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   Table of Contents - Current issue
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July-December 2020
Volume 3 | Issue 2
Page Nos. 129-270

Online since Monday, July 13, 2020

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EDITORIAL  

Impact of COVID-19 on spine surgery: How can we work towards evolving best practices p. 129
Saumyajit Basu
DOI:10.4103/isj.isj_45_20  
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SYMPOSIUM: ADOLESCENT IDIOPATHIC SCOLIOSIS Top

Etiology and natural history of adolescent idiopathic scoliosis: A review p. 131
Rajasekaran Shanmuganathan, Karuppanan Sukumaran Sri Vijay Anand, Ajoy P Shetty
DOI:10.4103/isj.isj_62_19  
Adolescent idiopathic scoliosis (AIS) is the most common spinal deformity with a prevalence of 1.34%, although the percentage of population requiring treatment is substantially less. Understanding the etiopathogenesis and natural history of a disorder is most important to formulate effective treatment strategies. For the past few decades, researchers have probed the etiopathogenesis of AIS from various angles of genetic, neurological dysfunction, biomechanical, hormonal, and developmental disturbances. Various theories have been put forward based on association studies that found no correlation. However, direct cause–effect relationship has not been established for any individual factor till now. Also whether these findings are either primarily the cause for scoliosis or secondary to AIS remains unknown. From the existing literature, AIS appears to be a multifactorial disorder with a strong genetic predisposition, hormonal and environmental disturbances. Literature on the natural history of AIS is limited with only few studies that have long-term follow-ups on untreated scoliosis. On the basis of the available literature, it can be safely said that AIS has a benign course with very minimal or no functional disability in the long-term follow-up. The minimal risk of mortality is present only in curves of more than 100° with severe pulmonary dysfunction and cor pulmonale. Here we review the important theories, hypothesis, and recent trends in research on etiopathogenesis of AIS and also summarize on the natural history of the disorder.
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Classification systems in adolescent idiopathic scoliosis revisited: Is a three-dimensional classification needed? p. 143
Krishnankutty Venugopal Menon
DOI:10.4103/isj.isj_74_19  
Classification systems for adolescent idiopathic scoliosis (AIS) have been in existence since the Schulthess system of 1905. Despite the numerous schema that have evolved over the last 115 years, little has changed from the original system based on the location of the coronal plane apex of the curves. Attempts at adding the sagittal plane, axial plane and shoulder balance to the system has generally yielded unscientific schemas or unwieldy numbers of variables within the scheme. The fundamental flaw with all these classifications is that they are based on two-dimensional imaging. The introduction of 3-D imaging like EOS and surface topography studies allow us an entirely novel perception of the spinal orientation in space. Thus the 3-D classifications that have emerged does not necessarily mean adding on Cartesian co-ordinates to the existing systems, but a far more comprehensive, yet simplistic view of the spinal deformity. Evidently, we are far from fully establishing all the variables and potentials of such schemas. Current modalities of 3-D imaging and evaluation are largely in the research domain and have not yet reached the clinical practice stage. The clinical utility of such 3-D classifications is also conjectural at present. But it is eminently possible that in the foreseeable future scoliosis classifications would cease to appear and be applied as they are today.
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Bracing in adolescent idiopathic scoliosis p. 151
Bhavuk Garg, Kaustubh Ahuja, Saumyajit Basu
DOI:10.4103/isj.isj_21_20  
Bracing constitutes the most widely practiced treatment method for nonoperative management of adolescent idiopathic scoliosis (AIS). Brace treatment has undergone a large number of variations from the time of its inception, and it has led to a number of available options to choose from in present times. The evidence for bracing has also evolved tremendously in the last few years from single-center cohort studies to multicenter randomized controlled trials. For bracing to be successful, proper patient selection is an important prerequisite. A coordinated team effort from the patient, parents, family, the surgeon, and orthotist is also essential for ensuring compliance and treatment success. This article is a narrative review and focuses on the role of bracing in the management of AIS in terms of the brace history, types, indications, results, and drawbacks with relevant literature.
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Current concepts in level selection for fusion in the adolescent idiopathic scoliosis patient p. 160
Paul Jaewook Park, Andrew Sawires, Lawrence G Lenke
DOI:10.4103/isj.isj_67_19  
Over the past several decades, level selection for fusion in the patient with adolescent idiopathic scoliosis (AIS) has evolved alongside technique. Now, with the near ubiquitous use of pedicle screw fixation, selection criteria have changed to minimize the number of levels fused, especially distally in the lumbar spine. With each additional motion segment preserved, it has been suggested that postoperative function can be improved and the risk of degenerative disease down the line may be decreased. Currently, the Lenke classification for AIS is the most widely used system to describe AIS pathology. Understanding where the structural and nonstructural curves are may help determine the extent of fusion required distally. Proximally, shoulder balance is still considered a key consideration for upper instrumented vertebra (UIV) selection. In terms of the lowest instrumented vertebra (LIV), we focus on two key concepts to prevent serious complications such as distal junctional kyphosis (DJK) or adding-on phenomenon: the last touched vertebra (LTV) and the stable sagittal vertebra. In the AP radiograph, identifying the LTV as the LIV may allow the surgeon to save a fusion level without increasing risk of DJK or adding-on. However, one must also consider the sagittal plane; the authors identify the stable sagittal vertebra on the lateral radiograph to help determine the optimal LIV; of these two criteria, the more distal level will be selected to decrease the chance of adverse outcomes.
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Shoulder balance in adolescent idiopathic scoliosis: Current concepts and technical challenges p. 173
Saumyajit Basu, Tarun Suri
DOI:10.4103/isj.isj_8_20  
Cosmesis and self-image perception are important aspects of adolescent idiopathic scoliosis (AIS). Shoulder balance plays an important role in this aspect. In this article, we provide a broad narrative review of the clinical and radiological assessment of shoulder balance along with various factors affecting the postoperative shoulder imbalance (PSI). Systematic literature search was done using specific keywords, and studies were screened using PRISMA flowchart. Concept of medial and lateral shoulder balance, which are two distinct and independent entities, has been discussed. The trapezial angle and area are medial shoulder parameters, and are of more concern as they directly affect the cosmesis. Choice of the upper instrumented vertebra (UIV), behavior of the proximal thoracic curve, and preoperative levels of shoulder are important determinants of PSI. The relative correction of middle and distal curves also plays an important role to prevent imbalance and adding-on, especially in type 5 and 6 curves. Hooks at the UIV may provide a soft landing and help in the adjustment of any PSI.
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Posterior techniques for correcting deformity in adolescent idiopathic scoliosis––How much correction is optimal? p. 185
Sean M Rider, Daniel R Rubio, Munish C Gupta
DOI:10.4103/isj.isj_66_19  
The optimal surgical treatment of adolescent idiopathic scoliosis is heavily debated in the literature. This study aimed to review posterior surgical techniques in the treatment of adolescent idiopathic scoliosis. Literature review was performed. In treating adolescent idiopathic scoliosis with posterior spine fusion, there are many factors to consider when determining where to start and end the fusion construct: skeletal maturity, stress/bending radiographs, and assessment of vertebral rotation and translation. When considering selective thoracic fusion, the relative magnitudes of the main thoracic (MT) and thoracolumbar/lumbar (TL/L) curves and the overall sagittal profile of the thoracolumbar junction are assessed. Selective thoracic fusion can be appropriate if two of the three are found to be true: the MT-to-TL/L Cobb angle ratio is >1.2, the MT-to-TL/L apical vertebral translation (AVT) ratio is >1.2, and/or the MT-to-TL/L apical vertebral rotation (AVR) ratio is >1.2. Moreover, selective thoracic fusion can be an option in the presence of a nonstructural lumbar curve (bending Cobb angle <25°) with thoracolumbar (T10-L2) kyphosis <20°. When choosing the uppermost and lowest instrumented vertebra, one must consider standing coronal balance and regional kyphosis to lessen risk of postoperative complication. The uppermost instrumented vertebra should be a stable, neutral vertebra with <5° of junctional kyphosis; and the lowest instrument vertebra should be touched by the central sacral vertical line and within two vertebrae proximal to the neutral vertebra. To aid in correction, the addition of posterior surgical releases improves the mobility of spine, especially in more rigid curves, but may increase intraoperative blood loss and operative time. Rod derotation and vertebral translation appear to have similar results in correcting coronal and sagittal deformities. The addition of direct vertebral rotation and segmental rotation plays a role in surgical correction as well.
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Role of anterior surgery in idiopathic scoliosis: A literature review p. 196
Abhishek Srivastava, Naveen Pandita, Arvind Jayaswal
DOI:10.4103/isj.isj_80_19  
Scoliosis is lateral curvature of the spine, which includes three-dimensional deformity. Both anterior and posterior approaches have been used to treat the deformity. Over the period of time, anterior scoliosis surgery has been popularized by various people albeit for selective indications. A literature review was done searching available literature from 1970 to 2019, using medical search engines, PubMed and Google Scholar. Review was aimed at defining the current status and indications for anterior surgery in adolescent idiopathic scoliosis. Anterior scoliosis surgery leads to similar correction compared to posterior surgery with additional advantage of saving of fusion levels along with preservation of more mobility. The pulmonary function affection from clinical standpoint remains limited with anterior approaches. Currently, anterior approaches are used for treating Lenke type 5 and 6 curves with similar results to posterior surgery. In addition, anterior approach can be an essential adjunct to posterior surgery in severe curves where there is significant stiffness.
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Minimally invasive options in adolescent idiopathic scoliosis p. 207
Jiong Hao Tan, Hee-Kit Wong
DOI:10.4103/isj.isj_63_19  
Posterior spinal instrumentation and fusion is the gold standard of surgical treatment for adolescent idiopathic scoliosis (AIS). This procedure is conventionally performed open, through a posterior midline approach. Minimally invasive spinal surgery (MIS) has been found to be associated with decreased blood loss, shorter duration of hospital stays, earlier mobilization, and decreased analgesic requirements in other areas of spinal surgery. In the treatment of patients with AIS, these principles can be applied via a posterior MIS approach and an anterior thoracoscopic approach. This article aimed to provide an overview of the current state of knowledge of MIS for AIS surgery. We will describe the rationale for the use of posterior MIS for AIS, a description of the surgical technique and a discussion of the current evidence for its use. We will also describe the indications, surgical technique, and evidence for MIS anterior spinal fusion as a definitive procedure for AIS and for non-fusion convex growth modulation procedures.
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SPINE CLINIC Top

The spine clinics: Adolescent idiopathic scoliosis p. 216
Tarun Suri, Saumyajit Basu, T. Ajoy Prasad Shetty, Amit Jhala, Abhay Nene, Naveen Aggarwal, Sridhar Jakkepally, Sharvil Gajjar, Munjal S Shah
DOI:10.4103/isj.isj_49_20  
This section of the symposium brings to the reader seven case scenarios with regard to adolescent idiopathic scoliosis (AIS). These are the common curve patterns which a spine surgeon encounters in his practice. They have been contributed by different spine surgeons and highlight the varied approaches taken by them to achieve a satisfactory outcome. Each scenario highlights the proper workup required for such cases along with planning of the levels of fusion.
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ORIGINAL ARTICLES Top

Symptomatic pneumocephalus following spine surgery: An institutional experience and review of literature p. 231
Bharat R Dave, Amit Jain, Devanand Degulmadi, Ajay Krishnan, Paresh Bang
DOI:10.4103/isj.isj_4_19  
Purpose: The objective of this study was to alert spine surgeons about possibility of pneumocephalus after spine surgery and elaborate its causes, pathophysiology, symptomatology, and management. Materials and Methods: Four patients identified to have symptomatic pneumocephalus after spinal surgery (out of total 7940 operated spine cases over a period of 5 years from January 2013 to December 2017), were included in the study. Compiled data of medical records, operative notes, in-patient treatment records, and radiological findings of these patients were evaluated. Results: All four patients had dural injury with cerebrospinal fluid (CSF) leak. Dura was repaired in two patients and was covered with fat graft in other two. Bifrontal pneumocephalus occurred in three patients while one had intraparenchymal pneumocephalus. All patients were managed conservatively with Trendelenburg position, O2 inhalation, and intravenous hydration along with supportive measures. Conclusion: Pneumocephalus is a rare but serious complication following spine surgery and should be considered in the differential diagnosis in patients presenting in postoperative period with unexplained headache, confusion, and altered sensorium. A high index of suspicion is required to make a diagnosis. Computed tomography scan or magnetic resonance imaging of the brain is required to establish the diagnosis. Most cases respond favorably to conservative treatment. However, occurrence of tension pneumocephalus is a life-threatening condition and might require urgent neurosurgical intervention.
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Learning curve of tubular micro-endoscopic decompression in patients with degenerative lumbar canal stenosis over 200 cases p. 238
Sanyam Jain, Vishal Kundnani, Neilakou Kire, Zahir A Merchant, Jwalant Patel
DOI:10.4103/isj.isj_24_19  
Introduction: Tubular micro-endoscopic decompression is a technically demanding surgical technique involving familiarity of microscope handling with surgical and radiographic anatomical planning. Understanding the learning curve is necessary to delineate the problems faced during initial cases to reduce the complication rates and set guidelines for safe spine surgery through educational and training programs on bone-saw models and organizing workshops to enhance the standard of health care with improvement in surgical skills. Aims and Objectives: The aim of this study was to evaluate the learning curve of tubular micro-endoscopic decompression in patients with degenerative lumbar canal stenosis based on surgical and clinical parameters and delineate the challenges faced in early cases in long series of patients. Materials and Methods: Study design. Retrospective analysis of prospectively collected data. Study cohort. Data of first 220 consecutive patients with single-level degenerative lumbar canal stenosis managed with tubular micro-endoscopic decompression surgery from 2010 to 2016 with a minimum two-year follow-up were retrieved. Methodology. First 200 patients available at the final follow-up were divided into quartiles (50 each) as per the date of surgery with each consecutive group serving control for prior. Preoperatively and postoperatively clinical parameters (pain scores: visual analog scale [VAS]; functional disability: oswestry disability index [ODI] score), perioperative (operative time, blood loss, and hospital stay), technical issues (guide wire migration, tube docking-related problems, and dural tear), and postoperative complications (postoperative leg pain, neural injury, infection, and recurrence) were evaluated. Statistical analysis. The logarithmic curve-fit regression analysis and analysis of variance test were used to find the asymptote. Results: The mean age of patients was 61.81 years (ranging from 39 to 85) with male-to-female ratio of 121:79 with no significant difference among the quartiles. Statistically significant differences (P < 0.005) were noted in mean operative time (q1 = 109 min, q2 = 69.4 min) and mean blood loss (q1 = 110.6 mL, q2 = 69.6 mL) between the first and second quartiles with no further significant reduction in the third and fourth quartiles.Statistically significant differences (P < 0.005) in clinical parameters (VAS preoperative/postoperative 6.7/1.43; ODI preoperative/postoperative 39.08/12.63) were noted but were not associated with surgical experience. Hospital stay time did not show any significant difference among the quartiles.Guide wire-migrated issues, neural injury, dural tear, and tube docking-related problems significantly reduced after q1. However, recurrence occurred at any phase. Infection occurred in one patient in the first quartile.Although blood loss and operative time showed a declining trend, it was not significant after the second quartile. Therefore, asymptote lay in the first quartile; however, we recommend that novice surgeon should perform 50–100 cases to achieve mastery in this technique as different surgeons have different learning abilities. Conclusion: For mastering the art of tubular micro-endoscopic decompression for lumbar canal stenosis and to reduce its learning curve, novice surgeons can avoid the challenges and problems faced during initial cases with improvement in surgical skills by doing practice on cadavers and bone-saw models following certain recommendations that we came through our learning curve of surgical experience so that the results of their initial surgery are similar to the results that we had after achieving asymptote. Familiarity with instrumentation, communication between surgical team, and defined expectations from radiology technician are the keys to reduce the learning curve.
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Postoperative fungal discitis in immune-competent patients: A series of five patients p. 243
Arpit S Upadhyay, Mihir R Bapat, Bharat K Patel, Amandeep Gujral
DOI:10.4103/isj.isj_41_19  
Introduction: Postoperative fungal discitis is a rare phenomenon and sparse data are available concerning the cause and adequate treatment guidelines especially in immune-competent patients. This case series reports fungal spondylodiscitis in five immune-competent patients after minimal access spine surgery. Study Design: Retrospective observational study. Materials and Methods: Retrospectively five patients with postoperative fungal discitis were studied. Spine radiographs, gadolinium contrast magnetic resonance imaging, and hematological markers (erythrocyte sedimentation rate/C-reactive protein) were performed in all patients. All patients underwent posterior debridement and stabilization procedure followed by antifungal therapy at our center. The clinical outcomes in the form of Oswestry disability index (ODI) and visual analog scale (VAS) scores were recorded before index surgery, 3 months, and at final follow-up. Results: All patients, four men and one woman with an average age of 55.2 years (45–61), had primary coincidental minimal access spine surgery. The average delay from the primary surgery to onset of pain was 6.4 weeks (4–10 weeks). The average delay from the onset of symptoms, postprimary surgery to secondary surgery, at the author’s institution was 13.2 weeks (11–16 weeks). Preoperative values of ODI and VAS were significantly decreased from 78.8 and 8.2 to 14.4 and 1.4, respectively, at the final follow-up. There was one case of recurrence at adjacent level 3 months after antifungal treatment requiring a revision surgery and recommencement of antifungal treatment. Conclusion: A high index of suspicion is required for prompt diagnosis. Fungal study should be routinely included in tissues biopsied for infective etiology. Antifungal treatment of adequate duration with surgical debridement and stabilization should be the mainstay of treatment.
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CASE REPORTS Top

Multilevel noncontiguous spinal fractures in adolescent idiopathic scoliosis: A report of three cases p. 250
Chris Yin Wei Chan, Kumar Shantanu Anand, Mun Keong Kwan
DOI:10.4103/isj.isj_44_19  
This is a report of three cases of patients with Adolescent Idiopathic Scoliosis who presented with multilevel noncontiguous fractures of the spine. Interestingly, the apical vertebrae of the scoliotic curve were involved in all these three cases. The first patient had a fracture at apical T7 of the main thoracic curve and a fracture dislocation at apical L1 at the compensatory lumbar curve. In the second patient, the fractures occurred at the apex of a lumbar major curve and the compensatory main thoracic curve at L2 and T8, respectively. In the third patient, one of the four fractures occurred over the apex of thoracic curve at T8. Therefore, when a patient with idiopathic scoliosis presents following a high-energy accident, a higher index of suspicion should be maintained to diagnose multilevel fractures, especially over the apical vertebrae. Minimally Invasive Stabilization technique is useful in the stabilization of multilevel noncontiguous spinal fractures in these patients.
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A rare case of spontaneous pseudomeningocele with lytic spondylolisthesis p. 254
Paresh B Bang, Bharat R Dave, Devanand Degulmadi, Ajay Krishnan
DOI:10.4103/isj.isj_20_19  
Pseudomeningocele is an extra dural collection of cerebrospinal fluid arising from dural defect secondary to incidental durotomy, trauma or congenital. Lytic spondylolisthesis as a cause of dural defect leading to pseudomeningocele has been rarely reported. Pars defect in lytic spondylolisthesis has been documented to have highly organized collagen bundles and calcified fibro cartilaginous enthesis which probably leads to dural injury. We report a case of 56 year old female with grade 2 lytic spondylolisthesis at L4-L5 associated with spontaneous pseudomeningocele. During surgery CSF leak was noted with dural defect and herniated rootlets entangled in facet capsule. Underlying pathogenesis, imaging, surgical findings and management are discussed.
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Technological advancements that can be adopted for performing a safe vertebral column resection p. 258
Arun-Kumar Kaliya-Perumal, Jacob Yoong-Leong Oh
DOI:10.4103/isj.isj_17_19  
Recent technological advancements have reduced the risks involved in vertebral column resection (VCR) with a wide range of tools that can be adopted. We intend to highlight the importance of these tools for performing a safe VCR. The patient, a 35-year-old man, presented with hyperkyphotic thoracic spine and symptomatic thoracic myelopathy. Radiological evaluation showed anterior wedging and fused T6-T7 vertebra, resulting in a gibbus deformity causing significant canal stenosis. Hence, T3-T10 posterior stabilization, T5-T8 decompression, and T6-T7 VCR and anterior column reconstruction were planned. We used recent technological advancements such as: (1) three-dimensional printed spine model for preoperative planning, (2) multimodal intraoperative neuromonitoring, (3) ultrasonic bone debulking, and (4) computed tomography–based image-guided spinal navigation. These advancements have made spine surgery relatively safer, predictable, and precise. Moreover, the field is constantly evolving. Hence, adapting to these advancements and utilizing it in complex scenarios are highly beneficial.
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Psoriasis complicating wound healing after minimally invasive lumbar spinal fusion p. 265
Quan You Yeo, Arun-Kumar Kaliya-Perumal, Jacob Yoong-Leong Oh
DOI:10.4103/isj.isj_51_19  
Postoperative infections after spine surgery can be frustrating for the patient and the surgeon. Particularly, in a patient with psoriasis, the altered genetic and cellular defense mechanisms result in a higher risk of infection that can be difficult to manage. We encountered a 55-year-old woman with multiple plaque psoriasis and psoriatic arthropathy for 15 years, who underwent L4-S1 navigation-assisted minimally invasive fusion procedure for symptomatic lumbar spondylosis while under perioperative systemic antipsoriatic medications. During the early postoperative period, blistering and operative site infection complicated the wound-healing process. The patient developed what appeared to be a pustular flare of psoriasis with widespread erythema and desquamating plaques over multiple areas. The wounds remained nonhealing with marginal necrosis that demanded repeated debridement procedures. Ultimately, negative-pressure dressing was the only modality that prevented the spread of infection, induced healthy granulation, and enhanced wound contraction. Such an extensive dermatological condition with superadded infection complicating wound healing after spine surgery is rarely reported. These conditions can be difficult to manage and require a multidisciplinary approach involving the surgeon, dermatologist, and infectious disease physician.
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