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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.
  5,545 366 -
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.
  5,116 451 -
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.
  4,747 454 -
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.
  4,409 579 -
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.
  4,278 438 -
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.
  3,990 485 -
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.
  3,327 540 -
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.
  3,305 482 -
Development of the Marathi version of the Tampa scale of kinesiophobia 11: Cross-cultural adaptation, validity, and test–retest reliability in patients with low back pain
Kiran Harishchandra Satpute, Parag S Ranade, Toby M Hall
July-December 2019, 2(2):146-151
Background: The Tampa Scale of Kinesiophobia-11 (TSK-11) is used to assess fear of movement in patients with musculoskeletal dysfunction. However, for Indian-specific population, this scale is not available. We aim to cross-culturally adapt the TSK-11 into a regional Indian language (Marathi) and to assess its psychometric properties, validity, and reliability. Materials and Methods: The American Association of Orthopedic Surgeons guidelines were used for cross-cultural adaptation and psychometric testing. Psychometric testing included assessment of internal consistency (Cronbach's alpha) and test–retest repeatability (intraclass coefficient correlation), construct validity (Pearson correlation) by comparing the TSK-11 score to a visual analog scale (VAS) of confidence and pain, as well as the Marathi version of Oswestry Disability Index (ODI). Results: A total of 100 individuals with mean age of 38.9 years (Standard deviation = 11.34) completed the translated TSK-11 questionnaire on two occasions with an interval of one day. The translated Marathi version demonstrated excellent internal consistency (α = 0.85) and test–retest reliability (intraclass correlation coefficient = 0.93, confidence interval 95% = 0.90–0.95). There were moderate correlations between the total score of the TSK-11 questionnaire Marathi version and ODI score (r = 0.72), VAS pain score (r = 0.635), and VAS confidence score (r = −0.603). Receiver operating characteristics analysis indicated that the TSK-11 score was significantly able (P < 0.001) to discriminate the presence or absence of kinesiophobia. Conclusion: The Marathi version of TSK-11 is reliable and valid, with psychometric characteristics similar to the original English version. This assessment tool can be recommended to measure movement-related fear in future patient-oriented outcome studies for the Indian Marathi speaking population with low back pain.
  2,375 1,321 -
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.
  3,269 312 -
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.”
  3,237 332 -
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.
  3,042 353 -
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.
  2,997 317 -
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.
  2,639 391 -
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.
  2,518 415 1
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.
  2,601 309 -
A clinical and radiological study of nontraumatic coccygodynia in Indian population
Bharat R Dave, Paresh B Bang, Devanand Degulmadi, Pushpak Samel, Deepak Shah, Ajay Krishnan
July-December 2019, 2(2):128-133
Background: Nontraumatic coccygodynia is poorly understood. Dynamic radiographs help to identify a radiological lesion. This study was performed to evaluate these parameters and define a line of management. Materials and Methods: A total of 46 cases with nontraumatic coccygodynia and 46 controls who met the inclusion criteria were evaluated using dynamic radiographs between June 2015 and May 2017. Radiological parameters, such as sagittal movement of coccyx, intercoccygeal angle (ICA), base angle (BA), and angle of pelvic rotation (APR), were calculated and compared between cases and controls to identify the radiological lesion in cases. On the basis of clinico-radiological findings, a treatment algorithm for these patients was proposed. Results: A total of 46 cases and 46 controls were studied. The mean age was 41.8 years in cases and 40.6 years in controls. Body mass index (BMI) ranged from 19 to 33. Twenty-nine cases had BMI >25. Average visual analog scale score at initial presentation (6.9), at 6 weeks (4.7), and final follow-up (3.9) was noted. ICA ranged from 1° to 21° (mean 11.12°). BA ranged from 0° to 83° (mean 41.41°). APR ranged from 2° to 33° (mean 14.74°). Twenty-seven patients had a good relief with local hydrocortisone injection and manipulation, whereas nine cases needed coccygectomy. Conclusion: Dynamic radiographs help in defining the radiological parameters and planning treatment. The sagittal movement of extension, posterior subluxation, higher BA, and low APR are the radiological findings seen in patients of nontraumatic coccygodynia. Majority of patients respond to conservative management; however, few may need surgical intervention.
  2,503 243 1
Ossification of the posterior longitudinal ligament: Etiology, prevalence, progression, and surgical strategies
Yoshiharu Kawaguchi
January-June 2019, 2(1):52-58
Ossification of the posterior longitudinal ligament (OPLL) is characterized by replacement of the ligamentous tissue by ectopic new bone formation. OPLL often causes narrowing of the spinal canal and has been recognized as a cause of cervical myelopathy and/or radiculopathy. Although a clear inheritance of OPLL has not been identified, there is a strong genetic background for OPLL. A recent genome-wide association study using all Japan cohort reported that there were 6 susceptible loci for OPLL. In addition, there were several studies to seek the biomarkers of OPLL. OPLL is frequently found in the cervical spine. However, 53.4% had OPLL not only in the cervical spine, but also in other spinal regions in patients with cervical OPLL. Further, 65.2% with cervical OPLL had ossification of the ligamentum flavum (OLF) especially at the levels of the thoracic and the lumbar spine. There is no effective conservative treatment. Surgical decompression is considered in patients with severe and/or progressive myelopathy. Early surgical decompression of the spinal cord is recommended in patients with apparent myelopathy. Operative methods are divided into two procedures, anterior decompressive surgery and posterior decompressive surgery. The choice of the surgical procedure is determined according to several factors, such as local pathology of OPLL and spinal alignment.
  2,453 264 -
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.
  2,365 242 -
The spine clinics – Cervical spondylotic myelopathy – Clinical scenarios
Ankur Nanda, KR Renjith, Abhinandan Mallepally, C S Vishnu Prasath, Ajoy P Shetty
January-June 2019, 2(1):68-80
This section of the symposium deals with different case scenarios related to cervical spondylotic myelopathy (CSM) which in our daily clinical practice not only act as diagnostic challenges but also test our decision-making abilities. These cases have been handled by different experts and hence help the readers in providing a wider perspective to the problem of cervical myelopathy and its management. This section ends with comments by the authors on key takeaway points from each case scenario, and some literature supported recommendations for the management of CSM.
  2,299 209 -
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.
  2,289 211 -
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.
  2,139 328 -
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.
  2,278 174 -
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.
  2,241 201 -
Indian spine journal – A new beginning
Anil K Jain
January-June 2018, 1(1):1-1
  2,097 319 -