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   Table of Contents - Current issue
January-June 2023
Volume 6 | Issue 1
Page Nos. 1-114

Online since Saturday, February 11, 2023

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Complications in spine surgery: Awareness and action commentary p. 1
Gomatam Vijay Kumar, Naresh Babu
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Adjacent segment disease: Current evidence and the role of motion preservation technologies p. 3
Nirdesh Hiremaglur Jagadeesh, Kuldeep Bansal, Harvinder Singh Chhabra
Spinal fusion is gold-standard treatment for degenerative disc disease (DDD) both at cervical and lumbar spine, and it is time tested. Perhaps it has its bundle of complications. Elimination of motion results in accentuated degeneration of adjacent segments leading to adjacent segment degeneration radiographically and, if symptomatic, leads to adjacent segment disease. There is still a debate on whether there is such an entity or whether it is a manifestation of natural history or an iatrogenic phenomenon. Motion preservation surgeries were developed to address the same issue, which includes total disc replacement, nucleus replacement, interspinous implants, and dynamic posterior stabilization systems. The primary goal of motion preservation surgery is to maintain normal or near-normal motion in an attempt to prevent adverse outcomes, which are commonly seen with conventional spinal fusion, most notably the development of adjacent-level DDD. A search was conducted in PubMed using the terms (“adjacent segment”) AND (“disease” OR “degeneration” or “pathology”). Then the articles were shortlisted based on time of publication (2005 onward), publication in English and inclusion of human subjects. This resulted in 253 articles. Another search for ((“Motion preservation”) AND (“Spine”)) OR (“Adjacent segment disease”) OR (“Adjacent segment pathology”) OR (“Adjacent segment degeneration”) yielded 76 articles. This narrative review discusses various issues pertaining to the current evidence regarding adjacent segment disease (ASD), including the controversy on whether ASD is actually an entity, its etiopathogenesis, clinical features, as well as the role of motion preservation technologies to reduce its incidence. There is still enthusiasm and concerns regarding the benefits of motion preservation surgery since it is still an area of ongoing research.
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Intraoperative neuromonitoring in spine surgery: Does it reduce neural complications? Current evidence Highly accessed article p. 15
Saumyajit Basu, Kushal Gohil
Abstract The objectives were to review the evidence on whether intraoperative neurophysiological monitoring (IONM) sensitively and specifically detects intraoperative neurologic injury during spine surgery and whether it reduces neurological complications in spine surgery. A systematic literature review and meta-analysis were conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and studies spanning 1990–2022 were searched. The diagnostic accuracy of somatosensory evoked potentials (SSEPs) and motor-evoked potential (MEP) in predicting postoperative neurologic outcomes in spine surgery was assessed. We also analyzed clinical comparative studies that compared patients who underwent spine surgery with and without IONM to determine the rate of new neurologic events. Fifty studies that provided exact SSEP or MEP changes and postoperative neurological outcomes were analyzed. The features of SSEP changes included low sensitivity (67.7%), high specificity (94.1%), and strong negative predictive value (NPV) (92.1%). For the assessed alarm criteria of a 50% reduction, a 65% reduction, an 80% reduction in amplitude, and a total signal loss, the sensitivity and specificity values for MEP were 87.4%, 100%, 100%, and 100%, and 94.8%, 97%, 94.5%, and 90.5%, respectively. A random effects model was used to assess six research that compared neurological events with and without the use of IONM. The pooled Odds ratio was 0.5746 (confidence interval = 0.48; 0.67), z = 6.637, and the P value was 0.0001. The usefulness of IONM in detecting neurological events during spine surgery is well demonstrated by a growing body of research. However, prospective trials with high-level data are lacking to establish its efficacy in preventing new neurological deficits.
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Complications of growing rod technique for early onset scoliosis p. 27
Abhishek Srivastava, Anuj Gupta, Vikas Hanasoge, Arvind Jayaswal
Early onset scoliosis (EOS) is defined as scoliosis occurring in children less than 10 years of age. The EOS is a separate entity of discussion as development of lungs is restricted due to restricted growth of the chest wall, unlike in adolescent scoliosis which is more of a cosmetic problem. Therefore, in EOS, control of deformity at early stage and growth of the spine should go hand-in-hand. The most favored option in recent era is growing rods which allow growth of the spine but in a controlled manner. However due to fusionless nature, these techniques have high rate of complications. The complications primarily include implant related, wound related, and anesthetic complications. Recently impact of multiple surgeries on psychology of developing child has been reported. This narrative reviews the literature about complications associated with growing rod surgeries in EOS.
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Role of robotics and spinal navigation in reducing surgical complications p. 37
Guna Pratheep, Chandhan Murugan, Shanmuganathan Rajasekaran, Ajoy Prasad Shetty, Rishi Mugesh Kanna
Spine surgery has witnessed exponential technological innovation over the past few decades to overcome the challenges of complex surgeries, reduce complications, and increase safety. Advancements have occurred in biologics, implants, operative techniques, and equipment such as navigation and surgical robotics. In addition to patient safety, these technologies protect the operating personnel from the harmful effects of radiation. Navigation provides simultaneous and multiplanar visualization of anatomy, real-time feedback of instruments, and implant position, which, in turn, improves the accuracy and hand–eye coordination of the surgeon. Robotics further improves outcomes by reducing human error through increased precision in execution, indefatigability, motion scaling, and tremor filtration via mechanical actuation. This review provides an overview of the current navigation and robotic systems in spine surgeries and their role in the safety and prevention of surgical complications.
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Managing complications: Communication and medicolegal aspects p. 48
Krishnendu Mukherjee, Rik Mukherjee, Jayanta Das
Complications are neither entirely predictable nor preventable in the practice of spinal surgery. Communications, particularly the pre-operative consent, play an important role in the management of complications. Patient dissatisfaction leading to complaints and legal proceedings are common and expected sequelae to complications. This article is an overview of important aspects of doctor–patient communication and the relevant legal issues including the principles followed by the judicial system in India while adjudicating on alleged medical negligence.
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Complication that resulted in a change in my practice: Case scenarios p. 54
Naresh Babu Jambuladinne, Prajwal Gollahalli Shivashankar, Bhavuk Garg, Arvind Gopalrao Kulkarni, Priyambada Kumar, Pramod Vasant Lokhande, Bharat Rajendraprasad Dave
Over recent decades, the surgeries for spinal disorders have grown exponentially. Overall reported occurrence of complications in spine surgery is 16.4%. With the increased incidence of complications in spine surgeries, clinicians focused on the prevention of risk factors related to the onset of complications. Here we discuss four case scenarios with varied complications occurring in each case, namely (1) a case of proximal junctional failure, (2) placement of pin or guide wire first in minimally invasive transforaminal lumbar interbody fusion surgery, (3) a case of complication with endoscopic posterior cervical discectomy, and (4) few cases of complications with vertebroplasty.
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Pre-operative halo-gravity traction in the treatment of complex spinal deformities: What do we know so far?: A systematic review p. 65
Guna K Pratheep, Vibhu K Viswanathan, Sakthivel R R Manoharan
Spinal deformity surgeries are complex procedures associated with a high risk of complications. Halo-gravity traction (HGT) is a useful option that provides a gradual traction force to aid in deformity correction. Though its benefits are well-acknowledged, there still exist major ambiguities regarding its role in the management of complex spinal deformities. We performed a systematic review of the electronic databases including EMBASE, MEDLINE, PubMed, and Cochrane on November 12, 2021 to identify relevant articles on HGT; to analyze the existing literature on pre-operative HGT; and to compare the existing protocols for HGT in spinal deformity patients, its varied effects on the radiological parameters and general health status of the patients, and its associated complications. Among the 284 articles available in the literature, 34 articles were finally included and a total of 1151 patients [mean age, 14.6 years] were analyzed. Mean pre-traction coronal Cobb angle of 107° (72°–140.7°) was reduced by 24.8% [to a mean of 80.5° (42°–120.2°)] following HGT. Mean pre- and post-traction sagittal Cobb angles were 88° (56°–134.7°) and 65.4° (36°–113°; a reduction by 25.7%), respectively. Following HGT, mean body weight and body mass index (BMI) of patients improved by 7.2% and 9.1%, respectively. Mean improvement in forced vital capacity and forced expiratory volume has been reported to be 14.5% and 13.9%, respectively. Pre-operative HGT is a useful option in the treatment of spinal deformities. It aids in reducing curve magnitude and provides optimal time for improving general condition (pulmonary and nutritional status) of patients pre-operatively. It is a safe procedure with 2.1% neurological and 11.6% non-neurological complication rates.
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Contralateral sacral 1 root transection and transfer for lumbosacral plexus avulsion injuries: A systematic review p. 76
Pawan Agarwal, Dhananjaya Sharma
Contralateral sacral roots (cS1) transfer to treat avulsion injuries of lumbosacral plexus (LSP) has been described, however; concerns about its safety remain. We performed a systematic review of a hypothesis regarding safety of cS1 transection and transfer for treatment of LSP avulsion injuries from available studies. A literature search on Pub Med, Cochrane database and Goggle scholar was performed using appropriate key words for choosing relevant articles. Two authors independently assessed the methodological quality of selected articles using Brink’s criteria and results were analysed using level of evidence. The literature search retrieved a total of 877 publications; out of which 9 articles met the inclusion criteria and were reviewed. 6 articles were investigated for both the reliability and validity and 3 articles evaluated qualitatively; all were of limited quality. Though all studies showed that cS1 nerve root transfer leads to improvement in motor power of muscles and sensory recovery neurotised by cS1 with transient donor site morbidity however; evidence is limited. cS1 nerve root transection and transfer for the repair of LSP avulsion injury appears to be a safe option but the evidence is limited and further validation of this finding is needed.
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The perspectives of patients and spine surgeons on the effectiveness and reliability of telemedicine consultations for spine ailments—A glimpse at the Indian scenario p. 82
Vibhu Krishnan Viswanathan, Ajoy P Shetty, Chandhan Murugan, Rohit A Kavishkar, Rishi M Kanna, Shanmuganathan B Rajasekaran
Introduction: In view of the ongoing pandemic, telemedicine has been increasingly adopted worldwide. This study was planned to evaluate the effectiveness of telemedicine for patients with spine ailments, and to assess the satisfaction rates and concerns of spine surgeons and patients regarding telemedicine consultations in the Indian scenario. Materials and Methods: Telemedicine appointments for spine patients were conducted through “Zoom Healthcare” online platform between April and December 2020 in a tertiary-care spine center. Questionnaires (including nine and five questions, respectively) were filled by patients and doctors after their consultations. The questionnaire included questions on overall satisfaction, time consumption, ease of setting-up appointment, ease of communication, influence on decision-making, and patient preference. Results: Overall, 70.1%, 23.6%, and 6.3% of patients replied that they were “very satisfied,” “satisfied,” and dissatisfied,” respectively, with their telemedicine appointments. Among postoperative follow-up patients, 69%, 30.2%, and 0.8% expressed that they were “very satisfied,” “satisfied,” and dissatisfied,” respectively, with telemedicine. At the end of session, 88.5% patients opined that they would still prefer a telemedicine appointment for the completed consultation, and 93.4% were happy to use telemedicine for future visits. In all, 100%, 94.1%, and 75% of patients, who belonged to other countries, other cities, and same city, respectively, were satisfied or very satisfied from telemedicine consultations. The doctor’s responses were “very satisfied” or “satisfied” on 96.5% of occasions overall. The doctors required approximately 24.1 min for conducting a telemedicine appointment. Three major concerns for doctors included difficulty in procuring good-quality magnetic resonance imaging (17%), problems with connectivity (14.6%), and difficulty in eliciting certain physical findings (13.2%). Conclusion: Telemedicine is an effective alternative to in-person visits for the assessment of patients with spine ailments. Patients belonging to more distant geographic locations (as compared with local residents) and those requiring postoperative follow-ups can be significantly benefited by this modality.
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Impact of location on resectability and neurological outcome in spinal cutaneous inclusion tumors p. 89
Sundus Ali, Fauzia Sajjad, Adnan Qasim, Anwar M Chaudhary, Akmal M Azeemi, Asif Shabbir
Background: Spinal cutaneous inclusion tumors are extremely rare, accounting for less than 1% of intraspinal tumors. The existing literature is scarce; in last two decades, only eight case series have documented more than 10 patients. We tried to figure out if intramedullary and extramedullary locations have an impact on outcomes in terms of extent of resection and neurological recovery. Materials and Methods: A retrospective review of intraspinal epidermoid and dermoid tumors operated at our Neurosurgical Department, between May 2006 and May 2021, was made. McCormick grading was used to evaluate the neurological status of all patients at presentation, after surgery, and at the follow-up visit in the outpatient clinic. The neurological status at the last follow-up was taken as final. Results: Of 15 cases, eight (53.3%) were males with the age at presentation ranging from 7 to 60 years (mean = 24.4 years). Spinal dysraphism was associated in four patients. The proportion of region involved in descending order was lumbar (46.6%), thoracic/thoracolumbar/lumbosacral (13.3% each) and cervicothoracic/sacrococcygeal (6.6% each) with 11 gross total resections (73.3%) and four subtotal resections (all intramedullary). Two-tailed Fischer’s exact test showed a significant correlation between location, extent of resection, and neurological recovery, whereas histological subtype and region had no significant impact on the outcome. Conclusions: To the best of our knowledge, this is the eighth largest study in the last two decades, reporting 15 cases with long-term follow-up. We attempt to bring clarity to the notion of location having no effect on resectablity by specifying location in terms of spinal compartment involved and describing spinal level as region. Overall, our gross total resection rate was lower (73.3%) than other contemporary studies (86.6%–92%), but a subgroup analysis with regard to the location of tumor revealed the intramedullary location to be the primary determinant of the extent of resection.
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Isolated spinal intramedullary neurocysticercosis: Case report and review of literature p. 96
Selvin P Vijayan, Christopher Gerber, Anindya Basu, Radhika Mhatre
Cysticercosis is the most common parasitic disease of the central nervous system but an isolated spinal intramedullary involvement is very rare. We present one such case of a 68-year-old female who had spastic paraplegia with bladder involvement. Magnetic resonance imaging (MRI) revealed D3 intramedullary space-occupying lesion. She was treated with surgical excision and her diagnosis was confirmed to be cysticercosis by histopathological examination. With appropriate post-operative rehabilitation and medical management, she was found to have significant recovery. At final follow-up, she was walking with aid and regained her bladder control. A high index of suspicion is required in endemic zones, like India, when the MRI shows an unusual picture of space-occupying intramedullary lesions. With early diagnosis and initiation of treatment, neurocysticercosis (NCC) shows better prognosis than what was previously known.
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Anterior cervical discectomy and fixation fusion for Hirayama disease in a young male: Case report p. 101
Ashish Gupta, Rajesh Kumar Bharti
Hirayama disease (HD) is a rare, monomelic amyotrophy described by Hirayama in 1959. The condition is caused by chronic ischemic changes to the anterior horn cells of the cervical spine, caused by posterior dural sac laxity. It is a nonprogressive and self-limiting disease and has been noted to be a source of significant disability for affected young individuals. Early surgical intervention in HD limits the progression and thus decreases the degree of disability.
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A rare case of posterior spinal cord syndrome following commando surgery: A case report and review of literature p. 106
Bharat R Dave, Saral J Patel, Ravi B Patel, Akruti M Dave
A 60-year-old male who underwent commando surgery for oral cancer in a supine position and 20-degree neck extension developed sensory ataxia with a loss of proprioception in bilateral lower limbs and hands in the immediate postoperative period. The magnetic resonance imaging (MRI) of brain and screening of spine done within 6 h of surgery indicated a degenerative cervical canal stenosis from C3 to C7 level. A final diagnosis of posterior spinal cord syndrome (PCS) was made after excluding other causes clinically and radiologically. Emergency surgical decompression in the form of C3–C7 laminectomy and intravenous methylprednisolone were administered within 12 h of index surgery. An early diagnosis and treatment resulted in a good neurological recovery by the seventh postoperative day and he was ambulatory with minimal support at 3-month follow-up.
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Spinal hemangioblastoma causing a holocord syrinx: A report of two cases and review of literature p. 110
Tungish Bansal, Devasheesh Kamra, Sachin Borkar
Intramedullary spinal hemangioblastomas are often associated with syringomyelia. However, holocord syrinx associated with such lesions is a rare entity. We present two cases of dorsal spinal hemangioblastoma associated with holocord syrinx. Both the cases were treated with surgical excision which resulted in the resolution of holocord syrinx and good neurological recovery. In this case report, we discuss the various aspects of the diagnosis and surgical management in such cases. We also present an extensive review of literature of such lesions.
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