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   Table of Contents - Current issue
Coverpage
January-June 2021
Volume 4 | Issue 1
Page Nos. 1-145

Online since Wednesday, January 27, 2021

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EDITORIAL  

Optimism in COVID Times Highly accessed article p. 1
Manish Chadha, Anil K Jain
DOI:10.4103/ISJ.ISJ_4_21  
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ASSI ESSAY WRITING COMPETITION - FIRST PRIZE Top

COVID-19 Pandemic: Tapping opportunities in the face of adversity Highly accessed article p. 2
Rishi M Kanna
DOI:10.4103/ISJ.ISJ_1_21  
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ASSI ESSAY WRITING COMPETITION - SECOND PRIZE Top

COVID-19 pandemic: Tapping the opportunity in the face of adversity p. 4
Rohit Amritanand
DOI:10.4103/ISJ.ISJ_7_21  
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COVID-19 Pandemic: Tapping the opportunity in the face of adversity p. 6
Vibhu Krishnan Viswanathan
DOI:10.4103/ISJ.ISJ_96_20  
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ASSI ESSAY WRITING COMPETITION - THIRD PRIZE Top

COVID-19 pandemic: Tapping the opportunity in the face of adversity p. 8
Siddharth N Aiyer
DOI:10.4103/ISJ.ISJ_3_21  
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SYMPOSIUM: SPONDYLOLISTHESIS Top

Classification of spondylolisthesis: Current concepts p. 10
Sahil Batra, Bhavuk Garg
DOI:10.4103/ISJ.ISJ_61_20  
The restoration of global sagittal balance has become the keystone over the past decade. Various classification systems have been proposed for lumbosacral spondylolisthesis. This article describes the evolution, validation, and usage of these classification systems in the clinical setting in the current scenario.
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Current concepts in the treatment of degenerative spondylolisthesis p. 18
Kenny Samuel David, Nischal Ghimire, Venkatesh Krishnan, Rohit Amritanand, Justin Arockiaraj
DOI:10.4103/ISJ.ISJ_63_20  
Degenerative spondylolisthesis is one of the commonest spinal pathologies encountered in the aging population. The clinical presentation of degenerative spondylolisthesis can be highly variable, and a large proportion of patients can be managed non-operatively. Operative treatment is reserved for patients with activity limiting disability. Decompression alone can be offered to patients with no radiological or clinical evidence of segmental instability. Fusion procedures have shown high rates of clinical success, although long-term effects such as adjacent segment degeneration have spurred the evolution of non-fusion technologies. These newer options have shown evidence of motion preservation, although long-term clinical benefits have yet to be confirmed.
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Spondylolysis and pars repair technique: A comprehensive literature review of the current concepts p. 29
KS Sri Vijay Anand, Naresh Kumar Eamani, Ajoy Prasad Shetty, S Rajasekaran
DOI:10.4103/ISJ.ISJ_65_20  
Spondylolysis is an important cause of low back pain in children and adolescents, especially in those involved in athletic activities. Spondylolysis is caused either by a fracture or by a defect in the pars inter-articularis and can be unilateral or bilateral. Among the various hypotheses regarding the etiopathogenesis of pars lysis, the occurrence of chronic micro-fractures secondary to repetitive extension and rotational stresses across pars remains the most convincing explanation to date. The majority of these patients remain asymptomatic. Imaging contributes to the staging and prognostication of the lesions, planning the line of management, and monitoring the response to treatment. Nonoperative treatment with activity restriction, braces, graded physiotherapy, and rehabilitation forms the cornerstone of management. Surgery is indicated in a specific cohort of patients whose symptoms persist despite an adequate conservative trial and includes spinal fusion and pars defect repair techniques. Patients who demonstrate good pain relief after diagnostic pars infiltration can be considered for pars repair. Patients aged ≤25 years, those with an athletic background, unilateral pathologies, and those without associated spondylolisthesis, instability, or disc degeneration are ideal candidates for pars repair. The overall outcome in spondylolysis is good, and 85% to 90% of athletes return to sports at 6 months following conservative or surgical line of treatment. In this current narrative review, we comprehensively discuss the etiology, patho-anatomy, natural history, clinical features, diagnostic modalities, and management of spondylolysis with special emphasis on direct repair techniques of pars.
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Lateral and oblique interbody fusions in degenerative and isthmic spondylolisthesis p. 40
Ganesh Swamy, Vishwajeet Singh, Nathan Evaniew, Kenneth C Thomas
DOI:10.4103/ISJ.ISJ_66_20  
While symptomatic degenerative and isthmic spondylolisthesis cause pain and surgical management improves quality of life, it is less clear which surgical strategies are most helpful. In this review, we seek to outline the accuracy and reliability of classification schemes and suggest how machine-learning tools can potentially help identify optimal surgical strategies for individual patients. In addition, we examine the role of new surgical strategies in degenerative and isthmic spondylolisthesis, namely using lateral and oblique interbody fusions. Herein we discuss lateral and oblique interbody fusions in spondylolisthesis within a framework of accepted surgical goals, sagittal plane balance considerations, and cost-effectiveness.
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Traumatic lumbar spondylolisthesis: current concepts and a literature review p. 52
Kamran Farooque, Santanu Kar
DOI:10.4103/ISJ.ISJ_72_20  
The aim of the study was to review published literature on traumatic lumbar spondylolisthesis. Traumatic spondylolisthesis of the lumbosacral region is a relatively rare but serious spinal injury necessitating careful clinico-radiological evaluation and management for a successful outcome. Limited literature is available to date to guide clinicians to treat the injury comprehensively. This article analyses the published literature and promulgates an evidence-based management plan for this injury. PubMed, Cochrane, Scopus, Google Scholar databases were searched using the keywords “traumatic lumbar” AND “spondylolisthesis” following PRISMA guidelines. In total, 118 relevant articles were considered for full-text review; among them, 68 articles were finally selected for the analysis. In each article, the pathomechanism; clinical and radiological features; classifications; indications for nonoperative and operative management; operative approaches, techniques, and rehabilitation; and long-term outcomes were analyzed. Traumatic lumbar spondylolisthesis is high-energy spine trauma requiring thorough evaluation. Radiographs are the initial investigation technique used in the emergency department, computed tomography scans define the bony details of the injury, and magnetic resonance imaging is important for deciding the treatment protocol depending on the disc injury. Decompression and instrumented fusion are the standard treatment protocol. A satisfactory outcome is to be expected in the majority of cases.
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Surgical management of high-grade spondylolisthesis: Current recommendations p. 65
Karthik Kailash, Sudhir Ganesan, Nalli Ramanathan Yuvaraj, Appaji Krishnan, Charanjith S Dhillon, Kalale Sudarshan Pramod, Saikrishna Gadde
DOI:10.4103/ISJ.ISJ_64_20  
Spondylolisthesis is the slippage of one vertebra over the adjacent vertebrae and a usual cause of low back pain and spinal imbalance. High-grade spondylolisthesis (HGS) is defined as Meyerding grades III, IV, and V or greater than 50% anterior translation of vertebrae resulting in spinal canal stenosis and neural compression. Management of HGS has been varied and fraught with opinions and its spectrum of management consists of in situ fusion, fusion and reduction combination techniques and vertebrectomy. Literature review was done on the various modalities of treatment and studies showed good clinical outcomes with the procedures. This review highlights the biomechanics of HGS and spondyloptosis, description of techniques of in situ fusion, reduction and fusion and, thereby, evaluate and give current recommendations in the surgical management of HGS. A systematic search of PubMed, Cochrane, and Google Scholar for papers relevant to HGS was performed. Twenty-one articles were included after title, abstract, and full-text review and grouped to analyze the effect of surgical approach, instrumentation, reduction, and decompression on patient radiographic and clinical outcomes. The level of evidence was low in ascertaining the superiority of one technique over the other. HGS is a complex disorder that can be addressed with varying procedures for it. No single technique has been proven to be better than the other. Each of the procedures described earlier has their own advantages and disadvantages, and these have to be weighed with the clinical scenario and the individual skill level of the treating surgeon before deciding on the appropriate procedure. The ideal recommendations for doing the above procedures were enumerated. However, no single procedure can be taken as the best fit for the given condition as the literature does not show one to be better than the other.
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Complications in spondylolisthesis surgery: Common, uncommon, and rare p. 77
Sameer Ruparel, Ram Chaddha
DOI:10.4103/ISJ.ISJ_71_20  
Spondylolisthesis is a common pathological condition caused due to numerous etiologies in young and old alike. The forward slippage of one vertebra over the other alters the biomechanics to an extent that can result in various postoperative complications. The most common complications reported are pseudoarthrosis, neurological deficits, and transitional syndrome. The rate of pseudoarthrosis varies based on etiology as well as various intraoperative factors. The authors reviewed the literature for the varying incidence rates and suggest principles of reduction and fusion based on evidence and experience. Similarly, neurological complications are a common occurrence postoperatively particularly in the treatment of high-grade slips. Percentage of reduction of slips, slip angle, and traction injury to nerve roots tend to have a complex interaction leading to neurological injuries. The authors try to decipher this co-relation based on literature. Though most neurological issues have been found reversible, recent innovations like intraoperative neuromonitoring tend to decrease its incidence even further. The development of transition syndrome is an enigma in itself. Whether increased stresses at adjacent levels are due to fusion or a part of an ongoing degenerative process is yet to be understood. On the basis of case examples, the authors suggest recommendations to avoid them. Finally, minimally invasive spine surgeries (MISS) are now being used to treat spondylolisthesis. The authors reviewed comparative studies between open and MISS and found similar complication rates between them with regards to low-grade slips with a word of caution to treat high-grade listhesis with minimally invasive surgery techniques. Last but not the least, a few unusual and rare complications have been enlisted with case examples and learning points. This manuscript aims at reviewing the common, uncommon, and rare complications of treating cases of spondylolisthesis along with enlisting the principles to avoid and treat them in day to day practice.
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SPINE CLINIC Top

The spine clinics: Spondylolisthesis p. 89
Sahil Batra, Bhavuk Garg
DOI:10.4103/ISJ.ISJ_79_20  
This section of the symposium draws the reader’s attention to various types of spondylolisthesis that are commonly encountered in daily routine practice on the basis of the Spinal Deformity Study Group (SDSG) classification. Each clinical scenario underlines the workup required for such cases along with various technical tips.
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ORIGINAL ARTICLES Top

A prospective comparative study between day care spine surgery and conventional spine surgery p. 99
Chandra Kumar Thounaojam, Sachin A Borkar, Ravi Sharma, Manoj Phalak, Rajeev Sharma, Shashank Sharad Kale
DOI:10.4103/ISJ.ISJ_45_19  
Background: Day care spine surgery though practiced in many centers around the world, is still relatively an unchartered territory here in India, with very few centers performing spine surgeries in a day care setup. Our study was conducted to assess the feasibility of day care spine surgery in our setup. Materials and Methods: This is a prospective observational study in which patients who had undergone spinal surgery (lumbar discectomies, intradural-extramedullary lesions [IDEMs] and extradural space-occupying lesions [SOLs] extending up to one and a half vertebral levels, and one or two level anterior cervical discectomy and fusion [ACDF] in a day care setting) in our department from March 2018 to December 2018, were recruited. Of the 68 patients recruited, 33 were in the day care group and 35 were in the routine group. Data was collected on type of pathology, comorbidities, spinal segment involved, type of surgical procedure; visual analog scale (VAS) score in the preoperative period, immediately after surgery, 12h after the discharge, and at suture removal, length of hospital stay, cost, conversion of the day care to a routine admission, and disability/functional outcome. Results: We found comparable surgical results and postoperative pain profile in both the groups; median VAS in the immediate post-op period was found to be 5 in the day care and 4 in the routine group, at 12h after discharge, it was found to be 4 in both the groups, and at suture removal, it was found to be 2 in both the groups. There was statistically significant decrease in hospital stay and cost with a P value of 0.001 for both. Mean length of hospital stay was 1.15 ± 0.36 days in the day care and 9.66 ± 4.76 in the routine group. Mean cost was 2142.97 rupees in the day care, whereas it was 17971.94 rupees in the routine group. There were no new onset neurological deficits in the day care group. Five cases were converted from the day care group due to various reasons. Conclusion: One and two level lumbar prolapsed intervertebral discs (PIVDs)/canal stenosis, cervical PIVDs, especially single-level PIVD, IDEMs, and extradural SOLs can be performed in a day care setting.
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Do spino-pelvic parameters play a role in development of chronic low backache: A prospective analysis p. 105
Roop Singh, Sushil K Yadav, Rohtas K Yadav, Jitendra Wadhwani, Rajesh K Rohilla, Ravi Rohilla
DOI:10.4103/ISJ.ISJ_83_19  
Introduction: The sagittal spino-pelvic alignment patterns are still poorly understood in patients with chronic low back pain (LBP). Clinical observations suggest that aberrations of posture may play a role in the development of LBP. This study was undertaken with the aim to evaluate spino-pelvic parameters in patients with LBP and with a hypothesis that variation in these may predispose to LBP. Materials and Methods: Fifty patients (26 men and 24 women) with mean age 33.54 ± 8.33 years with a history of LBP of minimum 3 consecutive months constituted the study group and were subjected to standing sagittal spino-pelvic radiographs. Data were analyzed and compared with normative data. Results: The mean values of pelvic incidence (PI) and lumbar lordosis angle (LLA) were 48.52 ± 8.99 and 58.78 ± 9.51, respectively. The correlation of PI with lumbosacral angle (LSA), age, body mass index (BMI), and gender was not significant, but a significant correlation was observed with LLA, pelvic angle (PA), pelvic overhang (PO), pelvic tilt (PT), sacrofemoral distance (SFD), sacral horizontal angle (SHA), and sacropelvic translation (SPT). Sacral inclination angle (SIA), SHA, and PI were found to be significantly positively correlated with LLA, whereas pelvisacral angle (PSA), sacropelvic angle (PRS1), and SPT were found to be significantly negatively correlated. Statistically significant difference was observed only regarding pelvic thickness (PTH) and pelvic radius (PR) between patients with chronic LBP and healthy population. Conclusion: Most significant parameters (PI and LLA) used in spino-pelvic balance assessment have a positive significant correlation with majority of the other parameters and the harmony between them help in maintaining normal spinal column stability and alignment. Variation in some of the spino-pelvic parameters (PTH and PR) may predispose to LBP by putting stresses on the spinal column components and stabilizers.
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Position-related neurovascular injuries detected by intraoperative monitoring p. 113
Shaila Gowda
DOI:10.4103/ISJ.ISJ_59_19  
Background: Poor patient positioning during surgeries can result in vascular and peripheral nerve injuries. The purpose of this study was to analyze the various etiologic factors related to positioning detected by intraoperative monitoring (IOM) and make recommendations for prevention of comorbidities. Materials and Methods: The data for a total of 4450 consecutively monitored patients who underwent orthopedic and neurosurgical procedures were retrospectively reviewed. Patients with signal changes related to positioning detected by IOM were analyzed for position, modalities, timing of interventions, duration of surgery, and etiologic factors. Deficit and non-deficit groups were further compared using Wilcoxon rank sum test. Results: Intraoperative evidence of impending neurologic injury was seen 1.1% times, most frequently due to malpositioning of upper extremities (57%) in prone position (55%). Shoulder tape, bootstrap, thigh/hip pads, sitting and lower extremity malpositioning were other etiologic factors. Appropriate intervention was performed within 3min 66% of the time. Four patients developed new postoperative deficits: brachial plexopathy (n = 3) and bilateral sciatic neuropathy (n = 1). The deficit group had longer duration of surgery (P = 0.031), and neurophysiological (NP) signal changes persisted for an increased time interval (P = 0.0084) when compared to the non-deficit group. Conclusion: Prolonged duration of surgery and persistence of NP signal changes can increase the risk of potential neurovascular injury. Intraoperative neurovascular injuries due to positioning can occur in various settings. Early recognition of signal changes during monitoring and immediate intervention is likely to prevent neurological deficits.
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CASE REPORTS Top

Melorheostosis of spine: A very rare clinical entity p. 121
Jayprakash V Modi, Harshil R Patel
DOI:10.4103/ISJ.ISJ_68_19  
Melorheostosis is a medical developmental disorder and mesenchymal dysplasia in which bone cortex widens and becomes hyperdense in a sclerotomal distribution. Most of the cases reported till now are confined to appendicular skeleton, rarely affecting spine. It is well known by its characteristic appearance of “melting wax flowing down a candle” on radiographs. Here we report a rare case of melorheostosis of thoracic spine in a middle-aged male patient with features of myelopathy treated by early decompression surgery, leading to complete relief of symptoms postoperatively. Final follow-up was of 2 years. It is a very rare, benign and disabling entity, and the diagnosis is primarily a radiological one. Early diagnosis and decompression surgery leads to dramatic improvement in clinical outcome and prevents unwarranted biopsy.
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A seemingly usual case of paraplegia with MRI diagnosis of meningioma: An unexpected course of events leading to inflammatory necrotizing myelopathy p. 128
Punit Tiwari, Harmeet Kaur, Gaurav Sharma
DOI:10.4103/ISJ.ISJ_58_19  
Necrotizing myelopathy is a rare but potentially devastating disease and an important cause of paralysis. Its diagnosis can be challenging inspite of availability of magnetic resonance imaging (MRI) and laboratory investigations. The differential diagnoses of this condition are tuberculosis, Foix–Alajouanine syndrome, transverse myelitis, and spinal tumors. The purpose of this case report was to document the pathological findings of this entity and highlight the misleading tendency of postoperative thick fibrous scar tissue, which may complicate the MRI picture of necrotizing myelopathy and it may masquerade as an intradural meningioma. The spinal cord biopsy is the only way to confirm the diagnosis in suspected cases based on the gradual subacute progression of clinical symptoms and MRI findings of rim-like rather than solid enhancement.
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Myelopathy secondary to isolated thoracic spine involvement mimicking metastasis in Erdheim–Chester disease: A case report and review of literature p. 133
Rajesh Rajavelu, Ajoy P Shetty, Rishi M Kanna, S Rajasekaran
DOI:10.4103/ISJ.ISJ_78_19  
Erdheim–Chester disease (ECD) is a rare non-Langerhans histiocytosis. Appendicular skeleton involvement is more common whereas axial skeletal manifestation is very rare. Isolated thoracic spine involvement with myelopathy in ECD is reported extremely rarely. This case report aims to highlight the isolated axial skeletal involvement in the form of thoracic myelopathy, its diagnostic challenge, various treatment options and prognosis of the disease. We have managed our patient, presented with thoracic myelopathy, by posterior instrumented decompression followed by radiotherapy. This case report will contribute to increased awareness on isolated axial skeletal involvement in ECD.
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Infliximab-related tubercular spinal epidural abscess without osseous involvement in a patient with Crohn’s disease: A case report p. 138
Phani Kiran Surapuraju, Srinivas M., Subramanian Swaminathan
DOI:10.4103/ISJ.ISJ_7_20  
Tubercular spinal epidural abscess without osseous involvement is an extremely rare presentation of spinal tuberculosis. We report a case of perianal Crohn’s disease, who developed a tubercular epidural abscess in lumbosacral spine without osseous involvement, secondary to infliximab administration, despite being on 6 months of antituberculous therapy for perianal tuberculosis even as the primary focus healed well. This is probably the first case of infliximab-related tubercular spinal epidural abscess without osseous involvement. A combination of surgical treatment and antitubercular therapy gives a good outcome. This case highlights the rare and atypical nature of presentation of spinal tuberculosis in this scenario and emphasizes the importance of vigilant follow-up to prevent delayed diagnosis, due to atypical presentations following anti-tumor necrosis factor therapy.
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Spontaneous spinal epidural hematoma: A rare cause of quadriparesis in a young person p. 142
Pavan Pralobh Joga, Pramod Philip Nittala, Anindita Mishra, Vinay Nyapathy
DOI:10.4103/ISJ.ISJ_18_19  
Spontaneous spinal epidural hematoma (SSEH) is a rare condition with an incidence of 0.1 in 100,000 population. These are usually seen in the lumbar region in patients above 40 years and in the cervical and dorsal spine in younger patients. Posterior or dorsal epidural hematomas are more common than ventral hematomas. Patients present with sharp pain in the neck or back with or without neurological deficit. We present a case of a 20-year-old male who presented with quadriparesis and bowel and bladder incontinence for 5 days. No history of trauma or other aggravating factors were present. Magnetic resonance imaging revealed a posterior epidural hematoma with cord compression and edema. Patient underwent surgery and hematoma was evacuated. Patient symptoms improved gradually. Because of the severe preoperative neurological deficit and delay in surgery, patient had mild residual neurological deficit in the early post op period, which resolved over a period of two months
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