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The spine clinics – Postoperative spinal infections - Clinical scenarios
Bidre Upendra, Rishi M Kanna, Ketan Khurjekar, Bijjawara Mahesh, Siddharth A Badve
January-June 2018, 1(1):32-45
This section of the symposium brings four different clinical scenarios in patients presenting with postoperative surgical site infections (SSI) after spine surgery. The patients were managed in various medical centres having different infrastructures and different spine care professionals. The spine clinics aims at providing the reader with an overview of the difficult scenarios faced in the setting of postoperative spinal infection and the different lines of treatment chosen by the attending spine surgeons at their centres. The section ends with few literature supported guidelines in the management of surgical site infection (SSI) after spine surgery.
  2,532 245 -
Predisposing factors and protocols for prevention of surgical site infections following spine surgery: A review of literature
Suneetha Narreddy, Venkata Ravikumar Chepuri, Silpita Katragadda, Ravikiran Abraham Barigala, Raghava Dutt Mulukutla
January-June 2018, 1(1):2-6
Surgical site infections (SSIs) following spinal surgery and its treatment are highly debated topics over decades, constituting one of the major causes of morbidity in patients undergoing spine surgery. The importance of this topic lies in the fact that, if ignored, it can lead to high morbidity and mortality, which may require prolonged hospitalization. This review deals with rates of SSI in various spine surgeries, then dwells on few studies exploring causes and prevention of SSI, provides a summary of SSI preventive protocols by various organizations, recommendations for antibiotic prophylaxis, and finally on medical management of established postoperative infections.
  2,053 299 -
Imaging of postoperative spinal infections
Vadapalli Sai VenkataRammohan, Raghava Dutt Mulukutla, Abhinav Sriram Vadapalli
January-June 2018, 1(1):7-16
The spectrum of postoperative spinal infections includes superficial and deep infections, wound infections, spondylodiscitis, intraspinal epidural abscess, infective arachnoiditis, the extraspinal pre- and paravertebral extension of intraspinal abscesses, and necrotic collections. Imaging modalities for detection of these pathologies include plain radiographs, multidetector computed tomography, magnetic resonance imaging (MRI), and radionucleotide scintigraphy. MRI allows adequate visualization of both the bony structures and soft tissues. Contrast enhanced MRI with gadolinium is the imaging modality of choice to delineate postprocedural and postoperative spine infections and complications. MRI has high sensitivity and specificity in the diagnosis of postoperative spondylodiscitis, epidural abscesses, and infective arachnoiditis. Metallic orthopedic hardware may produce artifacts that degrade image quality which is resolved by a metal artifacts reduction sequence to optimize the image quality in bone and soft tissues. F-18 fluorodeoxyglucose positron-emitted tomography is superior to MRI not only in patients with surgical history and high grade infection but also in the patient with low grade spondylodiscitis.
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Hyperplastic hematopoietic bone marrow of the spine mimicking spinal metastasis: A case report and review of literature
Wen Loong Paul Yuen, Wenxian Png, Shree Kumar Dinesh, Wee Lim Loo
July-December 2018, 1(2):135-139
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.
  1,756 152 -
Atypical spinal infections in immunocompromised patients
Harvinder Singh Chhabra, Rajat Mahajan, Abhinandan Mallepally Reddy
January-June 2018, 1(1):24-31
Spinal infections in immunocompromised patients are a potential threat due to atypical presentations and delay in diagnosis. These patients often present with back pain, fever, and neurological deficits. It is crucial to have knowledge of atypical etiology of vertebral osteomyelitis. Immunocompromised status of the patients presumably prevents them from mounting an inflammatory or vascular response necessary to counter the disease process. The diagnostic delay of such disastrous conditions remains unsatisfactorily long. Identification of the causative microorganisms and timely initiation of treatment are of prime importance in the management of such infections. Magnetic resonance imaging with/without gadolinium contrast is the choice of noninvasive investigation in spinal infections, and an appropriate tissue biopsy for isolation of causative organism is required for confirmation of the diagnosis. Patients are best managed by a multidisciplinary approach. Surgical intervention may be necessary for effective management and prevention of complications due to atypical spinal infections.
  1,726 180 -
The scope of minimally invasive techniques in spinal infections
Arvind Gopalrao Kulkarni, Navin Geralal Mewara
January-June 2018, 1(1):17-23
The primary goals for treating infectious spinal conditions are to make an accurate diagnosis, isolate the causative organism, and prescribe effective antibiotic therapy based on the culture reports. A positive culture is extremely important for successful treatment and prevention of further morbidity. Surgically collected samples have shown to have a greater chance of demonstrating growth of organism on culture as compared to computed tomography-guided fine-needle samples. Surgical drainage and/or reconstruction with/or without fixation is usually indicated when there is no or poor response to antibiotic therapy, systemic toxicity with evidence of large collections, progressive spinal deformity, or instability or neurological impairment. However, the incidence of perioperative morbidity is particularly increased in elderly patients or in those with a poor general condition. With improved instrumentation and techniques in minimally invasive spine surgery, spinal infections can be successfully treated by minimally invasive debridement followed by pharmacological treatment, without causing any destabilization to spine. Where major reconstruction and fixation procedures are deemed mandatory, various MIS techniques can be utilized to decrease the surgery related morbidity and allow for faster rehabilitation. These procedures are associated with steep learning curve. With the advent of intraoperative navigation, the exposure to radiations can be significantly reduced.
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A review of thoracolumbar spine fracture classification systems
Parthasarathy Srinivasan
July-December 2018, 1(2):71-78
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.
  1,314 256 -
Natural history, prevalence, and pathophysiology of cervical spondylotic myelopathy
Gomatam Raghavan Vijay Kumar, Dibyendu Kumar Ray, Rupant Kumar Das
January-June 2019, 2(1):5-12
This study is a narrative review performed to summarize the current knowledge about the epidemiology, natural history and pathogenesis of cervical spondylotic myelopathy (CSM). A comprehensive search was undertaken to look at all available articles between January 1, 1956 to May 1, 2018, on PubMed and the Cochrane Collaboration Library. The natural history of CSM is variable. The main determinants of the clinical course of CSM are the extent of neurological impairment, age, cervical instability, abnormalities of cord conduction, canal diameter, congenitally stenotic spinal canal and the extent of involvement and tract disruption on diffusion tensor imaging (DTI) imaging. There is little data on the true incidence and prevalence of CSM across the globe and none from India. The pathoanatomic basis of CSM is cord compression, either dynamic or static. The biological events that are thought to play a significant role in the development of CSM are ischemia, derangement of the blood-spinal cord barrier, chronic neuronal inflammation, and apoptosis. Emerging knowledge about the molecular biology holds promise for potential intervention, both for prevention and for cure, of this common and debilitating condition.
  1,280 240 -
Indian spine journal – A new beginning
Anil K Jain
January-June 2018, 1(1):1-1
  1,290 225 -
Thoracolumbar fractures: Nonsurgical versus surgical treatment
Gururaj Sangondimath, Kalidutta Das, Kalyan Varma
July-December 2018, 1(2):79-85
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.
  1,282 221 -
Fractures in ankylosed spines: Current concepts
Ramakanth Rao Ilinani, Ajoy Prasad Shetty
July-December 2018, 1(2):101-111
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.”
  1,335 162 -
Imaging in cervical myelopathy
Rajavelu Rajesh, Shanmuganathan Rajasekaran, Sri Vijayanand
January-June 2019, 2(1):20-32
This is a narrative review. The objective of this study is to provide an overview on the imaging modalities and their utilization in cervical myelopathy (CM). Using PubMed, studies published on the “imaging modalities in CM,” “cervical spondylotic myelopathy (CSM) imaging,” “computed tomography (CT) and magnetic resonance imaging (MRI) in CM,” “imaging in ossified posterior longitudinal ligament (OPLL),” “dural ossification in OPLL,” “diffusion tensor imaging (DTI) in CSM,” and “dynamic MRI, functional MRI, and magnetic resonance spectroscopy (MRS) in CSM” were evaluated. The review addresses the evaluation of CM with various imaging modalities ranging from radiographs, CT, and MRI to advanced imaging techniques such as DTI and MRS. Each investigation contributes specific detail to the disease process in a different dimension. Specific parameters for CSM and OPLL, and their influence on outcome are discussed. Imaging in CM plays an important role in analyzing the cause of myelopathy, defining the level of the lesion, parameters to assess the time of intervention and to predict the outcome.
  1,258 216 -
Socioeconomic impact of cervical spinal cord injury operated in patients with lower income group
Shakti A Goel, Hitesh N Modi, Bharat R Dave, Pankaj R Patel, Rushin Patel
January-June 2018, 1(1):46-50
Background: The socioeconomic impact after cervical spine surgery in patients with cervical spine injury have not been reviewed. The aim of this study was to analyze the clinico-radiological results and socioeconomic impact even after radiologically successful surgery. Materials and Methods: One hundred and thirteen surviving individuals (out of 166) were included in this retrospective study from hospital record who belonged to lower socioeconomic group as per Kuppuswamy scale. All patients had undergone cervical spine surgery (anterior or posterior) for cervical spinal injury from 2007 to 2014. The injury sustained was either purely traumatic or trivial trauma in an existing cervical myelopathy. Average income per family was Rs. 2215.13 ± 870.46 ($39.55) per month with cervical spine injury who underwent surgery. Pre- and postoperative Oswestry Disability Index, Kuppuswamy score, and Nurick Scale were used to assess the degree of loss of function in individuals and roentograms for fixation assessment. The individuals were contacted on phone or during hospital visit to evaluate their expectations and daily living. Results: The average age of study group was 46.65 ± 16.89 years with 65 (57%) comprising males. Fifty-one (46.7%) patients were laborers or farmers, 24/47% lost their jobs after injury. About 19% (Rs. 414.9 ± 162.89) of the monthly expenditure was spent on their rehabilitation and medicines and 63 (56%) had expectations to get government support in the form of financial help or rehabilitation. The Nurick scale did not show any significant change in pre- and postoperative periods (3.06 vs. 2.83; P = 0.180). The postoperative Oswestry Disability Index score was not significantly decreased as compared to the preoperative stage (82.4 ± 1.8 vs. 78.2 ± 2.9 P > 0.05). However, there was a significant reduction in the Kuppuswamy score in the postoperative period (12.5 ± 2.5 vs. 8.2 ± 1.5, P < 0.05). Despite good radiological results and improvement in the clinical symptoms, the socioeconomic condition of the individuals deteriorated in the study group. Conclusions: These findings suggest a socioeconomic impact after cervical spine injury. Cervical spine surgery alone does not make sure of a good functional outcome for the patients of spinal cord injury. It also required a good rehabilitation program which is always a challenge in the lower socioeconomic group, hence socieconomic status of an individual, possibility/ availability of rehabilitation program should be kept in mind to predict/ prognosticate the outcome.
  1,253 188 -
Thoracolumbar trauma with delayed presentation
Rishi M Kanna, Ketan Khurjekar
July-December 2018, 1(2):94-100
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.
  1,163 151 -
Is there a role for anterior augmentation in thoracolumbar burst fractures?
Wesley H Bronson, Alexander R Vaccaro
July-December 2018, 1(2):86-93
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.
  1,068 207 -
Dorsally migrated epidural disc herniation with intradural extension: A rare clinical entity
Vibhu Krishnan Viswanathan, Ajoy Prasad Shetty, Rishi Mugesh Kanna, Anupama Mahesh, Rajasekaran Shanmuganathan
January-June 2018, 1(1):61-64
Migration of disc fragment into the dorsal epidural space is a rare phenomenon. It happens when a sequestrated disc fragment transgresses the anatomical barriers to reach dorsal to the dural sheath. We describe a rare situation where a dorsally migrated, sequestrated disc fragment also had a partial intradural extension. The case is highlighted for the extreme rarity of such presentation, role of magnetic resonance imaging scan on the preoperative diagnosis and crucial surgical principles.
  1,154 119 -
Rapid onset debilitating illness with multiple vertebral lesions: A confounding diagnosis of peripheral T-cell lymphoma
Arun-Kumar Kaliya-Perumal, Chi-Chien Niu, Wen-Yu Chuang, Tsung-Ting Tsai
July-December 2018, 1(2):140-143
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.
  1,138 77 -
Transforaminal approach to cervical spine with use of cervical pedicle screws: Technical description of a novel approach
Bijjawara H Mahesh, Bidre N Upendra, Rao Raghavendra, Sekharappa Vijay, Kumar Arun, Reddy Srinivasa
January-June 2018, 1(1):51-60
Background: The success and popularity of the transforaminal approach in the lumbar spine has been made possible by the routine use of pedicle screws in the lumbar spine. Transforaminal approach in the cervical spine can give access to the disc and the vertebral body anteriorly and avoid an additional anterior approach in certain clinical situations. We report technical aspects of transforaminal approach in the lower cervical spine with the authors learning experience. Materials and Methods: Fifteen patients underwent transforaminal approach with cervical pedicle screw (CPS) instrumentation at our institute from July 2011 to October 2014. Five patients underwent foraminal decompression alone (Group-1); 9 patients underwent transforaminal cervical interbody fusion (TCIF) with foraminal decompression, discectomy, and interbody bone grafting (Group-2); and 1 patient underwent partial corpectomy (Group-3). All patients were evaluated for the placement of pedicle screws, for clinical improvement using modified Japanese Orthopaedic Association (mJOA) scoring and interbody graft positioning. The average follow-up was 34.6 months (22–64 months). Results: The average age was 45 years (25–80 years). The average blood loss was 198 ml (100–450 ml) and the average operative time was 142 min (90–200 min). Interbody graft pieces extruded anteriorly in 4 patients (Group-II). The preoperative average mJOA score of 11.4 (0–15) improved to 15.73 (0–18) at final followup. Conclusion: Transforaminal approach in lower cervical spine, though has a learning curve, seems to be a feasible technique along with the use of cervical pedicle screws. Safety and reproducibility of the approach needs to be substantiated with a larger study. Further, TCIF can avoid an additional anterior surgery in certain situations in the cervical spine.
  994 168 -
Clinical spectrum and importance of evaluation systems in degenerative cervical myeloradiculopathy
Ganesh Swaminathan, Vetrivel Muralidharan, Baylis Vivek Joseph
January-June 2019, 2(1):13-19
Degenerative cervical myelopathy includes facet joint arthropathy and/or intervertebral disc prolapse, as well as aberration (hypertrophy, calcification, or ossification) in the ligamentum flavum, and/or posterior longitudinal ligament. Cervical spondylotic myelopathy and ossification of posterior longitudinal ligament are two major conditions under this spectrum. Patients with degenerative changes of the cervical spine can present with wide spectrum of symptoms and signs ranging from axial neck pain, radiculopathy or myelopathy. A combination of history, physical examination, and provocative tests such as Spurling's sign, shoulder abduction test, neck distraction test, Valsalva maneuver, Elvey's upper limb tension/brachial plexus tension test increase the likelihood of diagnosis of cervical radiculopathy. Myelopathy can manifest in the early stage as subtle changes in the upper limb dexterity or mild walking difficulty and in late stage with severe spasticity and flexor spasms. Clinicians are increasingly using quantitative or semi-quantitative scales of neurological impairment. However, there is no gold standard evaluation systems that can reliably assess disease severity.
  981 179 -
Cervical ribs as a caution for spine surgeons in thoracic spinal surgery
Yat Wa Wong, Kenny Yat Hong Kwan, Keith Dip Kei Luk
January-June 2018, 1(1):65-68
Cervical ribs are well-described anomalous additional ribs arising from the seventh cervical vertebrae, but they can be a potential cause for wrong-level surgery. We report a case of a 71-year-old female with bilateral lower limb weakness and numbness due to spinal stenosis from T8 to T11 correlated on magnetic resonance imaging (MRI). However, computed tomography (CT) of thoracic spine showed ossification of the yellow ligament (OYL) one level distal at T9-T12. The whole spine CT revealed the presence of cervical ribs, and the initial discrepancy was caused by counting thoracic spinal levels according to the rib heads. Intraoperative decompression confirmed the dura had merged with OYL at T8–T11. The patient made a partial neurological recovery and could walk independently at 6-month follow-up. This case serves as a reminder for spine surgeons surgical implications of cervical ribs when operating on the thoracic spine, and the authors suggest additional radiological examinations to include the cervical spine to minimize the chances of wrong-level surgery.
  1,049 101 -
Evidence-based medicine: What does it mean to spine surgeon
Anil K Jain, Manish Chadha
July-December 2018, 1(2):69-70
  981 156 -
Surgical management of postoperative infections in spine surgery
Rohit Amritanand
July-December 2018, 1(2):117-121
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.
  905 88 -
Publish or perish
Anil K Jain, Manish Chadha
January-June 2019, 2(1):1-3
  678 170 -
Intraoperative stress in spine surgery – Surgeon versus assistant
Maximilian Reinhold, Jonas Kremer, Declan Stewart
July-December 2018, 1(2):122-127
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.
  728 95 -
Achromobacter spondylodiscitis: A case report and review of literature
Hamza Shaikh, Thomas J Kishen
July-December 2018, 1(2):144-147
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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