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This section of the symposium deals with different clinical situations related to the management of traumatic cervical spine cord injury (SCI) and its complications. These cases give an overview of the clinical dilemmas that test our decision-making abilities in dealing with patients with cervical SCI and its associated complications. The patients were managed in various centers across India with different infrastructures and facilities. They are managed by different experts in the field of spine surgery. This should help the reader in providing a wider perspective in the management of vertebral lesions of traumatic cervical SCI. This section also helps in understanding the newer advances in dealing with the dreaded complication of invasive long-term ventilation in a patient with cervical SCI. The spine clinic ends with comments by the authors on key takeaway points from each case scenario, and some literature supported recommendations for the management of traumatic cervical SCI.

Study Design Observational study of computed tomography (CT) data. Purpose We performed a CT-based radiographic analysis of sub-axial cervical lamina in the Indian population to assess the feasibility of laminar screws. Overview of Literature Morphometric studies have been performed for populations of various ethnic groups, but none exist for Indian populations. Methods Cervical spine CT scans of 50 adults with a minimum slice thickness of

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.

Study DesignA retrospective computed tomography (CT)-based morphometric study of 82 occipital condyles in the Indian population, focusing on critical morphometric dimensions with relation to placing condylar screws.PurposeThis study focused on determining the feasibility of placing occipital condylar screws in an Indian population using CT anatomical morphometric data.Overview of LiteratureThe occipital condylar screw is a novel technique being explored as one of the options in occipitocervical stabilization. Sex and ethnic variations in anatomical structures may restrict the feasibility of this technique in some populations. To the best of our knowledge, there are no CT-based data on an Indian population that assess the feasibility of occipital condylar screws.MethodsWe measured the dimensions of 82 occipital condyles in 41 adults on coronal, sagittal, and axial reconstructed CT images. The differences were noted between the right and left sides and also between males and females. Statistical analysis was performed using the t-test, with a p-value of

Study DesignA retrospective computed tomography (CT)-based morphometric study of 84 C1pedicles in an Indian population focusing on critical morphometric dimensions vis-a-vis C1 pedicle screw placement.PurposeTo determine the feasibility of C1 pedicle screw placement in an Indian population and propose a novel classification system for the same.Overview of LiteratureAt present, C1 pedicle screws are rarely used, and very few studies have focused on the feasibility of pedicle screw placement in terms of racial, gender, and ethnic variations in anatomical structures. There are no CT-based data on C1 pedicles that assess the feasibility of pedicle screw placement in the Indian population.MethodsWe measured C1 pedicle diameter on CT coronal scan images of 42 adult patients. Extramedullary height (EMH) and intramedullary height (IMH) were measured. We examined the differences between the right and left atlas pedicles and compared measures between males and females. These data were analyzed using significance tests. Based on the results, we propose a novel classification system, which we believe will help in determining the feasibility of C1 pedicle screw placement.ResultsForty-two adult patients (84 pedicles) were examined. Average EMH and IMH were 4.48±0.91 and 0.86±0.77, respectively. Approximately, 32% of the C1 pedicles had bone thicknesses of

Objectives: Various types of minimally invasive techniques have been developed for the treatment of lumbar disc herniation. The original laminectomy was refined into microdiscectomy (MD). MD is the gold standard in management of lumbar disc herniation and is used as a yardstick for comparison with newer procedures such as tubular discectomy. So far, no studies have been reported in Indian population comparing tubular discectomy and microdiscectomy. The aim of this study was to compare immediate postoperative and 1-year outcome of patients undergoing tubular discectomy with those undergoing MD and to evaluate the learning curve as well as complication rates of tubular discectomy. Materials and Methods: Forty-six patients of MD and 102 (48 early and 54 late) patients of tubular discectomy (TD) were operated at Indian Spinal Injuries Centre, which is a tertiary level center between July 2009 and January 2012. They were studied for the following data: Baseline characteristics, visual analog scale (VAS) for leg pain and back pain, Oswestry Disability Index (ODI) scores, length of hospital stay, time taken to return to work, duration of surgery, intra- and post-operative complications, and reoperation rates. Results: The VAS score for leg pain, back pain, and ODI scores showed improvement in both groups during the 1st year after surgery. Time taken to return to work and mean hospital stay was shorter in case of TD as compared to MD group. The mean duration of surgery was 34 min shorter for conventional MD. The incidence of dural tear was 6.5% in MD group and 10.4% in early TD and decreased to 7.4% in late TD group. Conclusion: This study revealed that rate of recovery is significantly faster for TD as compared to conventional MD. In contrast, we encountered fewer complications in MD approach as compared to TD which although were not statistically significant and which also decreased as we gained experience.

A three-year-old girl presented with primary complaint of severe low back pain with radiation to both lower limbs below the knees since 2 months following history of fall and marked restriction of her daily routine activities. After clinicoradiological evaluation she was diagnosed of having dysplastic L5-S1 spondyloptosis. A staged procedure was planned after thorough discussion with her parents. During initial stage she underwent posterior decompression along L5-S1 segment including exposure of bilateral L5 and S1 nerve roots followed by instrumented reduction (L3-S2 5.5 mm pedicle screws) utilizing a rotational-translational technique. No interbody fusion was done at L5-S1 level and inner nuts of bilateral L3, L4, and S2 screws were intentionally kept loose. Subsequently after about symptom-free three-year follow up, she presented with recurrence of symptoms and underwent revision surgery as per initial plan discussed with her parents. Removals of posterior implants were done followed by stabilization with larger diameter pedicle screws (6.5 mm) at L5 and S1 level. During the same stage through anterior transperitoneal approach L5-S1 interbody fusion was done. At one-year follow-up after second-stage definitive surgery, patient remains symptom-free and fully active without any radiological evidence of reduction loss or implant failure.

Renal tubular acidosis (RTA) is a disorder of renal acidification characterized by inability to acidify urine to pH

Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) is a rare but well-reported clinical entity. It is classically described as symmetrical involvement of both upper extremities. Asymmetrical involvement had also been reported, but unilateral presentation is very rare. We hereby report a case of unilateral RS3PE in a patient of seronegative rheumatoid arthritis which was initially misdiagnosed as cellulitis and was given high dose antibiotics without any significant improvement. Later a rheumatologic consultation leads to a prompt diagnosis, and treatment with steroids leads to dramatic reversal of symptoms. This case demonstrates the rare presentation of this rare clinical entity and highlights the necessity of awareness regarding unilateral disease to clinicians.

Purpose: The objectives of this study are to describe the outcome of adolescent idiopathic scoliosis (AIS) patients treated with Video Assisted Thoracoscopic Surgery (VATS) plus supplementary minimal incision in the lumbar region for thoracic and lumbar deformity correction and fusion., Materials and Methods: This is a case series of 13 patients treated with VATS plus lumbar mini-open surgery for AIS. A total of 13 patients requiring fusions of both the thoracic and lumbar regions were included in this study: 5 of these patients were classified as Lenke type 1A and 8 as Lenke type 5C. Fusion was performed using VATS up to T12 or L1 vertebral level. Lower levels were accessed via a small mini-incision in the lumbar area to gain access to the lumbar spine via the retroperitoneal space. All patients had a minimum follow-up of 1 year., Results: The average number of fused vertebrae was 7.1 levels. A significant correction in the Cobb angle was obtained at the final follow-up (p = 0.001). The instrumented segmental angle in the sagittal plane was relatively well-maintained following surgery, albeit with a slight increase. Scoliosis Research Society-22 (SRS-22) scores were noted have significantly improved at the final follow-up (p < 0.05)., Conclusion: Indications for the use of VATS may be extended from patients with localized thoracic scoliosis to those with thoracolumbar scoliosis. By utilizing a supplementary minimal incision in the lumbar region, a satisfactory deformity correction may be accomplished with minimal post-operative scarring.

Study Design: Retrospective comparative study., Purpose: To study and compare the surgical outcomes of muscular dystrophy (MD) and spinal muscle atrophy (SMA)., Overview of Literature: There are few reports that have evaluated and compared the surgical outcomes of MD and SMA patients., Methods: The patients (n = 35) were divided into two groups: a MD group with 24 patients and a SMA group with 11 patients. The average follow-up period was 21 months. All patients were operated for scoliosis correction using posterior instrumentation and fusion. In the immediate postoperative period, all efforts were made to reduce the pulmonary complications using non-invasive positive pressure ventilation and a coughing assist devices. The patients were evaluated by radiograph in terms of the Cobb's angle, pelvic obliquity, T1 translation, thoracic kyphosis and lumbar lordosis. The pulmonary function and self-image satisfaction were also assessed., Results: There was a lower correction rate in the MD group (41.5%) than in the SMA group (48.3%), even though the curves were smaller in the MD group. The correction in the pelvic obliquity was significantly better in the SMA group (p = 0.03). The predicted vital capacity showed a 4% reduction in the MD group 1 year after surgery, while the SMA group showed a 10% reduction. The peak cough flow and end tidal PCO(2) did not deteriorate and were well maintained. The average score for the improvement in self-image satisfaction postoperatively was 3.96 and 4.64 for the MD and SMA groups, respectively. The total complication rate was 45.7%; 14.3% of which were respiratory-related., Conclusions: Surgical intervention for MD and SMA may be performed safely in patients with a very low forced vital capacity (< 30%) through aggressive preoperative and postoperative rehabilitation efforts.