Search

Sacral tumors are rare and can be benign or malignant. Their management is multifactorial and is based on the pathology, extent, and local and distant spread. Managing sacral tumors is challenging due to their proximity to visceral and neural structures. Surgical wide excision has been the standard of care for aggressive benign and malignant tumors. Our purpose was to evaluate the outcomes of a multimodal approach to managing primary sacral tumors in Sakra World Hospital, a tertiary spine care center in Bengaluru, India and perform a literature review to determine a workflow pathway. Our study was a retrospective review of patient records and included 15 patients with primary sacral tumors. Eleven surgically treated patients were evaluated clinically and radiologically and underwent biopsy before surgical excision by an all-posterior approach. A multidisciplinary approach that included intraoperative neural monitoring, plastic reconstruction, adjuvant chemotherapy, and radiotherapy was implemented whenever necessary. Sacral root preservation was attempted whenever feasible. Functional outcomes (based on the Visual Analog Scale [VAS] and Biagini scoring system) were analyzed along with disease control, with a minimum of 2 years of follow-up. The mean follow-up was 29±9.8 months. The mean VAS score significantly improved from 7.8±2.6 to 3.7±3.8 (p=0.026). Bowel function showed statistically significant improvement, from a mean score of 0.81±0.47 to 0.63±0.52 (p=0.026) at 2 years of follow-up. The mean pretreatment motor and bladder function scores were 0.53±0.31 and 0.74±0.44, respectively, improving to 0.48±0.33 and 0.68±0.56 at follow-up but without statistical significance. There was no significant loss of function, which is expected in radical sacral resections. In conclusion, primary sacral tumors require a multidisciplinary approach and management for optimal outcomes. A stand-alone posterior approach can be employed to treat most sacral lesions. En-bloc wide resection is the optimal treatment for primary malignant and aggressive benign tumors. Preservation of at least one functional S2 nerve root is imperative to preserve bowel and bladder function.

Study Design Retrospective observational study. Purpose To share our experience of multimodal intraoperative neurophysiological monitoring (IONM) used in Sakra World Hospital, Bengaluru in various spine surgeries. Overview of Literature The development of new onset postoperative neurological deficits can be completely avoided. In order to avoid these, IONM has become a standard of care in recent times for early detection and manipulation of the surgical procedure to prevent postoperative neurological deficits. Methods This retrospective study was performed on 408 patients who had undergone spine surgeries with IONM during April 2014 to March 2020 at a single center. The operative report, anesthesia record, and IONM were reviewed. All the patients were reassessed for postoperative neurological deficits in the postoperative period and followed up based on the intraoperative findings and neurological deficits for 4 weeks. Signal changes in IONM were reviewed, and the obtained results were further categorized into true positive, true negative, false positive, or false negative. If changes were observed during the IONM, the patients were managed as per the algorithm. Results Of the 408 patients being monitored continuously during the intraoperative period, 38 showed changes in recordings, 28 developed postoperative neurological deficits, and one developed neurological deficit without any change in the IONM. Nine patients had transient neurological deficits, and the other 20 had permanent neurological deficits. Overall, the multimodal IONM used in our study had a sensitivity of 96.6%, specificity of 97.4%, a positive predictive value of 73.7%, and a negative predictive value of 99.7%. Conclusions Use of decision algorithm and multimodal neuromonitoring consisting of motor evoked potentials, somatosensory evoked potentials, and electromyography complement each other in the detection of neurological injury during the course the surgery, improve intraoperative care, and prevent further damage and morbidity in patients.

Background: Osteoporotic fracture of vertebrae is the presentation of osteoporosis, in most elderly patients and treatment of these fractures aims in pain relief, correction of kyphosis and management of osteoporosis. The purpose of the study is to evaluate the clinical usefulness of cement augmentation and the ability of cement augmented vertebrae to withstand physiological axial load. Materials and methods: We did a retrospective analysis of all patients (62 patients and 67 vertebrae) from 2015 to 2019 in whom a stand-alone percutaneous cement augmentation was done for primary osteoporotic vertebral fractures. The kyphotic angle (KA), wedge angle (WA) and anterior vertebral height (AVH) were measured in radiographs taken pre-operatively and post-operatively in slump sitting and supine position. The mobility of the vertebra was determined radiologically by the difference in KA, WA and AVH in two positions (slump sitting and supine) and were compared. Functional outcome was analyzed using VAS scores for back pain. Results: The mean age group was 67.66 + 11.49 years, with thoracolumbar region being the most commonly involved. There was a significant improvement in back pain scores post cement augmentation from a pre-operative VAS of 6.91 ± 1.7 to a post-operative VAS score of 1.74 ± 1.1. The kyphotic deformity parameters like KA, WA and AVH also improved post cement augmentation. The difference of KA, WA and AVH between sitting and supine position preoperatively were 4.85 ± 6.87degrees, 2.61 ± 6.35 degrees and 0.26 ± 0.47 cm. The difference of post-operative KA, WA and AVH in two different positions was 1.02 ± 0.76 degrees, 0.05 ± 0.21 degrees and 0.03 ± 0.04 and were statistically significant than pre-operative measurements. Conclusion: The cement augmentation technique in addition to pain relief, it also improves the kyphotic deformity of the fractured vertebrae. The kyphotic deformity correction achieved by the procedure remain sustained even in physiological axial loading of the cement augmented vertebra.

Anterior thoracic spinal cord herniation (ATSCH) is a rare cause of progressive neurological dysfunction of lower limbs where a portion of spinal cord tissue herniates through a ventral dural defect. We report a 19-year adolescent male who presented with myelopathy (Frankel D) secondary to ATSCH at D7 level and managed surgically by Anterior Patching of Dura. He worsened neurologically on the first post-operative day to Frankel B secondary to spinal cord oedema and underwent decompressive expansile duraplasty. The use of bedside neural monitoring helped in timely re-exploration and prognostication, as the patient recovered to normal neurological status in 6 months. This case report is to emphasise on considering the option of Expansile duraplasty while closing the posterior durotomy in ATSCH of more than 10 mm to prevent post-operative neurological worsening. Apart from its intra-operative applicability, electrophysiological testing could be an useful bedside tool to prognosticate neurological events in ATSCH.

Pyogenic Spondylodiscitis is a common affliction of the spine in which microorganism can spread by either direct or indirect route destroys the disc and vertebral end plates. Contiguous spread from nearby structures like mediastinum, oesophagus, intestines, penetrating injuries are well known. We report one such case where Self-expanding metallic [SEM] stenting done for Boerhaave syndrome lead on to T3-4 Spondylodiscitis with pathological fracture resulting in acute paraplegia as a complication. Spinal complications related to oesophageal stents are rarely reported in literature. We present our experience in managing this catastrophic presentation with a review of literature of similar cases. Keywords: Spondylodiscitis, Self-expanding metallic esophageal stent, Boerhaave syndrome

Introduction: Lumbar interbody fusion has become the standard of care for the management of lumbar instability, where fusion is achieved using bone grafts, cages, etc. Aim: The aim of the study was to compare the outcomes of the interbody fusion using interbody cage technique and stand alone local bone graft technique. Materials and Methods: A total of 30 patients, operated for single level instability with low grade lytic and degenerative spondylolisthesis of L4-5/L5-S1, were selected and grouped into two groups: Group I (stand alone grafts) and Group II (interbody cage and graft) based on computer generated random numbers. All patients who underwent interbody fusion through conventional open posterior approach were included in the study. Data regarding the time taken for interbody fusion, formaninal height maintenance, disc height restoration, translation, functional scores (VAS,ODI) and operative complications were analysed using in both the groups was collected and a student's-t test was performed to evaluate the difference. Results: The mean age of patients in Group I was 46.7 years whereas, the mean age of patients in Group II was 43.5 years with mean age of 46.7 years and 43.5 years respectively. Interbody fusion, was achieved in seven and eight months in Group I and II respectively (p>0.05). The clinical results of both groups were comparable and there was no significant difference between the two groups in VAS score (p-0.147) and ODI score (p-0.983). Radiological parameters were also comparable and there was no significant difference between the postoperative measurements of the two groups (p=0.348 for translation, p=0.310 for intervertebral disc height and p=0.135 for foraminal height). One patient in Group I had transient foot drop which recovered, while one in Group II had infection, wound was managed with wound wash and antibiotics and another patient in Group II had pseudoarthrosis. Conclusion: Lumbar interbody fusion with standalone local bone grafts is sufficient in single level low grade spondylolisthesis treated by conventional open surgery.

Introduction: The distal humeral fractures are common fractures of upper limb and are difficult to treat. These fractures, if left untreated or inadequately treated, leads to poor outcomes. Management of distal humeral fractures are pertained to many controversies and one among them is position of plates. Aim: To compare the clinical and radiological outcomes in patients with intra-articular distal humerus fractures, treated using parallel and perpendicular double plating methods. Materials and Methods: A total of 38 patients with distal humerus fractures, 20 in perpendicular plating group (group A) and 18 in parallel plating group (group B), were included in this prospective randomised study. At each follow up patients were evaluated clinically and radiologically for union and the outcomes were measured in terms of Mayo Elbow Performance Score (MEPS) consisting of pain intensity, range of motion, stability and function. MEP score greater than 90 is considered as excellent; Score 75 to 89 is good; Score 60 to 74 is fair and Score less than 60 is poor. Results: In our study, 15 patients (75%) in group A, and 13 patients (72.22%) in group B achieved excellent results. Two patients (10%) in group A and 4 patients (22.22%) in group B attained good results. Complications developed in 2 patients in each groups. No significant differences were found between the clinical outcomes of the two plating methods. Conclusion: Neither of the plating techniques are superior to the other, as inferred from the insignificant differences in bony union, elbow function and complications between the two plating techniques.