Rare Indication of Atlantoaxial Fusion-failed Conservative Management of Primary Atlantoaxial Osteoarthritis

Introduction

Osteoarthritis of the atlantoaxial joint is a significant cause of occipitocervical pain, which is often missed and has an increasing prevalence with age. The patients typically present with occipitocervical pain and restricted and painful neck rotations. Despite the primary reliance on conservative management for this pathology, surgical intervention becomes crucial for those not responding to standard conservative treatment. The presented case series highlights the rarity of the requirement of surgical intervention in the management of Atlantoaxial osteoarthritis (AAOA) and the clinical outcomes of surgical management in AAOA.

Case Report

This paper presents a case series of four patients who were managed surgically with atlantoaxial fusion, from a database of 108 patients with AAOA. The case series includes three males and one female with a mean age of presentation being 67.5 years. All four patients presented with occipitocervical pain, and painful neck movements and were diagnosed with AAOA on the anteroposterior open mouth view radiographs showing changes of osteoarthritis such as bone erosions, sclerosis, osteophytes. The patients were managed conservatively with non-steroidal anti-inflammatory drugs, intra-articular steroid injections, and cervical collar immobilization. Those not responding to conservative management and with incapacitating pain were managed surgically with atlantoaxial fusion procedures.

Conclusion

In a group of patients with a painful and debilitating degenerative AAOA only a small proportion of cases require surgical intervention. In this cohort, only 3.70 % of patients required surgery, highlighting the rarity of surgical intervention required in the management of AAOA. Nevertheless, when conducted, atlantoaxial fusion has proved to be efficacious with a low rate of serious complications and the patient self-rated outcome in terms of post-operative visual analog scale score and neck disability index scores indicating a high degree of satisfaction with the procedures.

Transforaminal Endoscopic Ventral Stenosis Decompression in Calcified Lumbar Disc Herniation: A Long Term Outcome in 79 Patients

BACKGROUND

Calcified lumbar disc herniations (CLDH) causing calcified ventral stenosis pose a therapeutic challenge to the treating surgeon due to their neural adhesions, location, and hardness.

METHODS

This retrospective study analyzed all the cases of CLDH/calcified ventral stenosis managed by transforaminal endoscopic lumbar discectomy with a minimum follow-up of 24 months. The preoperative images were analyzed for the level, migration; and grade (Lee's migration zones), and location (Michigan State University classification). Detailed surgical technique and intraoperative parameters including the duration of surgery and complications have been recorded. The clinical parameters including visual analog scale (VAS), Oswestry disability index (ODI), length of stay in hospital, days of return to basic work, and patient satisfaction index were analyzed. Postoperatively the images were analyzed for the adequacy of decompression.

RESULTS

The mean VAS for back pain and leg pain was 4.7 ± 2.6 (0-9), and 7.45 ± 2.2 (1-10), respectively. The mean preoperative ODI was 78.2 ± 13.2 (63.2-95.6). Nineteen patients (24%) had neurological deficits preoperatively. The mean duration of surgery was 90.5 ± 15.8 (58-131) minutes. Postoperative magnetic resonance imaging revealed adequate decompression in 97.5% (n = 77). The mean duration of hospital stay was 1.05 ± 0.22 (1-2) days, and the postoperative back and leg pain VAS was 1.14 ± 1.2 (0-3) (P < 0.05) and 1.7 ± 0.5 (0-6) (P < 0.05), respectively. The ODI at final follow-up was 6.5 ± 3.7 (2.2-18) (P < 0.05). Neurological recovery occurred in 17 (89.5%) patients and they returned to basic work/jobs in 19.5 ± 3.3 (14-26) days. The mean patient satisfaction index was 1.18 ± 0.47 (1-2) at a mean follow-up of 5.52 ± 2.91 (2-12.75) years.

CONCLUSIONS

Transforaminal endoscopic lumbar discectomy is a complete, safe, and efficacious procedure in patients with CLDH with earlier recovery considering the surgery is performed with the patient being awake.

Does Conventional Open TLIF cause more Muscle Injury when Compared to Minimally Invasive TLIF?-A Prospective Single Center Analysis

STUDY DESIGN

Prospective, observational.

OBJECTIVES

The aim of our study was to assess the amount of reduction in lean muscle mass (LMM) of multifidus muscle (MFM) between conventional open Transforaminal lumbar interbody fusion (CO-TLIF) as compared to Minimally invasive spine Transforaminal lumbar interbody fusion (MIS-TLIF).

METHODS

This study was conducted between 2017 and 2020. It included 100 patients divided into two groups, 50 patients treated with CO-TLIF, 50 treated with MIS-TLIF. Only patients undergoing single level, primary lumbar fusion at L4-5 or L5-S1 level for degenerative pathologies were included. All patients were assessed by magnetic resonance imaging (MRI) scans 1-year post surgery. Measurements were performed using ImageJ image processing program.

RESULTS

Mean percentage reduction in LMM in CO-TLIF group was 45.52 ± 12.36% and MIS-TLIF group was 25.83 ± 9.64% [statistically significant (t = 8.78, P < .001)]. Mean percentage reduction in LMM on side of cage insertion was 39.63 ± 15.96% and opposite side was 31.40 ± 15.01% [statistically significant (t = 9.06, P < .001)]. Mean reduction of LMM among males was 29.38 ± 15.23% and females was 40.42 ± 12.67% [statistically significant (t = -3.95, P < .001)].We observed significant but weak degree of correlation between age and percentage reduction of LMM (r = .22, P = .028).

CONCLUSION

Mean reduction in LMM was greater in CO-TLIF group as compared to MIS-TLIF. There was greater reduction in LMM in females and on side of cage insertion. We also found greater reduction in LMM with increasing age in both groups.

Long-term functional and radiological outcomes of cervical disc arthroplasty at a tertiary level spine center in India: A retrospective cohort analysis with minimum 2 years of follow-up

Context

Cervical disc arthroplasty (CDA) was developed for the treatment of cervical disc disease with the potential advantages of preservation of physiological motion at a discal level, thereby potentially reducing adjacent level stresses and degeneration, which were a known complication of anterior cervical arthrodesis. The objective of this study was the assessment of long-term functional and radiological outcomes overtime in all the patients who underwent CDA from 2011 to 2019 at our institute.

Materials and Methods

Forty-eight patients who underwent CDA (2011-2019) with a minimum 2-year follow-up were retrospectively evaluated. The functional outcome included the Visual Analog Score (VAS) and Neck Disability Index (NDI). Radiographs were assessed for range of motion (ROM) at the index surgical level, presence of heterotopic ossification (HO), and adjacent segment degeneration.

Results

The mean follow-up was 5.79 ± 2.96 (2.16-11.75) years. Significant improvement (P < 0.05) was observed in the VAS (8.91 ± 2.52 [preoperative] to 0.89 ± 1.27 [follow-up]) and NDI (65.5% ±23.06% [preoperative] to 4.79 ± 3.87 [follow-up]) score. Motion at index level increased significantly from 5.53° preoperatively to 7.47°, and 92% of the implanted segments were still mobile (referring to the threshold of ROM > 3°). HOs are responsible for the fusion of 4/50 (8%) levels at the last follow-up. Distal and proximal adjacent disc degeneration occurred in 36% and 28% of patients, respectively. No migration of the implant was observed on the radiograph.

Conclusion

Our study showed favorable clinical outcome of CDA with preservation of ROM at the index surgical level. CDA can be a promising alternative to anterior cervical arthrodesis when properly indicated.

Does MR Signal Intensity Change have Prognostic Value in Multilevel Cervical Myelopathy? A Single-Center, Prospective Study

Background and Objective

Neurological recovery in cervical myelopathy remains unpredictable. There is contradictory literature regarding the prognostic value of magnetic resonance imaging (MRI) in such cases. The objective of the present study is to evaluate the morphological changes in the spinal cord in cervical spondylotic myelopathy and compare them with clinical outcome.

Materials and Methods

This is a single-center, prospective, observational study. All patients with multilevel (two or more levels) cervical spondylotic myelopathy undergoing anterior spine surgery were included in the study. Patient demographics and radiological findings were recorded. MRI was repeated immediately post-op and at 1-year follow-up. MRI classification system based on axial images was used to evaluate presurgery and postsurgery changes and correlate them with clinical information.

Results

The study comprised 50 patients (40 males and 10 females) with a mean age of 59.5 years. Average duration of symptoms before surgery was 6.29 months. Thirty-four patients underwent two-level decompression, while 16 patients underwent more than two-level decompression. Average duration of follow-up was 26.82 months. Mean pre-op Nurick grade was 2.84, and mean recovery rate was 56.73. Most common pre-op MRI type was type 1. Analysis of data by logistic regression showed better recovery rate with lower age, lower pre-op Nurick grade, and lower pre-op MRI type.

Conclusion

MR classification based on signal intensity changes in axial images have been found to correlate with recovery rate.

A comparative morphometric analysis of operative windows for performing OLIF among normal and deformity group in lower lumbar spine

PURPOSE

To assess the radiological morphometric parameters of OLIF surgical technique in lower lumbar spine among normal and in patients with adult degenerative spine (levoscoliosis and dextroscoliosis).

METHOD

Standing AP radiographs and MRI in supine position were taken. Patients were divided into 3 groups based on Cobbs' angle into normal, levo and dextro scoliosis. Moros classification was used to calculate bare window (BW), vascular window (VW), Psoas window (PW), psoas major height (pmh) and width (pmw) at lower lumbar levels and measurements were done on PACS.

RESULTS

Seventy five patients (25 in each group) were assessed. BW has trend from L2-L3 > L3-L4 > L4-L5 in dextro and levoscoliosis. PW has trend from L3-L4 > L2-L3 > L4-L5 in levoscoliosis and normal group. VW has trend from L4-L5 > L3-L4 > L2-L3 in dextro and levoscoliosis; pmw has trend from L4-L5 > L3-L4 > L2-L3 in Levo and dextroscoliosis; pmh has trend from L4-L5 > L3-L4 > L2-L3 in levoscoliosis and normal group.

CONCLUSION

BW was noted to be highest at L3-4, lowest at L4-5 in normal group. VW was constant, BW showed a reverse trend with PW across all the levels. Though levoscoliosis group of patients had significantly higher BW, psoas retraction issues are to be kept in mind in view of anatomically taught psoas.

'Higher the grade-smaller the pedicle': a study of pedicle dimensional variations in 100 cases of high grade lytic spondylolisthesis

PURPOSE

To measure the pedicle dimensions in high grade lytic spondylolisthesis (HGL) and to classify them, which helps the spine surgeon in proper selection of pedicle screws.

METHODS

A study of CT scans in 100 consecutive patients between Jan 2017 and April 2021 diagnosed as single-level HGL on standing radiographs. Pedicle height (PH), Pedicle width (PW), Differential pedicle height (DPH), Screw length (SL) and Transverse pedicle angle (TPA) were measured and analyzed. PH and PW were classified into four grades as-grade A less than 5.0 mm, grade B between 5.0 and 6.0 mm, grade C between 6.0 and 7.0 mm, and grade D above 7.0 mm.

RESULTS

5 males and 95 females with mean age of 49.1 years. PH in 44% lytic vertebra were grade A, B (less than 6 mm) and the rest 56% had grade C, D (greater than 6 mm). PH averaged 6.6 mm in grade 3 HGL, 5.61 mm in grade 4 HGL. Change in PW, SL and TPA was not statistically significant with regards to grade or level of listhesis. A total of 37 cases were noted to have DPH (25 cases had a difference < 2 mm and 12 had a difference > 2 mm).

CONCLUSION

44% of the PH in lytic vertebra was grade A and B (less than 6 mm) that stresses the importance of pre-op CT assessment and planning the appropriate screw dimensions. Change in PH was statistically significant with regards to the grade of listhesis (P-value < 0.01). Differential pedicle height also need to be looked for.

Results of in situ fixation of Andersson lesion by posterior approach in 35 cases

STUDY OBJECTIVE

Due to the rarity of the Andersson lesion (AL), the literature is ambiguous regarding the type of surgical fixation, need for debridement and deformity correction. The purpose of this retrospective study is to evaluate the efficacy, feasibility and functional outcome of posterior fixation in AL.

MATERIALS AND METHODS

This study included 35 patients having thoracolumbar AL operated for in situ fixation and fusion with minimum of 24-month follow-up. VAS (Visual Analogue Score) back pain, ODI (Oswestry Disability Index), Frankel's grade were compared and analyzed. Union status was noted with complications.

RESULTS

The mean age of 35 patients was 56.34(± 11.3) years with average follow-up of 51.49 months. Two patients had AL at two levels. 27/37 AL were at discal level. Average estimated blood loss (EBL) was 276.43 ml and duration of surgery was 130.43 min. On an average, operated segments needed 7.77 screws. There were ten minor complications without long-term sequel. Neurological improvement was noted in 30 patients. Average preoperative VAS score improved from 8.69 to 3.14, ODI score improved from 68.76 to 18.77 at final follow-up which were significant (p < 0.05). There was significant improvement in Frankel's grading (Z = - 4.354, P = 0.00).

CONCLUSIONS

Surgical management of AL by posterior approach and posterior stabilization can give satisfactory results without the need of extensive anterior reconstruction, bone grafting or deformity correction procedures without added morbidity and complications.

RCC (reinforced criss-cross construct): an easy and effective multi-rod thoraco-lumbar posterior reconstruction technique

STUDY DESIGN

Surgical technical note and literature review.

OBJECTIVES

To describe a technique that uses 4 rod constructs in cases of complex thoracolumbar spinal deformity correction or revision surgeries based on the hybrid use of two different types of purchase points by a staggered pedicle screw fixation. It utilizes two rods on either side of the spine using a lateral and medial entry point of pedicle screws in the vertebral body.

METHODS

Pedicle screws using extra-pedicular technique are more converging screws and are inserted alternately in the vertebral body and connected by rods. The left-out alternate vertebral bodies are fixed by a relatively straighter pedicle entry screw and connected to each other by a separate rod. So, two trajectories are independently used for a four-rod construct. This reconstruction has been named RCC (reinforced criss-cross construct). The screws in the index case were placed by free hand method, but we have increasingly utilized navigation guidance for placement of screws in recent times.

RESULTS

We present a surgical technical note in a patient with human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV-AIDS). He was diagnosed to have multi-drug-resistant (MDR) tuberculous spondylodiscitis, complicated with Immune reconstitution inflammatory syndrome (IRIS) and implant failure resulting in kyphosis and thoracic myelopathy. RCC with pharmacological management achieved healing and union, which was maintained at 4 years follow-up. Our method of four-rod construct provides a strong and lasting construct in the management of spinal deformities and three-column osteotomies. It provides good structural support to the spine till bony union is achieved.

CONCLUSION

Hybrid multi-rod construct like RCC provides a rigid mechanical support to the instrumentation and reduces the chances of rod failure especially in complex thoraco-lumbar spinal deformity correction surgeries.

Transpedicular vertebral biopsy under O-arm navigation: a technical note

Background

Despite emerging techniques, sample inadequacy remains the most important factor that necessitates need for repeat biopsy. Transpedicular Biopsy has diagnostic accuracy ranging from 75 to 90% in both computed tomography guided or percutaneous C-arm guided biopsy. Presenting in this article is an add on technique as a modification to enhance quality and quantity of sample obtained using a self designed trocar cannula with computed tomography-based Navigation.

Main body

We have used transpedicular biopsy technique under C Arm fluoroscopy, previously, where we used a self-designed trocar and cannula in our study of 71 cases & reported an accuracy of 88.7% with no reported complications. This is add on modification of same technique where under 3D navigation, we introduce a pituitary forceps through a correctly positioned cannula. This helps for biopsy of soft lesions/ discal level pathologies. Also, multi-planar adjustment of cannula after initial Stealth O-Arm navigation helps in sampling of different regions of vertebral body by reinsertion of pituitary forceps with simple manipulation of cannula without withdrawal. This minimizes risk of fracturing pedicle. With our technical modification, cannulated drill bit with core opening can be drilled through cannula to retrieve a sample. Our technique has limitations being experience driven and also enabling technology dependent. However, same method can be applied using 2-dimensional fluoroscopy without navigation.

Conclusion

Our technique of using pituitary forceps through cannula is highly effective in getting adequate representative sample with spectrum ranging from hard sclerotic lesions to soft lesions and discal pathologies. This procedure can be used with traditional 2-dimensional fluoroscopy as well as with 3-dimensional navigated precision.

Thoracic Spine Stenosis: Does Ultrasonic Osteotome Improve Outcome in Comparison to Conventional Technique?

INTRODUCTION

To investigate the efficacy of Ultrasonic Bone Scalpel (UBS) in thoracic spinal stenosis (TSS) in comparison to traditional technique.

MATERIAL AND METHODS

A total of 55 patients who had undergone conventional surgery (Group A) are compared with 45 patients of UBS (Group B) in TSS. The primary outcome measure of Modified Japanese Orthopaedic Association score (m JOA) with neurological complications and dural injury were assessed. Secondary outcome measures of total blood loss (TBL), time duration of surgery (ORT) and length of hospital stay (LHS) were analysed.

RESULTS

The pre-operative mJOA score 5.00(4.00-6.00) in the group A and 5.00(4.00-6.00) in the group B improved to 7.00(7.00-8.00) in the group A and 9.00(9.00-10.00) in the group B, respectively (P<0.001) at final average follow-up of 117.55 months for group A and 75.69 months in group B. More significant grade of myelopathy improvement and mJOA recovery rate (RR) were noted in group B. The TBL, ORT and LHS were more favourable in group B as compared to group A (p<0.0001). The group A had 9 (16.36%) neurological deficits compared to 2 (4.44%) in group B (p<0.001). Dural tears occurred in both groups (A=11, B=9). It was more frequent and not repairable in group A but without significant statistical difference.

CONCLUSION

UBS can reduce neurological deficits and improve outcomes in TSS. Secondarily, reduced blood loss, lesser surgical time and reduced LHS are significant added advantages of this new technology.

The Effect of Head Loading on Cervical Spine in Manual Laborers

STUDY DESIGN

A prospective case-control study.

PURPOSE

To determine the effect of axial loading on the cervical spine when weights are carried on the head.

OVERVIEW OF LITERATURE

Traditionally, carrying weights on the head has been a common practice in developing countries. The laborers working in agriculture, construction, and other industries, as well as porters at railway platforms, are required to lift heavy weights. Since controversy exists regarding carrying weights on the head, we decided to evaluate its effect on the cervical spine.

METHODS

The study comprised 62 subjects. Of this number, 32 subjects (group A) were unskilled laborers from the construction industry; the other 30 subjects (group B) were in the control group and had never previously carried heavy weights on their heads. Cervical spine radiographs were taken for all the 62 subjects. Subjects in group A were asked to carry a load (approximately 35 kg) on their heads and walk for about 65 m, with their cervical spine radiographs taken afterward.

RESULTS

The mean ages of patients in groups A and B were 27.17 and 25.75 years, respectively. The mean cervical lordosis observed in group A (18.96°) was dramatically less compared with group B (25.40°), showing a further decrease in head loading (3.35°). Five subjects had a reversal of lordosis (-5.61°). A statistically significant reduction in disc height and listhesis was observed when the load was carried on the head with a further decrease after walking with the load. Accelerated degenerative changes, particularly affecting the upper cervical spine, were observed in head loaders.

CONCLUSIONS

Carrying a load on the head leads to accelerated degenerative changes, which involve the upper cervical spine more than the lower cervical spine and predisposes it to injury at a lower threshold. Thus, alternative methods of carrying loads should be proposed.

Transforaminal Thoracic Interbody Fusion for Thoracic Disc Prolapse: Surgicoradiological Analysis of 18 Cases

STUDY DESIGN

Retrospective observational study.

OBJECTIVES

Thoracic disc prolapse (TDP) surgeries have reported complications ranging from paraplegia to approach related complications. This study is to present a series of TDP patients surgically treated with transforaminal thoracic interbody fusion (TTIF). Emphasis on surgical technique and strategies to avoid complications are analyzed.

METHODS

Eighteen patients with TDP were included. Imagings were analyzed for end-plate changes and calcification. Type of disc prolapse (central/para-central) and percentage of canal occupancy were noted. Objective outcome was quantified with Visual Analogue Scale (VAS), modified Nurick's grade, and ASIA (American Spinal Injury Association) score. All complications were noted.

RESULTS

Eighteen patients (average age 43.65 years) having total 22 levels operated, that included double level (n = 2) and missed level (n = 2) are reported. All patients had myelopathy. Calcification of disc (n = 13), central disc prolapses (n = 9), para-central (n = 11) and more than 50% canal occupancy (n = 8) were noted. VAS back pain, modified Nurick's grade and ASIA grade improved significantly in all patients. One patient had postoperative transient deficit. The functional score achieved its maximum at 1 year follow-up and remained static at final follow-up of 65.05 months. Union was achieved in all patients.

CONCLUSIONS

The most important factor for outcome in TDP is the technical aspect of avoiding cord manhandling and avoiding wrong level surgeries. TTIF is not devoid of complications but can give good results to posterior approach trained surgeons.

The Effectiveness and Safety of Ultrasonic Bone Scalpel Versus Conventional Method in Cervical Laminectomy: A Retrospective Study of 311 Patients

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

The aim of this study was to compare the results of cervical laminectomy (CL) performed with ultrasonic bone scalpel (UBS) or conventional method (CM).

METHOD

This study comprised 311 CL performed by a single surgeon between January 2004 and December 2017. Group A (GpA) comprised 124 cases of CL performed using UBS, while Group B (GpB) comprised 187 cases of CL performed using CM. These 2 groups were compared in terms of demographic characteristics of patients, duration of surgery, estimated blood loss, and surgical complications.

RESULTS

GpA included 112 males and 12 females, mean age being 61.18 years. GpB comprised 166 males and 21 females, mean age being 62.04 years. Mean duration of surgery, estimated blood loss, and length of hospital stay was 65.52/70.87 minutes, 90.24/98.40 mL, and 4.80/4.87 days in GpA and GpB, respectively. Six patients were reported to have dural injuries in each group. In GpA, 2 cases of C5 palsy and 1 nerve root injury was observed, while in GpB, 3 cases of C5 palsy and no nerve root injury was reported. One patient had developed transient neurological deterioration postsurgery in GpA as against 11 patients in GpB.

CONCLUSION

Neurological complications observed in CM leads to intensive care unit admission, additional morbidity, and additional expenditure, whereas UBS provides a safe, rapid, and effective means of performing CL, thereby decreasing the rate of surgical complications and postoperative morbidity.

Age - Does it really count? A study of the Perioperative Morbidity and Long-Term Outcome in Patients Above 70 Years of Age Undergoing Spine surgery for Lumbar Degenerative Disorders

Objective  To assess the long-term outcome and perioperative morbidity in spine surgeries for lumbar degenerative disorders and, thereby, to evaluate the safety of surgery in the aging population.

Methods  Retrospective study of patients aged > 70 years, operated for degenerative lumbar disorders between 2011 and 2015. We evaluated patient demographic, clinical and surgical data; comorbidities, perioperative complications, pre & postoperative pain scores and Oswestry disability index (ODI) scores, patient satisfaction and overall mortality.

Results  A total of 103 patients (Males: Females55:48) with mean age 74.6 years (70–85yrs) were studied. 60 patients (58.2%) had decompression alone, while 43 (41.8%) had decompression & fusion. Mean hospital stay was 5.7days. Mean follow-up was 47.6months (24–73mnths). Patients reported significant improvement in backpain (Numerical pain score 7.7 vs 1.6; p  < 0.001), leg pain (Numerical pain score 7.4 vs 1.7; p  < 0.001), disability (ODI 82.3 vs 19.1; p  < 0.001) and walking distance ( p  < 0.001). 76% patients were satisfied with the results at the time of final follow-up. 26 patients (25.24%) had perioperative complications which were all minor, without mortality. Most common intraoperative & postoperative complications were dural tear (6.79%) & urinary tract infection (6.79%) respectively.

Conclusions  With meticulous perioperative care lumbar spine surgery is safe and effective in elderly population. Patients had longer mean hospital stay in view of the gradual and comprehensive rehabilitation program. Presence of comorbidities or minor perioperative complications did not increase the overall morbidity or affect the clinical outcomes of surgery in our study.

Ventral sculpting decompression: a novel bone scalpel-based technique in thoracic ventral stenosis/kyphosis with myelopathy

Background

Thoracic kyphosis is not so uncommon, which presents with devastating myelopathy. In the past, the surgical treatment for it had been somewhat controversial. Traditionally, it had been addressed by open decompression and stabilization with significant dissection and disruption of normal tissues and complications.

Main body

Recently, correction techniques have evolved as the standard of care. A substantial body of evidence now supports the benefits of correction but can be questioned in view of the fact that upper dorsal kyphosis is never a cosmetic concern in our part of the world. New technique has reduced complications, but it is not solely due to the technique but due to accessory gadgets like O-arm, navigation, and IONM making it safer. We describe a method of 360° decompression alone with the use of an Ultrasonic Bone Scalpel (UBS) that preserves maximum bony stability and achieves an optimum bone sculpting that negates the need for correction.

Conclusion

This technique of ventral sculpting decompression in the thoracic spine may be more utilized in the future to be applied for more wider indications.

Superior Mesenteric Artery Syndrome Complicating Spinal Deformity Correction Surgery: A Case Report and Review of the Literature

CASE

A 13-year-old female presenting with untreated congenital scoliosis underwent single-stage anterior plus posterior deformity correction surgery. On the sixth postoperative day, she started vomiting and complained of abdominal pain. Imaging studies suggested superior mesenteric artery syndrome (SMAS). Conservative treatment for 3 weeks yielded no improvement in symptoms. She subsequently underwent laparoscopic duodenojejunostomy, which resolved her symptoms.

CONCLUSIONS

SMAS, although rare, is a morbid complication of deformity correction surgery. Medical management is the treatment of choice, with surgery reserved for nonresponders. Prompt diagnosis and appropriate intervention can provide effective treatment, thus preventing catastrophic consequences.

Trans-foraminal endoscopic uniportal decompression in degenerative lumbar spondylolisthesis: a technical and case report

Background

Degenerative spondylolisthesis is a common spinal pathology. Traditionally, spinal fusion is an accepted standard surgical treatment for listhesis. But fusion is a major intervention with its known pitfalls. With technological progression, minimally invasive spinal fusion (MISF) procedures are becoming mainstream. Percutaneous trans-foraminal endoscopic lumbar discectomy/decompressions (PTELD) without stabilization has many advantages over even a MISF for select group of patients.

Case presentation

In this case report, we describe using a uniportal unilateral trans-foraminal approach (TFA) for stable listhesis with lumbar disc herniation (LDH) causing chronic bilateral radicular symptoms and back pain with acute exacerbation. Under local anesthesia, we used a flat entry for PTELD, which facilitates an approach to both disc sides ventrally and even dorsal aspect lateral recess decompression on the dominant ipsilateral side. No fixation was done. An excellent outcome is obtained immediately at 6 weeks and maintained at 39 months of follow-up.

Conclusion

PTELD is worth considering as an intermediate procedure before fusion is offered in lateral recess stenosis in stable listhesis patients who have consented and understand the progressive cascade of spinal degeneration.

Limbus Vertebral Fracture Presenting as Cauda Equina Syndrome Masquerading An Acute Disc Prolapse - A Rare Case Report and Review of Literature

Introduction:

Limbus vertebral fracture is an uncommon injury described in adolescents. It refers to the separation of a bony fragment from the unfused ring apophysis of lumbar vertebral end plate. It usually presents with back pain with/without radiculopathy masquerading an acute disc prolapse. However, the presentation as acute cauda equina syndrome has seldom been reported.

Case Report:

A 15-year-old male presented to the casualty with a history of acute-onset low back pain and bilateral lower limb radicular pain with weakness, after lifting of a heavy Indian musical instrument (Dholak). This was associated with urinary retention and numbness in perineal region. Examination revealed L5 and S1 weakness with absent ankle jerks bilaterally. Bulbocavernosus reflex was absent. Emergency magnetic resonance imaging imaging was done, which revealed a limbus fracture of cephalad part of L4 vertebral body with displaced fragment into the spinal canal causing compression of the cauda equina. Emergency surgery was done in the form of L3-L4 midline interlaminar microscopic decompression. The patient had complete neurological recovery including the bladder control within 1 month of surgery. The patient had no functional deficits during follow-up at 3 and6 months. Dynamic radiographs taken at the end of 6 months did not show any sign of instability.

Conclusion:

When an adolescent patient with no previous history of backpain presents with acute cauda equina syndrome, a possibility of limbus fracture should also be considered. Early diagnosis and surgical decompression in such cases can bring about complete neurological recovery and excellent clinical outcome.

A Radiological Study of the Association of Facet Joint Tropism and Facet Angulation With Degenerative Spondylolisthesis

Objective

To study the association of facet joint angulation and joint tropism with degenerative spondylolisthesis (DS) through a comparison with a matched control group.

Methods

This radiographic study was carried out in 2 groups of 45 patients each. Group A contained patients with single-level DS, while group B (control) contained non-DS patients with similar age and degeneration who underwent surgery for disc prolapse or lumbar stenosis. DS was diagnosed based on translation of ≥ 3 mm on standing lateral radiography. Axial magnetic resonance imaging from L3 to S1 was utilized to assess the angulation of facet joints in relation to the coronal plane; a difference of ≥ 8° was considered to indicate tropism.

Results

Among 45 patients with DS, 15 were males and 30 females. Their mean age was 62.2 years. Facet tropism was identified in 20 of 45 patients at the level of DS, 12 patients at a level proximal to DS, and 15 patients at a level distal to DS. Facet tropism was found in 7 of the 45 patients in group B. At L3–4, facet tropism was observed in 13 patients (28.88%) in group A and 2 (4.44%) in group B. At L4–5, tropism was observed in 19 patients (42.22%) in group A and 5 (11.11%) in group B. At L5–S1, tropism was seen in 17 patients (37.77%) in group A and 2 (4.44%) in group B. Group A showed a significantly higher prevalence of multilevel facet tropism and tropism at levels adjacent to the DS level. A higher average angulation of facet joints was observed in the DS group, but the difference was not statistically significant at all levels.

Conclusion

The present study documented a statistically significant relationship between facet tropism and DS. A higher prevalence of facet tropism was also found in DS patients at non-DS levels, which is a novel observation. This finding supports the argument that facet tropism is a pre-existing morphological variation contributing to the development of DS, not a result of secondary remodelling.

Congenital malformed posterior arch of atlas with fusion defect: a case of developmental canal stenosis causing cervical myelopathy

Congenital anomalies of the posterior arch of the atlas (PAA) are usually asymptomatic and diagnosed incidentally. Very rarely, they present with cervical myelopathy, usually being associated with partial aplasia or agenesis of PAA. We describe a 44-year-old lady with cervical myelopathy secondary to a malformed PAA with developmental atlas-level spinal stenosis and a congenital posterior fusion defect with persistent midline cleft showing significant non-osseous fibro-cartilaginous hypertrophy, causing critical cord compression. Spinal decompression by en-bloc wide excision of anomalous arch with occipito-cervical fusion was performed. Post-operatively, the patient's neurology improved gradually over 12 months, with radicular symptoms being the earliest and gait disturbance being the last symptom to resolve. At 24 months, she was asymptomatic with imaging showing good spinal cord decompression at the level of atlas. Developmental atlas stenosis with hypertrophic posterior arch fusion defect is an unusual cause of cervical myelopathy, which can be effectively treated with decompression with/without stabilization. Being aware of such an entity can avoid diagnostic dilemma and facilitate prognostication of outcomes, accurate surgical planning in the stenotic segment thereby ensuring effective management of these patients.

Quality of life and nutritional status in alcohol addicts and patients with chronic liver disease

OBJECTIVE

The aim of the study was to assess and compare the nutritional status and quality of life in chronic liver disease (alcoholic and non-alcoholic) patients and alcohol addicts.

METHODS

Patients with alcoholic liver disease (n=41), nonalcoholic liver disease (n=40), alcohol addicts (n=25) without liver disease and healthy controls (n=25) were randomly selected. Nutritional status was assessed using anthropometric measurements viz. skin fold thickness, arm muscle circumference and area. Biochemical estimations included liver function tests. Food intake was assessed using 48 hour recall and macro-nutrient intake was calculated. Quality of life was assessed using the SF-36 questionnaire.

RESULTS

The mean value of mid-arm muscle area was significantly lower in patients from the non-alcoholic liver disease group when compared with the other 2 groups (p= 0.0). Body fat store depletion was significantly lower in the alcohol addict group when set against the alcoholic liver disease and non-alcoholic liver disease groups (p= 0.0). The mean percentages of ideal calories (p= 0.0) and proteins (p= 0.0) were significantly higher in alcohol addicts but no significant differences in the mean percentage of fat intake (p= 0.1) was observed. The frequency of macro-nutrient deficiency was highest in the non-alcoholic liver disease group (p= 0.0). Ethanol consumption was not significantly different between alcohol addicts and patients suffering from alcoholic liver disease (p=0.06). Patients with liver disease (irrespective of aetiology) scored significantly lower on the quality of life scale when compared to alcohol addicts.

CONCLUSIONS

Malnutrition is more frequent and severe in patients suffering from chronic liver disease in comparison to alcohol addicts. The health status is significantly poorer in patients suffering from alcoholic liver disease. Alcohol does not seem to play a primary role in the pathogenesis of liver disease and malnutrition.

Magnetic loop basket: a "two-in-one" instrument

BACKGROUND AND STUDY AIMS

Ingested coins are the most common foreign bodies encountered in the upper gastrointestinal tract in India and if they remain in the stomach for more than 5 days they need to be removed. Ferromagnetic retrieval instruments only work if the coins are ferromagnetic; and it is difficult to maneuver a loop basket in the fundus of the stomach. A magnetic loop basket was designed in an effort to overcome these difficulties and we assessed its feasibility, safety, and effectiveness in the removal of coins from the fundus of the stomach.

PATIENTS AND METHODS

Twenty patients with a history of ingested coins were scheduled for removal of the coins using the magnetic loop basket. The time taken, complications, and failure rates were recorded.

RESULTS

Twelve ferromagnetic coins were removed in a mean time of 60 seconds (range 30 - 90 seconds) and eight non-ferromagnetic coins were removed in a mean time of 150 seconds (range 90 - 180 seconds) without any failures or complications.

CONCLUSION

The magnetic loop basket is a safe, effective, and quick method for removing both ferromagnetic and non-ferromagnetic metallic coins.

Comparison of nutritional status between patients with alcoholic and non-alcoholic liver cirrhosis

OBJECTIVE

The aim of the study was to assess and compare the nutritional status of alcoholic and non alcoholic cirrhotic patients.

METHODS

81 patients with liver cirrhosis--41 alcoholic (AC) & 40 non alcoholic (NAC), were selected. Nutritional status was assessed using anthropometric measurements viz. skin fold thickness, arm and muscle circumferences and areas. Food intake was evaluated using 48 hour dietary recall. Creatinine Height Index and Lean Body Mass were calculated from 24 hour urinary creatinine excretion.

RESULTS

Mean values of Mid Arm Muscle Area, for both AC and NAC (2947+/-8.12 mm(2) v/s 3534+/-6.96 mm(2) respectively), were below the 5th percentile of Frisancho's cut off, with significant reduction in alcoholics (P = 0.00). Creatinine Height Index (CHI) and Lean Body Mass (LBM) were higher in patients without fluid retention as compared to those with fluid retention. Patients without Ascites showed a positive correlation between body weight and Lean Body Mass (r=0.471; rho=0.438; P=0.00).

CONCLUSIONS

Malnutrition is widely prevalent in cirrhotics, with greater impairment in alcoholics. A positive correlation could be elicited between Lean Body Mass & Actual Body Weight in patients without ascites. Creatinine Height Index and Lean Body Mass may be more reliable parameters for the assessment of nutritional status in patients with liver cirrhosis.

Achalasia cardia: A study of 113 patients managed with indigenous dilator

BACKGROUND

Endoscopic dilatation of achalasia cardia is an effective nonsurgical management option. It requires costly pneumatic dilators which are used under fluoroscopic guidance. This study assesses the efficacy and safety of an indigenous pneumatic dilator used without fluoroscopic guidance.

METHODS

Over a period of eleven years, 113 patients (69M, 44F) ofachalasia cardia underwent dilatation with indigenous pneumatic dilators without fluoroscopic guidance. The dilatation was performed under endoscopic vision.

RESULTS

The procedure was successful in all patients. After six weeks following dilatation, there was significant improvement in the mean dysphagia score 3.63 + 0.61 to 0.53 + 0.93 (P<0.01). The response was still significant (0.78 + 1.03, P <0.05) at the end of one year. Excellent response with single dilatation was seen in 70.7% patients. After two dilatation sessions 92% of patients showed an excellent response. One patient had perforation. There was no mortality.

CONCLUSION

Pneumatic dilatation under endoscopic vision without fluoroscopic assistance with the indigenous dilator is very effective and safe for short term treatment of achalasia carida.

Endoscopic band ligation for non variceal bleed

Endoscopic band ligation (EBL) is an infrequently used modality for treatment of non-variceal hemorrhage. We report the successful use of this technique for the management of bleed from blue rubber bleb nevus syndrome lesions and post polypectomy bleeding stalk.

Improvized pneumatic dilator for achalasia cardia

The indigenous pneumatic dilator for achalasia cardia reported previously by the authors was being placed alongside the endoscope to perform dilatation under direct vision. It has now been improvised to make the procedure wire-guided and fluoroscopy-assisted as well. The improvization includes insertion of a central Teflon tube for passage of a guidewire and presence of three radio-opaque markers, which define the proximal, central and distal ends of the dilator and help in precise positioning under fluoroscopy. Dilatation for achalasia cardia using the improvized pneumatic dilator with fluoroscopic guidance was performed successfully on 10 patients at our center. All patients had clinical response with greater than 50% improvement in total symptom score. Barium swallow examination after dilatation showed improvement in esophageal transit in all patients. None of the patients developed any complication. Cost of the dilator is approximately 50 times less than that of commercially available dilators. The dilator can be re-used by sterilizing it, which further reduces the cost.

Seroepidemiology of hepatitis A infection in India: changing pattern

OBJECTIVE

Recent changes in the epidemiology of hepatitis A virus (HAV) infection and the availability of effective vaccines have renewed interest in this infection. We determined the age-related prevalence of anti-HAV antibodies in India and looked for differences by known risk factors for HAV infection.

METHODS

In this prospective study, serum samples obtained from 1612 subjects aged 1 to 60 at six centers in five cities (Calcutta, Cochin, Indore, Jaipur and Patna) during the period February to August 1998 were tested for anti-HAV antibodies. Demographic and socio-economic information was obtained by questionnaire.

RESULTS

The overall seroprevalence rate was 65.9%, varying from 26.2% to 85.3% in various cities; there was no difference between males and females. Seropositivity increased with age from 52.2% in the 1-5 year age group to 80.8% in those aged 16 years or more. Seroprevalence rates were significantly lower in those aged 1-5 years compared with other age groups (p<0.0001). There was no difference in seroprevalence between those with monthly family income <Rs 5000 and >Rs 5001. Multivariate analysis showed that anti-HAV seroprevalence varied significantly by source of water supply, being highest when the supply was municipal.

CONCLUSION

Our results indicate an epidemiological pattern of intermediate endemicity. This finding has public health implications as it indicates that a significant proportion of the Indian adolescent and adult population is at risk of HAV infection.

Evaluation of garlic oil as a contact dissolution agent for gallstones: comparison with monooctanoin

AIM

To find a better contact solvent to dissolve gallstones we studied invitro use of garlic oil and compared it with monooctanoin.

METHODS

In the first stage gall stones obtained from patients after cholecystectomy were subjected to dissolution in different concentrations of garlic oil. Then the rate of dissolution of gall stones in garlic oil was compared to that in monooctanoin in stage II. Efficacy of various concentration of garlic oil and monoocatanoin in dissolving gallstones in artificial gall bladder and common bile duct models were compared in stage III.

RESULTS

Garlic oil dissolved the cholesterol gall stones in proportion to the concentration used. The gall stone fragmentation was faster [6 hours V/s 36 hours] and more [88.30% V/s 71.01%] by garlic oil in comparison to monooctanoin in test tubes and even in artificial gallbladder and common bile duct models.

CONCLUSIONS

Garlic oil is a better contact dissolving agent of gallstones than monooctanoin.

Primary aortoesophageal fistula: presenting as massive upper gastrointestinal hemorrhage

Primary aortoesophageal fistula is a rare cause of upper gastrointestinal bleeding. A six-year-old boy presented with massive upper gastrointestinal hemorrhage. Endoscopy revealed a submucosal bulge in the esophagus with an ulcer and clot at the top. Lateral skiagram of the chest showed a posterior mediastinal mass. CT scan of the chest revealed a ruptured aortic aneurysm into the oesophagus, confirmed the diagnosis. The patient succumbed to the illness before he could be subjected to definitive treatment.