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   Table of Contents - Current issue
Coverpage
July-December 2019
Volume 2 | Issue 2
Page Nos. 111-194

Online since Tuesday, July 23, 2019

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EDITORIAL  

From plaster beds to robotics… evolution of spine surgery in India p. 111
Raghava Dutt Mulukutla
DOI:10.4103/isj.isj_47_19  
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ORIGINAL ARTICLES Top

Treatment of scoliosis in osteogenesis imperfecta: Experience at a single institution p. 114
Mutlu Cobanoglu, Jennifer M Bauer, Geraldine Neiss, Petya Yorgova, Kenneth Rogers, Richard W Kruse, Suken A Shah
DOI:10.4103/isj.isj_36_18  
Background: Spinal deformities are frequently seen in osteogenesis imperfecta (OI). We investigated contemporary spinal fusion techniques including pedicle screw fixation with or without cement augmentation in OI patients with scoliosis. Materials and Methods: OI patients with posterior-only scoliosis surgery were reviewed retrospectively (2005–2017). Preoperative and postoperative clinical status was compared. The radiographic review included pelvic obliquity, major curve magnitude, coronal balance, apical vertebral translation (AVT), lowest instrumented vertebrae (LIV) tilt angle, proximal and distal junctional angle, T1–S1 distance, and T1-pelvic angle. Results: Sixteen patients were included in the study. The mean age at surgery was 14 years (range, 6–19). The average follow-up period was 80 ± 40 months (range, 24–148). Mean preoperative curve magnitude of 76° ± 19° was significantly larger than the initial (31° ± 16°) and final (32° ± 17°) postoperative curve magnitudes (58% correction; P < 0.001). Mean preoperative AVT and LIV tilt angle were significantly higher than the initial and final postoperative measurements (P < 0.001 and P < 0.001, respectively). There was no difference between the measurements of coronal balance, pelvic obliquity, and T1–S1 distance among the preoperative, initial postoperative, and final follow-up measurements (P = 0.479, P= 0.125, and P= 0.05, respectively). There was no proximal junctional failure but one distal junctional failure led to revision surgery. Ambulatory status was unchanged in all patients, but an improvement in subjective self-reported clinical complaints was observed. Conclusion: Pedicle screw instrumentation with or without cement augmentation provided stability with few complications and improved clinical outcomes. Although preoperative activity level did not change compared with postoperative activity, there was an improvement in self-reported clinical complaints.
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Clinico-radiological outcomes of single level TLIF using local morselized impacted bone graft vs cage with local bone graft p. 122
Sandeep Gokhale, Aditya Anand Dahapute, Sandeep Sonone, Saurabh Muni, Sai Gautham, Shubhanshu Bhaladhare
DOI:10.4103/isj.isj_41_17  
Aim: To study the fusion rate and clinical outcome of transforaminal lumbar interbody fusion (TLIF) with cage and TLIF with local morselized graft. Design: Retrospective. Materials and Methods: We retrospectively studied thirty patients who received the TLIF with local morselized impacted bone grafts without a cage (Group 1), thirty patients who received TLIF with local bone graft combined with one titanium cage with 4° lordosis (Group 2) with an average follow-up of 15 months. Patients were clinically evaluated at regular intervals along with radiographs. Computed tomography (CT) scans were also performed at 6 months and 1 year after surgery. Functional outcome was assessed using the Modified Oswestry Score (MOS) and Visual Analog Score (VAS) for back pain preoperatively, immediate postoperatively, and at 3 months, 6 months, and 1 year. Statistical Analysis Used:P < 0.05 was taken as the level of significance. SPSS software version 17 was used for analysis. Results: The VAS scores in group 2 (TLIF with cage group) at preoperatively, 3 months, 6 months, and at the end of 1 year improved significantly from 8.47, 3.53, 2.27, and 1.60, respectively; in TLIF without cage group (Group 1), it improved from 8.73, 4.00, 2.53, and 1.47, respectively. The MOS improved from 75.87 preoperatively in the TLIF with cage group (Group 2) to 34.53 at the end of 1 year. In the TLIF without cage group (Group 1), it improved from the preoperative P value of 75.47 to 35.30. Fusion was present in all the cases radiologically. Brantigan criteria were used to assess fusion on CT scan. The mean lordotic angle in the cage group decreased from 17.3° immediately after surgery to 16.5° at 1 year. The mean change was 0.80° in Group 1 (no cage), and the mean lordotic angle decreased from 16.5° immediately after surgery to 14.4° in group 2 (with cage) at 1 year. Conclusion: If we compare clinical and radiological results between the local bone graft with a cage and the morselized impacted bone graft groups, for one-level TLIF, the difference is not significant.
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A clinical and radiological study of nontraumatic coccygodynia in Indian population p. 128
Bharat R Dave, Paresh B Bang, Devanand Degulmadi, Pushpak Samel, Deepak Shah, Ajay Krishnan
DOI:10.4103/isj.isj_15_18  
Background: Nontraumatic coccygodynia is poorly understood. Dynamic radiographs help to identify a radiological lesion. This study was performed to evaluate these parameters and define a line of management. Materials and Methods: A total of 46 cases with nontraumatic coccygodynia and 46 controls who met the inclusion criteria were evaluated using dynamic radiographs between June 2015 and May 2017. Radiological parameters, such as sagittal movement of coccyx, intercoccygeal angle (ICA), base angle (BA), and angle of pelvic rotation (APR), were calculated and compared between cases and controls to identify the radiological lesion in cases. On the basis of clinico-radiological findings, a treatment algorithm for these patients was proposed. Results: A total of 46 cases and 46 controls were studied. The mean age was 41.8 years in cases and 40.6 years in controls. Body mass index (BMI) ranged from 19 to 33. Twenty-nine cases had BMI >25. Average visual analog scale score at initial presentation (6.9), at 6 weeks (4.7), and final follow-up (3.9) was noted. ICA ranged from 1° to 21° (mean 11.12°). BA ranged from 0° to 83° (mean 41.41°). APR ranged from 2° to 33° (mean 14.74°). Twenty-seven patients had a good relief with local hydrocortisone injection and manipulation, whereas nine cases needed coccygectomy. Conclusion: Dynamic radiographs help in defining the radiological parameters and planning treatment. The sagittal movement of extension, posterior subluxation, higher BA, and low APR are the radiological findings seen in patients of nontraumatic coccygodynia. Majority of patients respond to conservative management; however, few may need surgical intervention.
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Lateral Approach to the Lumbar Spine of Sprague Dawley Rat: Development of a Novel Animal Model for Spine Surgery p. 134
Shakti A Goel, Puja Nagpal, Perumal Nagarajan, AK Panda, Harvinder Singh Chhabra
DOI:10.4103/isj.isj_59_18  
Background: Low back pain is a common ailment affecting individuals all around the globe. Animal models are required to study and further explore the treatment modalities. Lumbar spinal surgeries and disc repair is an important tissue engineering research domain. Dorsal and ventral approaches to access rat spine have been traditionally performed but suffer from a number of shortcomings such as higher morbidity, loss of neurology, high postoperative pain, and longer surgery. Methods: We used ten male Sprague Dawly rats, 3 months of age, and weighing an average of 280 gm. The surgeries were performed under dissociative anesthesia (ketamine: 50 mg/kg body weight). The spine was approached by left lateral incision extending from iliac crest and centering the level to be exposed. Skin and subcutaneous tissues were cut, external and internal oblique muscles were split in the direction of fibers, transverse abdominis was split vertically, and psoas was sacrificed. This made the spine and disc levels visible from the left lateral aspect. The muscles were approximated, and skin was closed with nonabsorbable mattress sutures. Postoperative analgesics (meloxicam 5 mg/kg body weight) and antibiotics (ceftriaxone 30 mg/kg body weight) were used. Results: This work has led to the development of a novel in vivo rat model using lateral retroperitoneal approach. This approach provides less pain and faster recovery in the postoperative stage. Moreover, it allows easy exposure and little surgery-related peri- or post-operative complications. Conclusion: Lateral retroperitoneal approach is a novel and safe method of spinal exposure in rats which may pave way for various live rat spine surgery models and experiments in future.
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A comparative prospective study of clinical and radiological outcomes between open and minimally invasive transforaminal lumbar interbody fusion p. 138
Sai Gautham Balasubramanian, Sandeep Sonone, Aditya Anand Dahapute, Saurabh Muni, Rohan Gala, Nandan Marathe, Kuber Sakhare, Shubhanshu Bhaladhare
DOI:10.4103/isj.isj_40_17  
Context: Fusion of lumbar spine is one of the standards of care for various pathologies such as lumbar canal stenosis and spondylolisthesis. Transforaminal lumbar interbody fusion (TLIF) achieves the necessary goals but with greater muscular trauma due to denervation and loss of muscle mass which may result in poor short-term outcomes. Minimally invasive-TLIF (MIS-TLIF) overcomes these shortcomings by preserving the muscle mass by splitting and dilating the muscles. Aims: The goals of the minimally invasive procedures are to reduce iatrogenic muscle injury, postoperative pain, and disability without compromising on the goals of the surgery. Aim of this study was to compare the 1-year postoperative results of TLIF by a minimally invasive technique and open approach in relation to improvement in functional outcome and interbody fusion. Settings and Design: This was a prospective study. Subjects and Methods: We performed a comparative prospective study on 80 patients. All patients were followed up for minimum of 1-year postoperatively. Functional outcome in all patients was assessed by visual analog scale (VAS), Oswestry Disability Index (ODI), and short form-36 (SF-36) scores. Creatinine phosphokinase (CPK) was assessed at the third-day postoperatively. All patients were radiologically assessed with X-rays and computed tomography scans at 1 year to assess fusion. Statistical Analysis Used: SPSS version 17 was used for analysis. P < 0.05 was considered to be statistically significant. Results: We found that CPK levels as measured on the 3rd-day postoperatively were less (statistically significant) in MIS-TLIF group (16.56 + 4.41 u/L vs. 24.52 + 7.2 u/L). The functional outcomes of the patient measured by VAS, modified ODI, and SF-36 were significantly improved (P < 0.05) at the end of 6 weeks, but long-term outcomes were not statistically significant. However, radiation exposure was increased in MIS-TLIF. Conclusion: It can be safely concluded that the immediate postoperative benefits of MIS-TLIF are better compared to open group due to lesser tissue trauma which corresponds to better functional outcome to the patients. However, the outcomes at 1-year follow-up were equal and comparable to the open TLIF.
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Development of the Marathi version of the Tampa scale of kinesiophobia 11: Cross-cultural adaptation, validity, and test–retest reliability in patients with low back pain Highly accessed article p. 146
Kiran Harishchandra Satpute, Parag S Ranade, Toby M Hall
DOI:10.4103/isj.isj_13_18  
Background: The Tampa Scale of Kinesiophobia-11 (TSK-11) is used to assess fear of movement in patients with musculoskeletal dysfunction. However, for Indian-specific population, this scale is not available. We aim to cross-culturally adapt the TSK-11 into a regional Indian language (Marathi) and to assess its psychometric properties, validity, and reliability. Materials and Methods: The American Association of Orthopedic Surgeons guidelines were used for cross-cultural adaptation and psychometric testing. Psychometric testing included assessment of internal consistency (Cronbach's alpha) and test–retest repeatability (intraclass coefficient correlation), construct validity (Pearson correlation) by comparing the TSK-11 score to a visual analog scale (VAS) of confidence and pain, as well as the Marathi version of Oswestry Disability Index (ODI). Results: A total of 100 individuals with mean age of 38.9 years (Standard deviation = 11.34) completed the translated TSK-11 questionnaire on two occasions with an interval of one day. The translated Marathi version demonstrated excellent internal consistency (α = 0.85) and test–retest reliability (intraclass correlation coefficient = 0.93, confidence interval 95% = 0.90–0.95). There were moderate correlations between the total score of the TSK-11 questionnaire Marathi version and ODI score (r = 0.72), VAS pain score (r = 0.635), and VAS confidence score (r = −0.603). Receiver operating characteristics analysis indicated that the TSK-11 score was significantly able (P < 0.001) to discriminate the presence or absence of kinesiophobia. Conclusion: The Marathi version of TSK-11 is reliable and valid, with psychometric characteristics similar to the original English version. This assessment tool can be recommended to measure movement-related fear in future patient-oriented outcome studies for the Indian Marathi speaking population with low back pain.
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CASE REPORTS Top

Delayed postoperative spondylodiscitis in a case of diffuse idiopathic skeletal hyperostosis following surgical intervention for traumatic C7-T1 bifacetal dislocation p. 152
S Dilip Chand Raja, Ajoy Prasad Shetty, Rishi Mugesh Kanna, S Rajasekaran
DOI:10.4103/isj.isj_26_18  
Postoperative spinal infections are on the rise owing to the ever-increasing number of spine surgeries. Spinal instrumentation is associated with an infection rate of 2%–8%. Both surgical and patient factors have been associated with infection. Delayed cases of postoperative infection are mostly related to patient-related factors and can be easily missed as they lack the classic clinical and systemic features. However, if left unidentified, progressive involvement of contiguous levels would result in collapse, instability, deformity, and instrumentation failure. A high index of suspicion is to be maintained, and higher imaging options such as magnetic resonance imaging and computed tomography should be used judiciously so as to diagnose infection at the earliest. We herein describe the background history, clinical features, imaging characteristics, and successful management of infective spondylodiscitis following instrumentation in a narrative manner. Relevant literature and management options have also been discussed.
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Multiple spinal schwannomas in absence of neurofibromatosis (Schwannomatosis) – A rare condition: Review with case report p. 158
Sandeep Bhardwaj, Kunj Bihari Saraswat, Amit Pratap Singh Deora, Ashok Gupta
DOI:10.4103/isj.isj_2_18  
Schwannomas are benign, slow-growing tumors originating from sensory rootlets. Schwannomatosis is a distinct clinical syndrome characterized by the presence of multiple schwannomas in the spine with the absence of typical features suggestive of either neurofibromatosis 1 (NF1) and neurofibromatosis 2 (NF2). It is essential to name schwannomatosis as a distinct syndrome on the basis of genetic and molecular studies. Management in schwannomatosis is surgical removal if symptomatic, and if asymptomatic it is better to follow-up with regular screening. The author reports here a rare case of a 33-year-old male patient, who had a history of being operated for dorsal spine schwannoma at D6 level 7 years back. Now, after 7 years, the patient presented with back pain, moderate to severe, associated with difficulty in walking. After proper history, clinical and radiological evaluation the patient was found to be having multiple lesions at D12 and L3 level with no family history, and on histopathology, both lesions were found to be schwannomas. Hence, this case was diagnosed as a case of multiple schwannomas without any features suggestive of either NF1 or NF2 (schwannomatosis). Regular follow-up is very essential in every case suggestive of schwannoma, as new multiple lesions can develop at any time, after years as discussed in our case.
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Use of o-arm navigation to excise a posterior element osteoid osteoma p. 163
Pradhyumn P Rathi, Vishal B Peshattiwar
DOI:10.4103/isj.isj_45_18  
There are only few reports of the advantages of three-dimensional (3D) computed tomography based navigation system being used for spinal tumor excision. A 33 year old male presented in the clinic with mid-back ache with change in posture. Radiology suggested an osteoid osteoma involving the superior articular process of the D11 vertebra. Accurate localization and complete extirpation of the lesion were performed using a translaminar approach with O-arm Navigation. 3D navigation with the O-arm system provided an easy and accurate localization of the lesion, reducing the risk of instability subsequently and avoiding instrumented stabilization. This technique also provided for histopathological confirmation of the diagnosis.
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Foramen magnum syndrome after iatrogenic cerebrospinal fluid leak during lumbar spine surgery: A series of two cases p. 169
Siddharth A Badve, Michael Galgano, Richard A Tallarico, William F Lavelle
DOI:10.4103/isj.isj_47_18  
Foramen magnum syndrome (FMS) is a rare complication from lumbar spine surgery. Cerebrospinal fluid (CSF) leaks can be difficult to treat. FMS is a dangerous complication due to excessive distal CSF drainage from a dural tear or secondary to a “controlled” lumbar drainage. We present two cases of FMS after iatrogenic CSF leaks. Both patients underwent decompressive laminectomy as a part of the index surgery. Intraoperative dural tear was not identified in either case. A postoperative computed tomography (CT) myelogram ordered in view of the positional headaches indicated a CSF leak. A lumbar drain was placed, but both the patients worsened symptomatically. CT head in Case 1 indicated tonsillar ectopia within the foramen magnum, while that in Case 2 revealed a posterior fossa hemorrhage with fullness of the foramen magnum and profound hydrocephalus. Both patients were treated surgically. Additional corrective measures were also initiated to reverse the pathology. Both patients made a good recovery with resolution of symptoms. Development of neurological changes in a patient with CSF leak may indicate an acute intracranial process. Treatment of foramen magnum syndrome requires prompt realization of the underlying pathology and measures to cease or modulate the CSF drainage. The dangers of excessive distal CSF drainage, whether it is from a dural tear or from “controlled” lumbar drainage, should be considered.
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Intramedullary arachnoid cysts – Report of three cases and literature review p. 174
Anuj Arun Bhide, Vernon L Velho, Anirudha G Mohite
DOI:10.4103/isj.isj_54_18  
Arachnoid cysts are rare lesions of the spine and occur most commonly in the extradural location. Intramedullary location is a very rare site, and only 15 cases have been reported in literature till date. We report a series of three cases with intramedullary arachnoid cysts having diverse etiopathogenesis and clinical presentations. Recurrent cyst and cyst associated with tethering of the cord are unique to our series and have not been reported previously.
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A rare case of giant cell tumor of body of axis: Surgical management with staged posterior occipitocervical fusion, anterior excision and reconstruction through anterior mandibulotomy p. 179
Bharat R Dave, Gayadhar Behera, Ajay Krishnan, Devanand Degulmadi
DOI:10.4103/isj.isj_21_19  
Giant cell tumor (GCT) constitutes around 5% of all the skeletal tumors which usually occur between second and fourth decade. Cervical spine GCT is very rare, and only a few case reports have been reported. In view of complex anatomy, variable aggressiveness, and scanty literature, there is a lack of clear consensus in the evaluation and management of high cervical GCT. We present a 30-year-old male patient, a case of GCT involving C2 vertebral body with severe neck pain, C1–C2 instability, and neurological deficit (visual analog scale [VAS] - 10/10, Nurick Grade-IV, NDI - 97.7%) managed by staged procedures. Posterior occipitocervical stabilization followed by anterior corpectomy, intralesional excision of the mass through anterior mandibulotomy, and reconstruction with iliac crest bone graft was performed. Postoperatively, the patient received adjuvant Denosumab therapy for 6 months. Complete neurological improvement was seen by 3 months. The VAS and NDI scores were 1/10 and 11.1%, respectively, at 1-year follow-up. No radiological recurrence was seen on radiograph and magnetic resonance imaging at 2-year follow-up. C2 GCT managed by intralesional excision and global stabilization combined with Denosumab therapy provides good clinical improvement without recurrence on medium-term follow-up. We believe that extended transoral transmandibular approach provides an excellent wide field for excision of high cervical aggressive tumors.
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Modified three-stage Gaines procedure for symptomatic adult spondyloptosis p. 184
Charanjit Singh Dhillon, Mithun Jakkan, Narendra Reddy Medagam
DOI:10.4103/isj.isj_51_18  
Spondyloptosis or complete anterior dislocation of the L5 vertebra over S1 is a rare clinical condition. In general, the surgical management of spondyloptosis includes either posterior long-segment in situ fusion (with total disregard for altered biomechanics) or restoration of lumbosacral kyphosis by reduction of spondyloptosis using multistaged procedures. Reduction is possible in spondyloptosis only after sacral dome osteotomy or L5 corpectomy with interbody fusion of L4 over S1 as described by Robert Gaines. We present the case of a 29 year old manual laborer who presented with complaints of severe low back pain and bilateral sciatica. He was diagnosed to have spondyloptosis of L5 over S1 with modified Newman's score of 10 + 10. The patient underwent three-staged modified Gaines procedure in the form of L5 corpectomy, reduction of L4 over S1 and interbody fusion between L4 and S1. The reduction was maintained at the end of 18 months and he was able to resume his job as a manual laborer.
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An Unconventional and Novel Therapeutic Technique of Anterior Indirect Decompression in a Case of C6–C7 Synovial Cyst Associated with Radiculopathy p. 190
Bharat R Dave, Gayadhar Behera, Yash Shah, Ajay Krishnan
DOI:10.4103/isj.isj_9_19  
Synovial cysts are infrequent findings in the spine and mostly located in the lumbar area. Even rarer is the occurrence of a synovial cyst in the cervical spine. The pathology arises from the facet joint and may cause pain, radiculopathy, or myelopathy. Few cases of symptomatic subaxial synovial cysts have been reported in the literature. Surgery is indicated in the presence of severe pain and neurologic compromise and involves the decompression of the cyst and the associated neural elements. Hemilaminectomy is the surgical treatment most commonly reported in the literature. However, other procedures such as complete laminectomy, CT-guided aspiration, and anterior corpectomy have been described. On the background of available literature till date, we report an unconventional and novel therapeutic technique of anterior indirect decompression in an uncommon case of a C6-C7 synovial cyst. A 67-year-old female patient had left upper limb radicular pain along the forearm and lateral fingers for 2 months. She had severe neck pain in extension and weak triceps (4/5) with the Neck Disability Index (NDI) score of 51.11% and visual analog scale (VAS) score of 8/10. Plain x-rays were suggestive of spondylosis. T2WI of MRI scan demonstrated cystic lesion on ventral aspect of C6-C7 (L) facet suggestive of synovial cyst. Anterior cervical discectomy and fusion was done, and indirect posterior decompression of the cyst was achieved. There was a complete resolution of radiculopathy immediate postoperative period with magnetic resonance imaging (MRI) showing the evidence. Motor weakness resolved by 3 months with NDI score of 8.88% and VAS of 2/10. She was asymptomatic with no evidence of disease recurrence on MRI at 24 months.
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