological diagnosis was spinal hyperplastic hematopoietic bone marrow. This condition is characterized by reconversion of fatty marrow to hematopoietic marrow, which can occur in chronic anemia, obesity, heavy smokers or following trauma. This case illustrates a rare differential diagnosis for suspected metastatic bone tumor, and our report discusses the important radiologic differences between both conditions.
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Rapid onset debilitating illness with multiple vertebral lesions: A confounding diagnosis of peripheral T-cell lymphoma Highly accessed article p. 140
Arun-Kumar Kaliya-Perumal, Chi-Chien Niu, Wen-Yu Chuang, Tsung-Ting Tsai
DOI:10.4103/isj.isj_43_17  
Peripheral T-cell lymphomas (PTCL) are uncommon and aggressive. Various subtypes are described, and presentations vary accordingly. It tends to grow rapidly and eventually become widespread, involving extranodal sites. Most cases are diagnosed in late stages and hence carry a poor prognosis. We report a 68-year-old male with complaints of progressive low back pain that later became associated with rapid weight loss and fever, eventually leading to cauda equina syndrome. X-rays were nonspecific, but magnetic resonance imaging showed scattered multicentric osseous lesions involving all regions of spine, associated with epidural lesions corresponding to some of the affected levels. Considering the neurological status, posterior decompression surgery was done, and specimens of lesions were collected. Based on histopathology and detailed immunophenotyping, a diagnosis of PTCL, not otherwise specified was made, and appropriate chemotherapy was initiated. However, terminal stage disease was irremediable, and the patient eventually succumbed to the disease. Extensive multicentric spinal involvement of lymphoma on the first presentation is rare. It puts forth a considerable challenge for the diagnosis. Hence, early signs and symptoms should not be ignored. Histopathology and immunophenotyping are vital for the diagnosis. Making a definitive diagnosis at the earliest can prompt expeditious intervention to increase the survival rate.
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Achromobacter spondylodiscitis: A case report and review of literature p. 144
Hamza Shaikh, Thomas J Kishen
DOI:10.4103/isj.isj_42_17  
We present a case of a 71-year-old male with T12-L1 spondylodiscitis, who was initially treated as a tubercular spondylodiscitis with antituberculous therapy drugs. One month later, the patient developed difficulty in walking with motor weakness in both lower limbs and a second magnetic resonance imaging scan revealed an increase in the volume of pus with cord compression. Pedicle screw stabilization (T9–L4) with T12-L1 laminectomy and curettage of the disc space was performed. Achromobacter denitrificans was identified in aerobic culture. He was treated with an extended course of antibiotics, and subsequently, the lower limb motor power recovered, and biochemical parameters returned to normal. To the best of our knowledge, there has been no report of Achromobacter causing spondylodiscitis in English medical literature. This report focuses on the steps taken in management with special reference to antibiotic therapy.
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LETTERS TO EDITOR Top

Socioeconomic impact of cervical Spinal Cord Injury (SCI) operated in patients with lower income group p. 148
Birudu Raju
DOI:10.4103/isj.isj_9_18  
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Author's Reply p. 149
Shakti A Goel, Hitesh N Modi, Bharat R Dave, Pankaj R Patel, Rushin Patel
DOI:10.4103/isj.isj_12_18  
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