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   Table of Contents - Current issue
Coverpage
January-June 2020
Volume 3 | Issue 1
Page Nos. 1-128

Online since Wednesday, February 5, 2020

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EDITORIAL  

Ethical issues while reporting in scientific journals p. 1
Manish Chadha, Anil K Jain
DOI:10.4103/isj.isj_2_20  
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SYMPOSIUM - MINIMALLY INVASIVE SPINE SURGERY Top

Fundamentals of minimally invasive spine surgery p. 4
Louis Chang, Sertac Kirnaz, Juan Del Castillo-Calcaneo, Ibrahim Hussain, Roger Härtl
DOI:10.4103/isj.isj_31_19  
Minimally invasive spine surgery (MISS) is a set of techniques and procedures that aims to minimize local tissue damage while achieving the same goals of traditional open surgery. In this article, we will provide a brief synopsis of the current state of MISS including its advantages over open surgery and its limitations. We will also describe basic techniques and essential tools needed to perform MISS effectively. As such, we have identified six interrelated fundamental principles to achieve success in MISS. They are the six Ts: Target, Technology, Technique, Training/Teaching, Testing, and Talent.
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Expanding the horizons of minimally invasive spine surgery p. 11
Arvind G Kulkarni, Tushar S Kunder, Swaroop Das, Sandeep Tapashetti
DOI:10.4103/isj.isj_19_19  
The trend of using smaller operative corridors is observed in various surgical specialties. The development of smart technologies with the overall aim of reducing surgical trauma has resulted in the concept of minimally invasive surgical techniques. Enhancements in microsurgery, tubes, endoscopy, and various percutaneous techniques, as well as improvement of implant materials, have proven to be milestones. The ease of performing surgery through tubes has recently evolved into percutaneous placement of spinal instrumentation, including intervertebral spacers, rods, and pedicle screws. The advancement of training of spine surgeons and the integration of image guidance with precise intraoperative imaging, computer-, and navigation-assisted treatment modalities constitute the era of reducing treatment morbidity in spinal surgery. This progress has led to the present era of preserving spinal function. In this report, we present a chronological perspective of the use of tubular retractors, the learning curve of tubular retractor in dealing complex cases and its wide applications, and expanding the horizon using tubular retractors.
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A review of minimally invasive techniques for correction of adult spine deformity p. 26
Aniruddh Agrawal, Neel Anand, Anisha Agrawal
DOI:10.4103/isj.isj_30_19  
This paper highlights the current status of minimally invasive surgery (MIS), with special attention to learning curve, cost-effectiveness, and different techniques, for the correction of adult spine deformity (ASD). A literature review was performed through the PubMed database. Studies that fit the inclusion criteria (n = 27) were analyzed by the authors through the MINORS criteria and their results were then presented. The abundance of data on the learning curve of the procedure shows that it takes at least 22–39 surgeries for a surgeon to reach optimal operative time. The literature search showed that there is a paucity of data available on the cost-effectiveness of the procedure in developing countries; however, if the results from the developed countries were to be considered, MIS is cost-effective for ASD correction. There are certain limitations to the procedure including inadequate sagittal balance as well as chances of proximal junctional kyphosis and adjacent segment disease; however, the overall benefits of MIS including decreased operative time, blood loss, and hospital stay could tilt the balance in its favor.
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Complications and limitations of tubular retractor system in minimally invasive spine surgery: A review Highly accessed article p. 34
Amit C Jhala, Sharvil C Gajjar
DOI:10.4103/isj.isj_33_19  
The aim of a minimally invasive spine surgery is to decrease the collateral damage to the surrounding soft tissue, while performing the same task as that of a conventional open spine surgery. With widening of applications of the tubular retractor system, complications are prone to occur while performing surgery using tubular retractors. The aim of this review was to assess the spectrum of complications that are associated with tubular access spine surgery. A systematic review in English language literature on PubMed for clinical outcomes or complications in minimally invasive spine surgery using tubular retractors was carried out. A total of 11 articles were filtered from 2010 to 2018. Articles that were excluded were those with focus on open spine surgery, surgeries without using tubular retractors, Destandau technique, and endoscopic spine surgeries. The studies were divided into discectomy, decompressions, and fusions. Overall complications that were observed in the review were incidental durotomy, neurodeficits, infection, instability, reherniation, implant malposition, pulmonary embolism, hematoma, and urinary retention. The manifold advantages that are offered by the tubular retractor system include decreased iatrogenic tissue damage, decreased probability of surgical wound infections, decreased chances of instability, and rapid ambulation of the patients, providing an impetus to the number of day care procedures being performed for spine conditions. The complication profile in this review is comparable to the open spine surgeries except the risk of higher radiation hazard in minimally invasive transforaminal lumbar interbody fusion surgery but more high-quality randomized studies are required.
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Current status of full-endoscopic spine surgery in cervical spine: Anterior and posterior approach p. 41
Sagar B Sharma, Jin-Sung Luke Kim, Naveen D Siddappa, Hussam E Jabri
DOI:10.4103/isj.isj_23_19  
The techniques for the treatment of cervical disc herniation and cervical myelopathy have evolved over the last two decades. Anterior cervical decompression and fusion has been considered to be the gold standard technique to date. Recently, it has been shown that full-endoscopic spine surgery with upgraded technology and instrumentation has the capability to decompress the exiting nerve root and thecal sac effectively in the cervical spine. Good clinical outcomes have been reported in the literature with endoscopic procedures. The full-endoscopic spine technique can be an alternative to avoid interbody fusion surgeries. Successful decompression under constant visualization with a small incision and minimal surgical trauma can be achieved. There are two percutaneous endoscopic cervical spine approaches: anterior and posterior. Decision-making depends on anatomical and pathological considerations. Attaining full-endoscopic cervical spine technique requires a steep learning curve, practical training under the experts, and proper selection of patients. The recent developments related to endoscopic equipment with the availability of better optics, three-dimensional monitors, lighting systems, and newer generation endoscopes have made these techniques applicable in complex surgeries as well. The objective of this review was to provide a technical description of full-endoscopic anterior and posterior cervical spine surgeries and their current status in management of various cervical spine pathologies.
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Transforaminal endoscopic surgery in lumbar spine: Technical aspects, current status, and evolving scope p. 54
Arun Bhanot, Pradyumna P Raiturker, Abhishek Kashyap, Meenakshi Arora
DOI:10.4103/isj.isj_29_19  
Study Design: This study is comprehensive literature review. Aims and Objectives: This study aimed to evaluate the effectiveness of transforaminal endoscopic technique for managing symptomatic lumbar disc herniations and foraminal/extraforaminal/lateral recess stenosis and to assess the comparative status vis-à-vis existing treatment methods. Materials and Methods: A comprehensive systematic literature search of PubMed, Embase, and Cochrane library databases was performed for articles, including case series, randomized controlled trials (RCTs), controlled clinical trials (CCTs), reviews, and metanalysis with the following search terms: transforaminal endoscopic disc surgery, full endoscopic transforaminal surgery, selective endoscopic discectomy, percutaneous endoscopic lumbar discectomy, transforaminal endoscopic surgery for lumbar stenosis, and endoscopic surgery for foraminal stenosis in various combinations. Results: Results were analyzed in terms of efficacy, safety, complications, recurrence rate, and learning curve in comparison with standard preexisting open procedures. Overall, the reviewed literature pointed toward the following observations: the endoscopic techniques had shorter operating times, less blood loss, less operative site pain, faster postoperative rehabilitation, shorter hospital stay, faster return to work than the microsurgical techniques, although some of the observations were limited in their scope. Endoscopic foraminal stenosis decompression could help avoid facetectomy and fusion procedures. Conclusion: Full endoscopic transforaminal surgeries for lumbar disc herniations and foraminal stenosis are safe and effective alternative to open surgery. Similar clinical outcomes as compared with conventional open surgeries can be reached with lesser incidence of complications and better opportunities for revision surgeries, if and when needed.
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Full-endoscopic interlaminar surgery of lumbar spine: Role in stenosis and disc pathologies p. 66
Pramod V Lokhande
DOI:10.4103/isj.isj_22_19  
The aim of this study was to evaluate the effectiveness of full-endoscopic interlaminar operations for symptomatic lumbar disc herniations and lumbar canal stenosis and to compare their results with conventional open procedures. A comprehensive systematic literature search of PubMed, Embase, and Cochrane Library databases was performed for articles, including randomized trials (RCTs), controlled clinical trials (CCTs), reviews, and meta-analysis with the following search terms: full-endoscopic discectomy, also known as percutaneous endoscopic lumbar discectomy, interlaminar discectomy, endoscopic, and percutaneous stenosis decompression in various combinations. Results were analyzed for their effectiveness, safety, complications, recurrence rate, and learning curve, and compared with standard open procedures. Overall, the endoscopic techniques had shorter operating times, less blood loss, less operative site pain, and faster postoperative rehabilitation/shorter hospital stay/faster return to work than the microsurgical techniques for both disc herniation and lumbar spinal stenosis surgeries. The advantages and disadvantages of variations in techniques and choice of anesthesia are discussed. This comprehensive literature review shows that full-endoscopic surgeries for lumbar disc herniations and lumbar spinal stenosis are safe and effective alternative to open surgery. These can achieve the same clinical results with added benefits of minimally invasive spine surgeries.
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Complications and limitations of endoscopic spine surgery and percutaneous instrumentation p. 78
Hyeun-Sung Kim, Sagar B Sharma, Pang Hung Wu, Harshavardhan D Raorane, Nitin M Adsul, Ravindra Singh, Il-Tae Jang
DOI:10.4103/isj.isj_27_19  
Endoscopic spine surgery has started replacing conventional microdiscectomy in various centers across the globe. With development in the field of optics and instrumentation, the field of percutaneous endoscopic spine surgery has evolved immensely. With increasing experience, endoscopic spine surgeons have expanded the indications not only to lumbar paramedian disc herniations but also to central disc herniations, high-grade migrated disc herniations, sequestered herniations, thoracic and cervical disc herniations, and more recently, lumbar canal stenosis. With broadening indications, unexpected adverse events are bound to increase. Hence, it is essential for the endoscopic spine surgeons to be aware of the potential hazards and unexpected complications of the procedure so that appropriate care is taken to avoid adverse events as much as possible. In this article, we summarize all the complications of transforaminal endoscopic discectomy reported in the literature. We have classified the complications into intraoperative, immediate postoperative, and late postoperative complications. The senior author has also suggested the tips to avoid these complications and carry out the procedure as safely as possible. As percutaneous instrumentation, particularly, percutaneous pedicular screws, is also becoming common with the development of minimally invasive spine surgery, we have also summarized its complications and limitations. An insight into these complications will help the endoscopic surgeons to take special precautions when performing the procedure.
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SPINE CLINIC Top

Illustrative case of multiple-level oblique lumbar interbody fusion (OLIF) p. 86
Niraj B Vasavada, Prateek P Lodha
DOI:10.4103/isj.isj_14_19  
We report the case of an 80-year old man who presented with nonischemic neurogenic claudication having predominantly right leg radiating pain. Magnetic resonance imaging confirmed it as a case of multiple level lumbar canal stenosis (L2-3, L3-4, L4-5) with right sided de-novo lumbar scoliosis. The patient underwent multiple-Level Oblique Lumbar Interbody Fusion (OLIF) with good clinical outcomes.
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Grade III Spondylolisthesis L5-S1 Treated by Minimally Invasive Spine Transforaminal Lumbar Interbody Fusion (MIS-TLIF) in a Patient of Rheumatoid Arthritis p. 91
Vinay H Patel, Vishal B Peshwattiwar
DOI:10.4103/isj.isj_28_19  
We present a case of a 76-year-old woman on treatment for rheumatoid arthritis, who was bedridden for the past 3 months due to severe neurological claudication. The patient’s radiologic evaluation showed Grade III spondylolisthesis. Spondylolisthesis was treated with minimally invasive transforaminal lumbar interbody fusion (TLIF) in which the reduction was achieved with distraction and restoring height at the disc space. She had no claudication on day 0 postoperative, and she was able to walk for 10min and climb a floor of stairs at discharge. At 6 weeks, she was able to carry out her activities of daily living independently. Computed tomography scan carried out at 1-year follow-up showed bony union at L5-S1 interspace. Thus, minimally invasive TLIF carried out for Grade III spondylolisthesis achieved good reduction with the described technique and had excellent functional results at 2-year follow-up.
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Thoracic discectomy by tubular retractor: Clinical case p. 97
Amit C Jhala, Shivam K Kiri, Sharvil Gajjar
DOI:10.4103/isj.isj_32_19  
Thoracic disc herniation is a rare condition in spine surgery. Surgical treatment is indicated for myelopathy, intractable radiculopathy, or persistent axial back pain. Various open approaches (anterior, anterolateral, posterior, or posterolateral), for thoracic discectomy have been described. These approaches have morbidity and a lot of collateral muscle damage. Minimally invasive approaches have been developed to decrease the morbidity of the open approaches. Here we describe the case of central thoracic disc herniation, which was operated by a minimally invasive transforaminal approach with technical details.
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ORIGINAL ARTICLES Top

Single-level lumbar pyogenic discitis treated with combined minimally invasive posterior and mini-open anterior approach: Functional outcome analysis p. 102
Charanjit Singh Dhillon, Narendra R Medagam, Shrikant Ega, Raviraj Tantry, Nilay P Chhasatia
DOI:10.4103/isj.isj_12_19  
Study Design: This was a retrospective study. Objective: The objective of this study was to evaluate the clinico-radiological outcome in single-level lumbar pyogenic discitis treated with single-stage combined percutaneous posterior stabilization with mini-open anterior debridement and fusion under single anesthesia. Materials and Methods: We retrospectively reviewed 27 patients with single-level lumbar pyogenic discitis who presented to our institute from January 2010 to August 2015. All the patients underwent preoperative evaluation with blood parameters including complete blood count, erythrocyte sedimentation rate, C-reactive protein, blood and urine cultures, and imaging studies. They underwent single-stage combined posterior percutaneous stabilization with mini-open anterior debridement and fusion with tricortical iliac crest graft under the same anesthesia. They were followed up at regular intervals with clinical and radiological assessment with minimum follow-up of 24 months. Preoperative and postoperative final follow-up assessments of neurological status, pain, and disability were conducted using the Frankel Grade scoring, visual analog scale (VAS) score, and Oswestry Disability Index (ODI), respectively. Results: This study included 10 women and 17 men (n = 27) with average age of 57 years (range: 45–73 years). The mean operative time was 194min (range: 150–230min). The mean intraoperative blood loss was 212mL (range: 100–350mL). The mean VAS score (0.56) at final follow-up was significantly lower than the mean preoperative VAS score (7.30) with P < 0.001. The ODI scores at final follow-up (mean, 13.48) were significantly lower than preoperative ODI scores (mean, 83.70) with P < 0.001. Conclusion: Single-stage combined posterior percutaneous stabilization with mini-open anterior debridement and fusion under one anesthesia is an effective alternative to conventional open technique as it allows thorough debridement and rigid fixation, and results in minimal blood loss and lesser postoperative complications.
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CASE REPORTS Top

Delayed-onset pneumothorax after posterior spinal fusion for idiopathic scoliosis: Report of two cases p. 110
Hidetomi Terai, Hiromitsu Toyoda, Kazunori Hayashi, Akinobu Suzuki, Masatoshi Hoshino, Shinji Takahashi, Koji Tamai, Kentaro Yamada, Hiroaki Nakamura
DOI:10.4103/isj.isj_16_19  
Most complications related to posterior spinal fusion (PSF) are reported to be caused by direct injury of the pedicle screws or by an indirect mechanical load generated by the deformity correction during surgery. Primary spontaneous pneumothorax (PSP) is caused by the rupture of bulla/bleb, and is a very rare complication after scoliosis surgery. Herein, we present two cases of delayed-onset PSP after scoliosis surgery. In Case 1, an 18-year-old woman with adolescent idiopathic scoliosis (Lenke 1CN) underwent PSF at T2-L2. The correction rate was 80%. The patient was discharged at 2 weeks after the operation. On the 18th postoperative day, she suddenly felt dyspnea after back pain at home, and walked to an outpatient clinic. She was diagnosed with PSP of the left lung by whole spine X-ray. In Case 2, a 20-year-old woman with idiopathic scoliosis (Lenke 6CN) underwent PSF at T3-L4. The correction rate was 73.6% in the thoracic region and 67.5% in the lumbar region. The patient felt dyspnea at three months after the operation. She was diagnosed with PSP (tension pneumothorax) in the left lung by whole spine X-ray. Both cases underwent video-assisted bulla resection following several days of emergency thoracic drainage, after which the subjects became asymptomatic. PSP should be considered as a complication of PSF when patients show dyspnea following back pain at several weeks after the operation. The presence of bullae/blebs should be examined by perioperative computed tomography to predict the occurrence of PSP.
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Larger screw on the concave side of apex pedicle: Friend or foe? Report on a rare cause of neurological deficit in scoliosis surgery p. 114
Bhavuk Garg, Nishank Mehta, Ashok Jaryal
DOI:10.4103/isj.isj_8_19  
Pedicle screw instrumentation is currently the “gold standard” in scoliosis surgery. However, placement of pedicle screws in thoracic spine is considered challenging. Previous studies have described morphometric changes in the pedicle when a larger screw is inserted, with pedicle expansion preceding screw cutout and pedicle fracture. We report an unusual case of neurological deficit due to cord compression by an expanded pedicle following pedicle screw insertion on the concave side of the apical vertebra in a 14-year-old patient with Lenke Type 3C(-) adolescent idiopathic scoliosis. Identification of the expanded pedicle as the cause of neurological symptoms, prompt action, and deferring the corrective surgery while accepting less correction helped us in negotiating the problem without causing permanent neurological deficit. Pedicle expansion in an immature spine can cause neurological complications. The screw diameter at the apical vertebrae on the concave side should be carefully selected.
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Surgical management of a case of C2 vertebral chordoma via staged anterior and posterior approach p. 118
Nigil S Palliyil, Kedar Deogaonkar, Milind Sankhe
DOI:10.4103/isj.isj_68_18  
Atlantoaxial chordomas being quite uncommon pose a significant therapeutic challenge to the surgeon due to their critical location and often late presentation. Recurrences are common after intralesional excision. Although en bloc excision is the preferred treatment, it may not be feasible due to anatomical constraints in this location. Hence, multimodality treatment in the form of surgery (maximal tumor excision) followed by targeted chemotherapy and radiotherapy is considered to be the next best treatment option. We present the case of a young male patient with C2 chordoma treated at our institution by multimodality approach, and follow-up for 21 months after surgery.
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Traumatic thoracic spine intramedullary hemorrhage: Rare spinal cord injury p. 123
Nitesh Gahlot, Abhay Elhence
DOI:10.4103/isj.isj_72_18  
The aim of this study was to report a rare case of post-traumatic thoracic spine intramedullary bleeding associated with spine fracture in the absence of compression due to fracture fragments on spinal cord. Magnetic resonance imaging scan showed thrombus formation inside the spinal cord with obliteration of neural elements. The patient was managed non-operatively and improved. Intramedullary hemorrhage in spinal cord is a rare cause of neurological deficit in post-traumatic cases and only a handful cases have been reported in the literature, giving no guidance regarding treatment of the condition. Conservative management can be considered a viable treatment option for intramedullary bleeds, especially in cases where there is no bony cord compression.
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OBITUARY Top

A true gem––Dr. Ketan Khurjekar p. 127
Shailesh Hadgaonkar
DOI:10.4103/isj.isj_84_19  
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