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Study Design A retrospective cohort study. Purpose To determine outcomes following all-posterior surgery using computed tomography navigation, hybrid stabilization, and multiple anchor point techniques in patients with neurofibromatosis type 1 (NF-1) and dystrophic scoliosis. Overview of Literature Previous studies favored antero-posterior fusion as the most reliable method; however, approaching the spine anteriorly was fraught with significant complications. With the advent of computer assisted navigation and multiple anchor point method, posterior only approach is reporting successful outcomes. Methods This study included patients who underwent all-posterior surgical deformity correction for dystrophic NF-1 curves. Coronal and sagittal Cobbs angles, apical rotation, and the presence of dystrophic features were evaluated before surgery. Postoperatively, sagittal, coronal, and axial correction, implant position, and implant densities were evaluated. The decline in curve correction and implant-related complications were evaluated at follow-up. Clinical outcomes were evaluated using the Scoliosis Research Society-22 revised index. Results This study involved 50 patients with a mean age of 13.6 years and a mean follow-up duration of 5.52 years. With a mean coronal flexibility of 18.7%, the mean apical vertebral rotation (AVR), preoperative coronal Cobb angle, and sagittal kyphosis were 27.4°, 64.01°, and 47.70°, respectively. The postoperative mean coronal Cobb angle was 30.17° (p

Study Design A retrospective cohort study. Purpose This study aimed to understand the role of magnetic resonance imaging (MRI) in predicting neurological deficits in traumatic lower lumbar fractures (LLFs; L3–L5). Overview of Literature Despite studies on the radiological risk factors for neurological deficits in thoracolumbar fractures, very few have focused on LLFs. Moreover, the potential utility of MRI in LLFs has not been evaluated. Methods In total, 108 patients who underwent surgery for traumatic LLFs between January 2010 and January 2020 were reviewed to obtain their demographic details, injury level, and neurology status at the time of presentation (American Spinal Injury Association [ASIA] grade). Preoperative computed tomography scans were used to measure parameters such as anterior vertebral body height, posterior vertebral body height, loss of vertebral body height, local kyphosis, retropulsion of fracture fragment, interpedicular distance, canal compromise, sagittal transverse ratio, and presence of vertical lamina fracture. MRI was used to measure the canal encroachment ratio (CER), cross-sectional area of the thecal sac (CSAT), and presence of an epidural hematoma. Results Of the 108 patients, 9 (8.3%) had ASIA A, 4 (3.7%) had ASIA B, 17 (15.7%) had ASIA C, 21 (19.4%) had ASIA D, and 57 (52.9%) had ASIA E neurology upon admission. The Thoracolumbar Injury Classification and Severity score (p=0.000), CER (p=0.050), and CSAT (p=0.019) were found to be independently associated with neurological deficits on the multivariate analysis. The receiver operating characteristic curves showed that only CER (area under the curve [AUC], 0.926; 95% confidence interval [CI], 0.860–0.968) and CSAT (AUC, 0.963; 95% CI, 0.908–0.990) had good discriminatory ability, with the optimal cutoff of 50% and 65.3 mm2, respectively. Conclusions Based on the results, the optimal cutoff values of CER >50% and CSAT >65.3 mm2 can predict the incidence of neurological deficits in LLFs.

Study Design Retrospective study. Purpose To investigate the radiological phenotype, patient and surgery-related risk factors influencing postoperative clinical outcome for cervical myelopathy caused by ossification of the posterior longitudinal ligament involving C2 following posterior instrumented laminectomy and fusion. Overview of Literature Ossified posterior longitudinal ligament (OPLL) is caused by ectopic ossification of the posterior longitudinal ligament. It can cause neurological impairment and severe disability. For multilevel cervical OPLL, studies have shown good neurological recovery following cord decompression via either an anterior or posterior approach. There is, however, a lacunae in the literature regarding the outcomes of patients with OPLL extending to C2 and above (C2 [+]). Methods We retrospectively studied 61 patients with C2 (+) OPLL who had posterior instrumented laminectomy and fusion at Ganga Hospital, Coimbatore between July 2011 and January 2021, with a minimum follow-up of 2 years. Data on demographics, clinical outcomes, radiology, and post-surgical outcomes were gathered. Results Among 61 patients, 56 were males and five were females. The OPLL pattern was mixed in 32 cases (52.5%), continuous in 26 cases (42.6%), segmental in two cases (3.3%), and circumscribed in one patient (1.6%). All of our patients showed signs of neurological improvement after a 24-month follow-up. The mean preoperative modified Japanese Orthopaedic Association (mJOA) score was 10.6 (range, 5–11) and the postoperative mJOA score was 15.8 (range, 12–18). The recovery rate was >75% in 27 patients (44.6%), >50% in 32 patients (52.5%), and >25% in two patients (3.3%). The average recovery rate was 71% (range, 33%–100%). The independent risk factor for predicting recovery rate is the preoperative mJOA score. Conclusions In C2 (+) OPLL, posterior instrumented decompression and fusion provide a relatively safe approach and satisfactory results.

Background: Spinal tuberculosis (TB) is the most common extrapulmonary form of tuberculosis. In both developing and developed countries, TB has been on the rising trend due to factors such as increasing HIV coinfection, multidrug resistance of the organism, and global migration. Spinal TB, which most often affects the lower thoracic and thoracolumbar area, accounts for 50% of all musculoskeletal tuberculosis. Methods: Using the Cochrane Database of Systematic Reviews, EMBASE, and PubMed, a systematic computerized literature search was performed. Analyses of studies published within the past 10 years were conducted. The searches were performed using Medical Subject Headings terms, with “spinal tuberculosis,” “diagnosis,” “epidemiology,” and “etiology”,“management,” “surgery,” and “therapy” as subheadings. Results: Progressive collapse, kyphosis, and neurological deficiency are hallmarks of the disease because of its destructive effect on the intervertebral disc and adjacent vertebral bodies. The condition may be identified using laboratory testing and distinctive imaging features, but the gold standard for diagnosis is tissue diagnosis using cultures, histology, and polymerase chain reaction. Uncomplicated spinal TB is today a medical condition that can be adequately treated by multidrug ambulatory chemotherapy. Surgery is reserved for individuals who have instability, neurological impairment, and deformity correction. Debridement, deformity correction, and stable fusion are the cornerstones of surgical treatment. Conclusions: Clinical results for the treatment of spinal TB are generally satisfactory when the disease is identified and treated early. However, the major health issue and the biggest obstacle in achieving the goals of the “End TB strategy” is the recent rise in the emergence of drug resistance. Hence strict vigilance and patient perseverance in the completion of the treatment is the main need of the hour.

Study Design Retrospective cohort. Purpose The current study was planned to evaluate deformity characteristics, assess relationship between morphology of syrinx/ Arnold Chiari malformation (ACM) and deformity, analyze effect of posterior fossa decompression (PFD), and evaluate outcome. Overview of Literature: Scoliosis in ACM-I and syringomyelia (SM) is uncommon, and deformity characteristics differ from those seen in idiopathic scoliosis. Methods Data regarding patients, who underwent PFD for ACM-I presenting with SM and scoliosis between January 2009 and December 2018, were retrospectively collected. Only patients with 2-year follow-up were included. Sagittal/coronal deformity and sagittal spinopelvic parameters were examined. Symmetry and extent of tonsillar descent, as well as morphology (configuration/variation) and extent of syrinx were determined. Results A total of 42 patients (20 females; age: 14.2±5.8 years) were included; 35 patients (83.3%) had atypical curves. Mean preoperative coronal Cobb was 57.7°±20.9°; and 12 (28.6%) had significant coronal imbalance. Tonsillar descent was classified as grade 1, 2, and 3 in 16 (38.1%), 11 (26.2%), and 15 (35.7%) patients; 35 patients (83.3%) had asymmetric tonsillar descent; 17 (40.4%), 3 (7.1%), 16 (38.1%), and 6 (14.4%) had circumscribed, moniliform, dilated, and slender syrinx patterns; and 9 (21.4%), 12 (28.6%), and 21 (50%) of syrinx were right-sided, left-sided, and centric. There was no significant relationship between side of tonsillar dominance (p=0.31), grade of descent (p=0.30), and convexity of deformity. There was significant association between side of syrinx and convexity of scoliosis (p=0.01). PFD was performed in all, and deformity correction was performed in 23 patients. In curves ≤40°, PFD alone could stabilize scoliosis progression (p=0.02). There was significant reduction in syrinx/cord ratio following PFD (p40°.

Study Design Profiling proteins expressed in the nucleus pulposus (NP) of intervertebral discs (IVDs) in five different biological states. Purpose To evaluate the molecular complexity of the collagen (COL) framework and its role in the health and disease of human IVDs. Overview of Literature Changes in COL composition have been linked to degenerative disk disease (DDD). Despite the fact that humans have 28 different types of COLs, most of the literature focuses solely on COL-1 and COL-2. This study used high-end proteomic technology to examine the entire COL composition of the human IVD across fetal (developmental-FD), normal (healthy-ND), scoliotic (early degeneration-SD), herniated (degenerate-DH), and degenerated (DD) disk phenotypes. Methods Forty NP tissues were snap-frozen in liquid nitrogen (−196°C) immediately before being subjected to proteomic and bioinformatic analyses from five different disk phenotypes (eight each). Results Tandem mass spectrometric analysis revealed a total of 1,050 proteins in FDs, 1,809 in ND, 1,487 in SD, 1,859 in DH, and 1,538 in the DD group. Of 28 major collagens reported in the human body, this study identified 24 different collagens with 34 subtypes in NP. Fibril-forming collagens (COL-1, 2, and 11A1) and fibril-associated collagens with interrupted triple helices (COL-9A1, 12A1, and 14A1) were abundantly expressed in FDs, representing their role in the development of NP. Multiplexin (COL-15), a hybrid proteoglycan–collagen molecule, was discovered only in FDs. Degeneration was associated with COL2A1 downregulation and COL-10A1 upregulation. Conclusions COL10 was discovered to be a new biomarker for disk degeneration. Besides COL-1 and 2, other important COLs (6, 9, 11, 12, 14, 15) with anabolic potential and abundant expression in the fetal phenotype could be investigated for tissue engineering and novel DDD therapy.

Study Design This was a retrospective study. Purpose To analyze the surgical and neurological outcomes following surgical decompression in patients with aggressive vertebral hemangioma (AVH) presenting with neurological deficit and to determine whether a less extensive approach is appropriate. Overview of Literature AVHs are a rare subset of benign vascular tumors frequently presenting with neurological deficit because of spinal cord compression. Though the results of surgical management have improved over time, there is a lack of consensus on the ideal management in this group of patients. Methods Twenty-one patients who underwent surgery for AVH between 2009 and 2018 were analyzed. Demographic and clinical details of patients were retrieved from hospital information system. Imaging information (i.e., radiography, computed tomography, magnetic resonance imaging) of all patients was accessed and analyzed in picture archiving and communication system. Tumor staging was performed using Enneking and Weinstein–Boriani–Biagini classifications and Spinal Instability Neoplastic Score. At follow-up, neurological and radiological evaluations were performed. Results Twenty-one patients (13 [61.9%] females and 8 [38.1%] males) were included with a mean age of 44.29 years (range, 14–72 years). All patients in the study had neurological deficit. Back pain was present in 80.9% of patients. Mean duration of symptoms was 4.6 months (range, 1 day to 10 months). Most common lesion location was thoracic spine (n=12), followed by thoracolumbar (D11–L2; n=7) and lumbar (n=2) regions. Ten patients had multiple level lesions. All patients underwent preoperative embolization. Nine patients underwent intralesional spondylectomy with reconstruction; another nine patients underwent stabilization, decompression, and vertebroplasty; three patients underwent decompression and stabilization. Neurology improved in all patients, and only one case of recurrence was noted in a mean follow-up of 55.78±25 months (range, 24–96 months). Conclusions In AVH, good clinical and neurological outcomes with low recurrence rates can be achieved using less extensive procedures, such as posterior instrumented decompression with vertebroplasty and intralesional tumor resection.

Osteoblastoma is a benign bone tumor that accounts for 10% of all spinal tumors and mostly arises from the posterior spinal elements. Isolated vertebral body osteoblastoma is relatively rare and generally requires extensive surgery. We report a rare case of L4 vertebral body osteoblastoma, which was managed successfully by computer navigation-guided transpedicular excision. A 22-year-old female presented with progressive lower back pain for the past six months. Radiological investigation revealed a sclerotic lesion involving the anterior cortex with a prominent central nidus in the anterior part of the L4 vertebral body. Based on the lesion size, a diagnosis of benign osteoblastoma (Enneking stage 2) was made, and she underwent computer navigation-assisted intralesional excision of the lesion by the bilateral transpedicular route. Histopathological examination confirmed the diagnosis of osteoblastoma. In the immediate postoperative period, the patient was completely relieved of symptoms, and the final follow-up magnetic resonance imaging showed no evidence of recurrence at the end of seven years. The intraoperative 3D navigation technology allowed a transpedicular minimal access approach to excise an osteoblastoma of the L4 vertebral body while preserving intervertebral stability and decreasing morbidity.

Spine surgery has witnessed exponential technological innovation over the past few decades to overcome the challenges of complex surgeries, reduce complications, and increase safety. Advancements have occurred in biologics, implants, operative techniques, and equipment such as navigation and surgical robotics. In addition to patient safety, these technologies protect the operating personnel from the harmful effects of radiation. Navigation provides simultaneous and multiplanar visualization of anatomy, real-time feedback of instruments, and implant position, which, in turn, improves the accuracy and hand–eye coordination of the surgeon. Robotics further improves outcomes by reducing human error through increased precision in execution, indefatigability, motion scaling, and tremor filtration via mechanical actuation. This review provides an overview of the current navigation and robotic systems in spine surgeries and their role in the safety and prevention of surgical complications.

Axial melorheostosis is rare with only few cases reported and even fewer with symptoms. While symptoms secondary to neural foramen or spinal canal stenosis caused by hyperostotic bone are common, only three symptomatic cases of spinal melorheostosis with associated intradural lipomatous lesions have been reported to date. In none of them the fibrous component of lipofibromatous lesion was identified preoperatively on magnetic resonance imaging. We report here a case of 18-year-old male who presented with thoracic myelopathy secondary to widespread spinal melorheostosis associated with extensive intradural lipomatosis and fibrous component in thoracic lipoma, causing tethering of thoracic spinal cord and myelomalacia. The patient was treated with T2 to T9 posterior instrumented stabilization followed by T3 to T8 laminectomy along with selective thoracic lipofibromatous tumor debulking. Detection of the fibromatous component in multilevel extensive intradural lipomatosis associated with melorheostosis is helpful in planning selection of the level of surgical excision and decompression.

Study Design Prospective observational study. Purpose In this study, we determined the effects of lumbar disk herniation (LDH) on male sexual activity and whether surgical intervention improved any related sexual dysfunction. Overview of Literature The impact of surgery on sexual activity has been extensively studied in arthroplasty, uro-gynecological surgery, and stroke, but there are relatively few studies on spine surgery, and none involve an Asian population to the best of our knowledge. Methods We evaluated sexually active male patients (n=22, 40.8±6.8 years) admitted for microdiscectomy with a questionnaire for assessing sexual function before and 8 weeks after surgery. The questionnaire included the Oswestry Disability Index, Hospital Anxiety Depression Score, and Brief Sexual Function Inventory (BSFI), as well as questions about perceived sexual dysfunction (frequency, performance, satisfaction). Results The average preoperative Visual Analog Scale (VAS) score was 4.36±2.59 (n=18) for low back pain (LBP) and 6.81±2.1 (n=22) for leg pain. The mean preoperative BSFI score was 27.8±11.2. Among the five BSFI components, sexual drive was reduced in 63.0% of patients, while erection and ejaculation were affected in 40.9% and 31.8%, respectively. The VAS score for LBP had a negative correlation with the preoperative BSFI score (p

Objective Various techniques of performing lumbar discectomy are prevalent, each having its rationale and claimed benefits. The authors ventured to assess the total complication rate of lumbar discectomy as well as the complication rates of individual complications, namely CSF leaks, superficial wound infections, deep wound infections, recurrence rates, re-operation rates, and wrong level surgery. Methods This was a retrospective study of patients operated using open discectomy (OD), microdiscectomy (MD), microendoscopic discectomy (MED), interlaminar endoscopic lumbar discectomy (IELD), transforaminal endoscopic lumbar discectomy (TELD), and Destandau techniques (DT) with a minimum follow-up of 2 years. The inclusion criteria were age>15 years, failed conservative treatment for 4-6 weeks, and the involvement of a single lumbar level. Results There is no statistically significant association between surgical technique and complications. The total complication rate was 12.89% in 946 operated cases. The most common complication was recurrence (5.81%), followed by re-operation (3.69%), CSF leak (1.90%), wrong level surgery (0.63%), superficial infection (0.52%) and deep infection (0.31%). There were minor differences in the incidence of complications between techniques. Conclusion This is the first study to compare the complication rates of all the prevalent discectomy techniques across the globe in 946 patients. Although there were minor differences in incidences of complications between individual techniques, there was no statistical significance. The various rates of individual complications provide a reference value for future studies related to complications following discectomy.

Background: Citrobacter species being a gram-negative, facultatively anaerobic bacteria affects extremes of age groups. Case report: We report a case of 27-yearold male with no associated comorbidities diagnosed with lumbar spondylodiscitis caused by C.koseri infection. He was managed conservatively and treated successfully with appropriate antibiotics. Conclusion: Spondylodiscitis due to C.koseri spondylodiscitis can occur in young healthy adults. Early diagnosis by blood or tissue culture & prompt medical treatment is essential for a good outcome.

Subaxial cervical spine injuries are common and encompass a spectrum of injuries ranging from a minor ligamentous sprain to fracture dislocation with spinal cord injury. These injuries are often missed in the initial evaluation, and a high index of suspicion is needed to evaluate and diagnose these injuries, which otherwise could lead to spinal cord injury. Computed tomography scans are the gold standard in the evaluation of fractures as plain radiographs have limited sensitivity. Magnetic resonance imaging (MRI) is necessary to identify injury to the disco-ligamentous complex and to assess cord injury. The principles of the treatment of cervical spine injuries include early immobilization to prevent secondary neurological injury, achieving alignment by reduction and stabilization of the unstable injured segment and decompression of the cord in the presence of cord injury. Owing to a broad spectrum of injuries, there is no unified approach, and the management plan depends on the morphology of injury, the extent of structures damaged, and the presence of neurological impairment. Various classifications grade and help assess the severity of the injury. Minor injuries are conservatively managed with cervical orthoses, and unstable injuries require stabilization either anterior, posterior, or combined approaches, depending on the injury morphology. Controversy exists over the safety of closed reduction in facetal subluxations, need for pre-reduction MRI, and the ideal approach for each injury. This review presents the current evidence and guidelines on the management of subaxial cervical spine injuries.

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 Randomized controlled trial. Purpose To compare the functional and radiological outcomes of anterior cervical discectomy and fusion (ACDF) using local graft and allograft Overview of Literature The choice of bone grafts for ACDF varies among different types: iliac crest, allograft, and substitutes. Availability, cost, and donor site morbidity are potential disadvantages. Local osteophyte grafts are then advantageous and shows to have good fusion. Methods We randomly sampled participants requiring a single level ACDF for degenerative conditions (n=27) between allograft (n=13) and local graft (n=14) groups. Follow-up of patients occurred at 6 weeks, 3 months, 6 months, and 1 year using Numerical Pain Rating Scale (NPRS) scores for arm and neck pain, Neck Disability Index (NDI), 2-item Short Form Health Survey (SF-12), and lateral disk height. We then assessed radiological fusion using computed tomography (CT) scan at 12 months, and graded as F− (no fusion), F (fusion seen through the cage), F+ (fusion seen through the cage, with bridging bone at one lateral edge), and F++ (fusion seen through cage with bridging bone bilaterally). Results There were no significant differences in the age, sex, duration of intervention, blood loss, and hospital stay between the two groups (p>0.05). Both groups showed significant improvements in all functional outcome scores including NPRS for arm and neck pain, NDI, and SF-12 at each visit (p

Study Design This is a retrospective study. Purpose Recent advances in intraoperative imaging and closed reduction techniques have led to a shifting trend toward surgical management in every unstable sacral fracture. This study aimed to evaluate the clinicoradiological outcome of the sacroiliac (SI) screw and lumbopelvic fixation (LPF) techniques and thereby delineate the indications for each. Overview of Literature Optimal management guidelines for unstable sacral fractures are still lacking probably due to the rarity of these injuries and varying fixation trends. Methods Out of the 67 patients, 40 and 27 were in the SI and LPF groups, respectively. The electronic medical record for each patient was reviewed, including patient demographic data, mode of trauma, coexisting injuries, neurological status (Gibbon’s four-grade system), Injury Severity Score, time from admission to operative stabilization, type of surgical stabilization, complications, return to the operating room, and treatment outcome measures using Majeed’s functional grading system and Matta’s radiological criteria. The minimum follow-up period was 2 years. Results Noncomminuted longitudinal injuries with normal neurology and acceptable closed reduction have undergone SI screw fixation (n=40). Irreducible, comminuted, or high transverse fractures associated with dysmorphic anatomy or neurodeficit were managed by LPF (n=27). Excellent and good Majeed and Matta scores at 86.57% and 92.54% of the patients, respectively, were postoperatively achieved. Conclusions Unstable sacral fractures can be effectively managed with percutaneous SI screw including vertically unstable injuries by paying strict attention to preoperative patient selection whereas LPF can be reserved for comminuted fractures, unacceptable closed reduction, associated neurodeficit, lumbosacral dysmorphism, and high transverse fractures.

Study designThe diversity of microflora inhabiting endplate (EP) and nucleus pulposus (NP) tissues of human intervertebral disc (IVD) was profiled through NGS-supported 16S rRNA amplicon sequencing. Sixteen EP and their corresponding NP were excised from the brain-dead voluntary organ donors with no clinical history of low back pain, and 12 herniated and 8 degenerated NP tissues isolated from the patients undergoing spinal surgery were subjected to study the alteration in the microbial diversity.Objective(s)To understand in normal IVD, whether the colonization of bacteria to the NP is through the EP in discs with intact annulus fibrosus. To identify significantly differing microbial population(s) between normal and diseased IVD (NP).Background of the studyThere is increasing evidence for subclinical infection by fastidious low, growing bacteria to be a cause of disc degeneration. Although the presence of bacteria in NP has been reported well in literature, the source of bacteria is not clearly proved as the disc is avascular in healthy condition. Documentation of similar bacterial populations in the EP and NP may add proof that bacterial inoculation of NP occurs via the EP.Materials and methodsSixteen EP and their corresponding NP excised from brain-dead voluntary organ donors with no history of back pain and 20 diseased discs collected from patients undergoing microdiscectomy/fusion surgery were used for profiling microbiome through 16S rRNA amplicon sequencing using primers specific for V1-V9 hypervariable regions. Changes in bacterial diversity and abundance were analysed to identify the key microbial populations in normal IVD NP and EP tissues and those significantly altered in diseased IVD (NP).ResultsNP and EP shared a similar spectrum of microbiome but with varying abundance. The five dominant phyla identified were Proteobacteria, Firmicutes, Actinobacteria, OD1, and Bacteroidetes. Proteobacteria was found to be the most abundant phyla in both NP (62%) and EP (53%) of the normal IVD. This was followed by Firmicutes (16%), Actinobacteriota (11%), OD1 (Parcubacteria) (7.6%), and Bacteroidetes (2%) in NP and Firmicutes (23.4%), OD1 (Parcubacteria) (17.6%), Actinobacteriota (2.8%), and Bacteroidetes (2.6%) in EP, respectively. Under diseased conditions, Proteobacteria (68%) was dominant when compared with other phyla. However, there was no significant difference in the abundance of Proteobacteria between the normal and diseased discs. Interestingly, the other dominant phyla such as Firmicutes (Normal-NP: 16.2%; Diseased-NP: 4.02%) and Actinobacteria (Normal-NP: 11%; Diseased-NP: 0.99%) showed a significant reduction in degenerated discs. To understand the key microbial populations that are significantly altered during disease, correlation analysis was performed among the three phyla, which revealed a negative correlation in the ratio of Actinobacteria + Firmicutes vs. Proteobacteria (p = 0.001) in DD.ConclusionResults of our study clearly demonstrated a similar bacterial diversity but with varying abundance between the EP and NP, suggesting the existence of the endplate–nucleus pulposus axis in the normal IVD microbiome. Further, our results have indicated that the changes in the abundance of Actinobacteria + Firmicutes vs. Proteobacteria during DDD need further investigation.

Study Design Prospective case series. Purpose This study aimed to investigate the impact of education, financial income, occupation, and patient counseling on the timing of enrolment in a spinal cord injury (SCI) rehabilitation program. Overview of Literature A rehabilitation program following SCI is essential to improve functional outcomes. Socioeconomic factors can affect the timing of enrolment to a rehabilitation program. Literature on the effects of socioeconomic factors among patients with SCI in the Indian scenario is limited. Methods A prospective, consecutive analysis of patients with SCI was performed with 1-year follow-up. Assessment of the timing of enrolment to a rehabilitation program was performed using the modified Kuppuswamy socioeconomic scores (MKSS). Patients admitted to the SCI unit (group A), underwent intensive individual, group, and family counseling sessions to encourage early enrolment into a rehabilitation program. Patients presenting directly for rehabilitation (group B) were analyzed for comparison. Results A total of 153 patients were recruited. Group A was composed of 122 patients who started the rehabilitation program after a mean of 28 days, compared with a mean of 149 days for 31 patients in group B. In group A, 104 patients (85%; mean MKSS, 14.02) and 18 patients (15%; mean MKSS, 15.61) enrolled for rehabilitation 0.05). Conclusions Early patient counseling in the acute care unit helps in the early enrolment of patients with poor socioeconomic demographic profile to a rehabilitation program.

Spondylolysis is an important cause of low back pain in children and adolescents, especially in those involved in athletic activities. Spondylolysis is caused either by a fracture or by a defect in the pars inter-articularis and can be unilateral or bilateral. Among the various hypotheses regarding the etiopathogenesis of pars lysis, the occurrence of chronic micro-fractures secondary to repetitive extension and rotational stresses across pars remains the most convincing explanation to date. The majority of these patients remain asymptomatic. Imaging contributes to the staging and prognostication of the lesions, planning the line of management, and monitoring the response to treatment. Nonoperative treatment with activity restriction, braces, graded physiotherapy, and rehabilitation forms the cornerstone of management. Surgery is indicated in a specific cohort of patients whose symptoms persist despite an adequate conservative trial and includes spinal fusion and pars defect repair techniques. Patients who demonstrate good pain relief after diagnostic pars infiltration can be considered for pars repair. Patients aged ≤25 years, those with an athletic background, unilateral pathologies, and those without associated spondylolisthesis, instability, or disc degeneration are ideal candidates for pars repair. The overall outcome in spondylolysis is good, and 85% to 90% of athletes return to sports at 6 months following conservative or surgical line of treatment. In this current narrative review, we comprehensively discuss the etiology, patho-anatomy, natural history, clinical features, diagnostic modalities, and management of spondylolysis with special emphasis on direct repair techniques of pars.

Study Design Retrospective study. Purpose Postoperative wound complications occurring after transforaminal lumbar interbody fusion (TLIF) are unique, as they can involve different tissue zones (subcutaneous, subfascial, osseous, peri-implant, and disc). Overview of Literature Management of postoperative infections occurring after TLIF remains controversial in the context of retention or removal of implants. Methods A total of 1,279 consecutive patients (1,520 segments) who underwent TLIF with a minimum follow-up of 1 year were analyzed. Patients with wound complications were classified anatomically into the following five types: type 1, suprafascial necrosis; type 2, wound dehiscence; type 3, pus around screws and rods; type 4, bone marrow edema; and type 5, pus in the disc space. Details pertaining to clinicoradiological and laboratory findings and management were also recorded. Results Of the 62 patients (4.8%) with wound complications, there were seven patients in type 1, 35 in type 2, 10 in type 3, four in type 4, and six in type 5. Patients in types 1 and 2 manifested delayed wound healing and were systemically well. In type 1, five patients were managed with resuturing and two were managed conservatively. In type 2, all patients had wound gaping and were managed by debridement, whereas three patients required vacuum-assisted closure. Patients in type 3 had severe back pain and fever, with demonstrable pus around the screw site. Tissue culture identified organisms in 90% of the patients. Patients in type 4 presented with increasing back pain, and magnetic resonance imaging revealed vertebral bone marrow edema. Those in type 5 had severe back pain and fever, with demonstrable pus in the disc space. Patients in types 3–5 required debridement, implant revision/retention, and long-term antibiotics. Conclusions The new anatomical classification of surgical site infections could help grade the severity of infection and provide tangible treatment guidelines, resulting in better infection clearance and patient outcomes.

Study Design Multicenter validation study. Purpose To evaluate the inter-rater reliability of Rajasekaran’s kyphosis classification through a multicenter validation study. Overview of Literature The classification of kyphosis, developed by Rajasekaran, incorporates factors related to curve characteristics, including column deficiency, disc mobility, curve magnitude, and osteotomy requirements. Although the classification offers significant benefits in determining prognosis and management decisions, it has not been subjected to multicenter validation. Methods A total of 30 sets of images, including plain radiographs, computed tomography scans, and magnetic resonance imaging scans, were randomly selected from our hospital patient database. All patients had undergone deformity correction surgery for kyphosis. Twelve spine surgeons from the Asia-Pacific region (six different countries) independently evaluated and classified the deformity types and proposed their surgical recommendations. This information was then compared with standard deformity classification and surgical recommendations. Results The kappa coefficients for the classification were as follows: 0.88 for type 1A, 0.78 for type 1B, 0.50 for type 2B, 0.40 for type 3A, 0.63 for type 3B, and 0.86 for type 3C deformities. The overall kappa coefficient for the classification was 0.68. Regarding the repeatability of osteotomy recommendations, kappa values were the highest for Ponte’s (Schwab type 2) osteotomy (kappa 0.8). Kappa values for other osteotomy recommendations were 0.52 for pedicle subtraction/disc-bone osteotomy (Schwab type 3/4), 0.42 for vertebral column resection (VCR, type 5), and 0.30 for multilevel VCRs (type 6). Conclusions Excellent accuracy was found for types 1A, 1B, and 3C deformities (ends of spectrum). There was more variation among surgeons in differentiating between one-column (types 2A and 2B) and two-column (types 3A and 3B) deficiencies, as surgeons often failed to recognize the radiological signs of posterior column failure. This failure to identify column deficiencies can potentially alter kyphosis management. There was excellent consensus among surgeons in the recommendation of type 2 osteotomy; however, some variation was observed in their choice for other osteotomies.

Study Design Prospective observational study. Purpose To assess the safety, efficacy, and benefits of computed tomography (CT)-guided C1 fracture fixation. Overview of Literature The surgical management of unstable C1 injuries by occipitocervical and atlantoaxial (AA) fusion compromises motion and function. Monosegmental C1 osteosynthesis negates these drawbacks and provides excellent functional outcomes. Methods The patients were positioned in a prone position, and cranial traction was applied using Mayfield tongs to restore the C0–C2 height and obtain a reduction in the displaced fracture fragments. An intraoperative, CT-based navigation system was used to enable the optimal placement of C1 screws. A transverse rod was then placed connecting the two screws, and controlled compression was applied across the fixation. The patients were prospectively evaluated in terms of their clinical, functional, and radiological outcomes, with a minimal follow-up of 2 years. Results A total of 10 screws were placed in five patients, with a mean follow-up of 40.8 months. The mean duration of surgery was 77±13.96 minutes, and the average blood loss was 84.4±8.04 mL. The mean combined lateral mass dislocation at presentation was 14.6±1.34 mm and following surgery, it was 5.2±1.64 mm, with a correction of 9.4±2.3 mm (p

Study Design Profiling proteins expressed in the nucleus pulposus of fetal intervertebral disc (IVD). Purpose To evaluate the molecular complexity of fetal IVDs not exposed to mechanical, traumatic, inflammatory, or infective insults to generate improved knowledge on disc homeostasis. Overview of Literature Low back pain is the most common musculoskeletal disorder, causing a significant reduction in the quality of life, and degenerative disc disorders mainly contribute to the increasing socioeconomic burden. Despite extensive research, the causative pathomechanisms behind degenerative disc disorders are poorly understood. Precise molecular studies on the intricate biological processes involved in maintaining normal disc homeostasis are needed. Methods IVDs of nine fetal specimens obtained from medical abortions were used to dissect out the annulus fibrosus and nucleus pulposus under sterile operating conditions. Dissected tissues were transferred to sterile Cryovials and snap frozen in liquid nitrogen before transporting to the research laboratory for protein extraction and further liquid chromatography tandem mass spectrometry (LC-MS/MS) analysis. Collected data were further analyzed using Gene Functional Classification Tool in DAVID and STRING databases. Results A total of 1,316 proteins were identified through LC-MS/MS analysis of nine fetal IVD tissues. Approximately 247 proteins present in at least four fetal discs were subjected to further bioinformatic analysis. The following 10 clusters of proteins were identified: collagens, ribosomal proteins, small leucine-rich proteins, matrilin and thrombospondin, annexins, protein disulfide isomerase family proteins and peroxiredoxins, tubulins, histones, hemoglobin, and prolyl 4-hydroxylase family proteins. Conclusions This study provides fundamental information on the proteome networks involved in the growth and development of healthy fetal discs in humans. Systematic cataloging of proteins involved in various structural and regulatory processes has been performed. Proteins expressed most abundantly (collagen type XIV alpha 1 chain, biglycan, matrilin 1, and thrombospondin 1) in their respective clusters also elucidate the possibility of utilizing these proteins for potential regenerative therapies.

Objective To catalog and characterize the proteome of normal human intervertebral disc (IVD). Methods Nine magnetic resonance imaging (MRI) normal IVDs were harvested from 9 different brain dead yet alive voluntary organ donors and were subjected to electrospray ionization-liquid chromatography tandem mass spectrometry (ESI-LC-MS/MS) acquisition. Results A total of 1,116 proteins were identified. Functional enrichment analysis tool DAVID ver. 6.8 categorized: extracellular proteins (38%), intracellular (31%), protein-containing complex (13%), organelle (9%), membrane proteins (6%), supramolecular complex (2%), and 1% in the cell junction. Molecular function revealed: binding activity (42%), catalytic activity (31%), regulatory activity (14%), and structural activity (7%). Molecular transducer, transporter, and transcription regulator activity together contributed to 6%. A comparison of the proteins obtained from this study to others in the literature showed a wide variation in content with only 3% of bovine, 5% of murine, 54% of human scoliotic discs, and 10.2% of discs adjacent to lumbar burst fractures common to our study of organ donors. Between proteins reported in scoliosis and lumbar fracture patients, only 13.51% were common, further signifying the contrast amongst the various MRI normal IVD samples. Conclusion The proteome of “healthy” human IVDs has been defined, and our results show that proteomic data on IVDs obtained from scoliosis, fracture patients, and cadavers lack normal physiological conditions and should not be used as biological controls despite normal MRI findings. This questions the validity of previous studies that have used such discs as controls for analyzing the pathomechanisms of disc degeneration.

Study Design Case-control study. Purpose Sarcopenia is an age associated condition characterized by decrease in muscle mass, strength, and physical performance. We aimed to investigate whether sarcopenia increased the risk of vertebral fragility fractures among the elderly. Overview of Literature Initial reports on sarcopenia suggest its contribution to the development of vertebral fragility fractures. However, recent studies showed contradictory findings. Methods Fifty-one consecutive patients with vertebral fragility fractures and matched controls without fractures were evaluated for sarcopenia, T-score, body mass index, and presence of preexisting vertebral fractures. Sarcopenia was diagnosed as total psoas cross-sectional area (TPA) 2 standard deviations below normative value from normal young adults and decreased handgrip strength (26 kg for men and 18 kg for women). Univariate and multivariate analyses were performed using the fresh fracture occurrence as the dependent variable. Results Sarcopenia was confirmed in 29.4% and 7.8% of cases and controls (p=0.005), respectively; 56.8% and 13.7% of cases and controls had previous vertebral fractures. Sarcopenia prevalence was greater among those with previous fractures (38% vs. 7.6%; odds ratio, 7.76; p

Study design Prospective study. Purpose During the last decades, an emergence of unplanned readmissions has been shown to be a useful tool to gage the healthcare quality and hospital performance. Previous studies were limited by their retrospective designs based on database information and short-term 30-day follow-up intervals. We analyzed the incidence and causes for unplanned readmissions following spine surgery at a 90-day interval and the difference at 30-, 31–60-, and 61–90-day intervals after discharge. Additionally, we assessed total bed-days lost and the economic impact of readmissions and probable risk factors. Overview of Literature Recent reports on readmission rates suggested the contribution of this parameter for the assessment of healthcare quality. Methods A prospective analysis of 2,860 admissions was performed over 1 year in a tertiary care orthopedic hospital. All unscheduled readmissions following spine surgery within 90 days of discharge were included, irrespective of type or location of surgery. Polytrauma, primary osseous infections, and planned readmissions were excluded. Results Our readmission rate was 3.32% (95/2,860). Leading readmission causes were surgical site infections (SSIs) accounting for 44.21% (n=42; superficial, 23; deep, 11; organ and space, 8), followed by aseptic pain 31.58% (n=30) and medical causes 13.68% (n=13). Though 86.95% of superficial SSIs occurred within 30 days, 21.1% of deep SSIs occurred beyond 30 days. During the 30–90-day interval, 33.68% of readmissions occurred. The financial burden amounted to 41,93,660 Indian Rupees, and the mean bed-days lost was 7.33 per readmission. Hospital stay ≥10 days, health insurance, and comorbid illnesses (diabetes, hypertension, and liver disease) were associated with readmissions (p

Objective: Cervical tubercular disease (CTB) is a rare pathology and constitutes 3–5% of all spinal TB. It includes atlantoaxial TB and sub-axial TB. As the literature evidence on this subject is scarce, majority of issues concerning CTB are still controversial. The current narrative review comprehensively discusses the various aspects related to CTB. Literature search: An elaborate search was made using keywords cervical tuberculosis, atlantoaxial tuberculosis, sub-axial tuberculosis, and cervico-thoracic tuberculosis, on pubmed and google ( scholar.google.com ) databases on 2 December 2020. We identified crucial questions regarding CTB and included relevant articles pertaining to them. Results: The initial search using keywords cervical tuberculosis, atlantoaxial tuberculosis, sub-axial tuberculosis, and cervico-thoracic tuberculosis yielded 4128, 76, 3 and 9 articles on ‘pubmed’ database, respectively. A similar search using the aforementioned keywords yielded 1,96,000, 2130, 117 and 728 articles on ‘google scholar’ database. The initial screening resulted in the identification of 178 articles. Full manuscripts were obtained for these articles and thoroughly scrutinised at the second stage. Review articles, randomised controlled trials and level 1 studies were given preference. Overall, 41 articles were included. Conclusion: AATB and SACTB constitute 0.3 to 1% and 3% of spinal TB, respectively. The incidence of neuro-deficit in CTB is significantly more than other spinal TB. The general principles of management of CTB are similar to spinal TB elsewhere and medical therapy remains the cornerstone. Surgery is advocated in specific scenarios involving gross neuro-deficit, later stages of disease with significant bony/ligamentous disruptions, altered sagittal balance, drug resistance, and poor response to medications. The surgical approaches for AATB include anterior-alone, posterior-alone and combined approaches, although posterior access is the most preferred. Most of the studies on SACTB have supported the role of anterior approach. Additionally, posterior stabilisation may be necessary in specific scenarios. The overall long-term outcome in CTB is favourable.

Study Design Observational retrospective computed tomography (CT) based study. Purpose To analyze the congenital anomalies of the cervical spine, their morphological variations and their clinical significance. Overview of Literature Studies published to date have focused mainly on upper cervical anomalies; no study has comprehensively reported on anomalies of both the occipitocervical and subaxial cervical spine. Methods Nine hundred and thirty cervical spine CT scans performed in Ganga Hospital, Coimbatore, India between January 2014 and November 2017 were screened by two independent observers to document anomalies of both the upper and lower cervical spine. CT scans conducted for infection, tumor, and/or deformity were excluded. Different morphological variations, embryological basis, and clinical significance of the anomalies were discussed. Results Of the 930 CT scans screened, 308 (33.1%) had congenital anomaly. Of these, 184 (59.7%) were males and 124 (40.2.7%) were females, with a mean age of 44.2 years (range, 14–78 years). A total of 377 anomalies were identified, with 69 cases (7.4%) having more than one anomaly. Two hundred and fifty (26.8%) anomalies of the upper cervical region (occiput to C2–C3 disk space) were identified, with the most common upper cervical anomalies being high-riding vertebral artery (108 cases, 11.6%) and ponticulus posticus (PP) (75 cases, 8%). One hundred and twenty seven (13.6%) anomalies of the lower cervical spine (C3–C7) were noted, of which double foramen transversarium was the most common anomaly observed in 46 cases (4.8%). Conclusions We found that 33.1% of CT scans had at least one congenital anomaly. Some anomalies, such as abnormal facet complex and arch anomalies, have to be differentiated from fractures in a trauma patient. Other anomalies, like PP, have to be looked for during preoperative planning to avoid complications during surgery. Therefore, knowledge of these anomalies is important as different anomalies have different clinical courses and management.

Study Design Prospective cohort study. Purpose The study was aimed at evaluating clinicoradiological factors affecting recovery of neurological deficits in cases of lumbar disc herniation (LDH) treated by lumbar microdiscectomy. Overview of Literature The majority of the available literature on neurological recovery following neurodeficit is limited to retrospective series. The literature is currently limited regarding variables that can help predict the recovery of neurodeficits following LDH. Methods A prospective analysis was performed on 70 consecutive patients who underwent lumbar microdiscectomy (L1–2 to L5–S1) owing to neurological deficits due to LDH. Patients with motor power ≤3/5 in L2–S1 myotomes were considered for analysis. Follow-up was performed at 2, 6, and 12 months to note recovery of motor deficits. Clinicoradiological parameters were compared between the recovered and nonrecovered groups. Results A total of 65 patients were available at the final follow-up: 41 (63%) had completely recovered by 2 months; four showed delayed recovery at the 6-month follow-up; and 20 (30.7%) showed no recovery at 1 year. Clinicoradiological factors, including diabetes, complete initial deficit, areflexia, multilevel disc prolapse, longer duration since initial symptoms, and ≥2 previous symptomatic episodes were associated with a significant risk of poorer recovery (p0.05 for all). Diabetes mellitus (p=0.033) and complete initial motor deficit (p=0.028) were significantly associated with delayed recovery in the multivariate analysis. Conclusions The overall neurological recovery rate in our study was 69%. Diabetes mellitus (p=0.033) and complete initial motor deficit were associated with delayed motor recovery.

Postoperative spinal infections are on the rise owing to the ever-increasing number of spine surgeries. Spinal instrumentation is associated with an infection rate of 2%–8%. Both surgical and patient factors have been associated with infection. Delayed cases of postoperative infection are mostly related to patient-related factors and can be easily missed as they lack the classic clinical and systemic features. However, if left unidentified, progressive involvement of contiguous levels would result in collapse, instability, deformity, and instrumentation failure. A high index of suspicion is to be maintained, and higher imaging options such as magnetic resonance imaging and computed tomography should be used judiciously so as to diagnose infection at the earliest. We herein describe the background history, clinical features, imaging characteristics, and successful management of infective spondylodiscitis following instrumentation in a narrative manner. Relevant literature and management options have also been discussed.

Subarachnoid pleural fistula (SPF) is an aberrant communication between the pleural cavity and subarachnoid space, resulting in uncontrolled cerebrospinal fluid drainage. The negative pressure of the pleural cavity creates a continuous suctioning effect, thereby impeding the spontaneous closure of these fistulas. Dural tears or punctures in cardiothoracic procedures, spinal operations, and trauma are known to cause such abnormal communications. Failure to recognize this entity may result in sudden neurological or respiratory complications. Hence, a high index of suspicion is required for early diagnosis and prompt management. Noninvasive positive pressure ventilation has been described to be effective in managing such fistulas, thus mitigating the high morbidity associated with exploratory surgery for primary repair. Herein, we describe the typical presentation of SPF and the clinical course, treatment, and follow-up of a patient who sustained SPF following anterior thoracic spinal surgery.

Study Design Prospective observational study. Purpose To determine the incidence of postoperative urinary retention (POUR) in patients undergoing elective posterior lumbar spine surgery and identify the risk factors associated with the development of POUR. Overview of Literature POUR following surgery can lead to detrusor dysfunction, urinary tract infections, prolonged hospital stay, and a higher treatment cost; however, the risk factors for POUR in spine surgery remain unclear. Methods A prospective, consecutive analysis was conducted on patients undergoing elective posterior lumbar surgery in the form of lumbar discectomy, lumbar decompression, and single-level lumbar fusions during a 6-month period. Patients with spine trauma, preoperative neurological deficit, previous urinary disturbance/symptoms, multiple-level fusion, and preoperative catheterization were excluded from the study. Potential patient- and surgery-dependent risk factors for the development of POUR were assessed. Univariate analysis and a multiple logistical regression analysis were performed. Results A total of 687 patients underwent posterior lumbar spine surgery during the study period; among these, 370 patients were included in the final analysis. Sixty-one patients developed POUR, with an incidence of 16.48%. Significant risk factors for POUR were older age, higher body mass index (BMI), surgery duration, intraoperative fluid administration, lumbar fusion versus discectomy/ decompression, and higher postoperative pain scores (p

Study DesignComputed tomographic (CT) morphometric analysis.PurposeTo assess the feasibility and safety of occipital condyle (OC)-based occipitocervical fixation (OCF) in Indians and to define anatomical zones and screw lengths for safe screw placement.Overview of LiteratureLimitations of occipital squama-based OCF has led to development of two novel OC-based OCF techniques.MethodsMorphometric analysis was performed on the OCs of 70 Indian adults. The feasibility of placing a 3.5-mm-diameter screw into OCs was investigated. Safe trajectories and screw lengths for OC screws and C0–C1 transarticular screws without hypoglossal canal or atlantooccipital joint compromise were estimated.ResultsThe average screw length and safe sagittal and medial angulations for OC screws were 19.9±2.3 mm, ≤6.4°±2.4° cranially, and 31.1°±3° medially, respectively. An OC screw could not be accommodated by 27% of the population. The safe sagittal angles and screw lengths for C0–C1 transarticular screw insertion (48.9°±5.7° cranial, 26.7±2.9 mm for junctional entry technique; 36.7°±4.6° cranial, 31.6±2.7 mm for caudal C1 arch entry technique, respectively) were significantly different than those in other populations. The risk of vertebral artery injury was high for the caudal C1 arch entry technique. Screw placement was uncertain in 48% of Indians due to the presence of aberrant anatomy.ConclusionsThere were significant differences in the metrics of OC-based OCF between Indian and other populations. Because of the smaller occipital squama dimensions in Indians, OC-based OCF techniques may have a higher application rate and could be a viable alternative/salvage option in selected cases. Preoperative CT, including three-dimensional-CT-angiography (to delineate vertebral artery course), is imperative to avoid complications resulting from aberrant bony and vascular anatomy. Our data can serve as a valuable reference guide in placing these screws safely under fluoroscopic guidance.

Study DesignRetrospective observational study.PurposeTo analyze the effect of low-density (LD) strategic pedicle screw fixation on the correction of coronal and sagittal parameters in adolescent idiopathic scoliosis (AIS) patients.Overview of LiteratureLD screw fixation achieves favorable coronal correction, but its effect on sagittal parameters is not well established. AIS is often associated with decreased thoracic kyphosis (TK), and the use of multi-level pedicle screws may result in further flattening of the sagittal profile.MethodsA retrospective analysis was performed on 92 patients with AIS to compare coronal and sagittal parameters preoperatively and at 2-year follow-up. All patients underwent posterior correction via LD strategic pedicle screw fixation. Radiographs were analyzed for primary Cobb angle (PCA), coronal imbalance, cervical sagittal angle (CSA), TK, lumbar lordosis (LL), pelvic incidence, pelvic tilt (PT), sacral slope (SS), C7 plumb line, spino-sacral angle, curve flexibility, and screw density.ResultsPCA changed significantly from 57.6°±13.9° to 19°±8.4° (p 40°) showed significant correction of TK (p

Study DesignRetrospective case series.PurposeTo correlate functional outcomes with spinopelvic parameters in patients with high-grade spondylolisthesis (HGS) treated with instrumented in-situ surgery or reduction and fusion.Overview of LiteratureSatisfactory functional outcomes are reported with reduction and in-situ fusion strategies in HGS. However, reasons for this are unclear. We hypothesize that following lumbosacral fusion, the L5 becomes part of the sacrum, which improves spinopelvic parameters, resulting in equivalent functional outcomes in both surgical methods.MethodsTwenty-six patients undergoing HGS (reduction group A, 13; in-situ group B, 13) were clinically evaluated using the Oswestry Disability Index (ODI), short form-12 (SF-12), and Visual Analogue Scale (VAS) scores. Spinopelvic parameters, including pelvic incidence, pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), lumbosacral kyphosis (LSK) angle, and sacrofemoral distance (SFD) were measured preoperatively from S1 and postoperatively from L5 as the new sacrum at 1 year follow-up. Sagittal alignment was assessed using the sagittal vertical axis.ResultsBoth groups were comparable in terms of age, sex, severity of slip, and preoperative spinopelvic parameters (p>0.05). Postoperative VAS, SF-12, and ODI scores significantly improved in both groups (p0.05).ConclusionsAfter fusion, the L5 becomes the new sacrum and influences spinopelvic parameters to change favorably. This possibly explains why reduction and in-situ fusion achieve equivalent functional outcomes in HGS.

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.

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.”

Study DesignA prospective genetic association study.PurposeThe etiology of Modic changes (MCs) is unclear. Recently, the role of genetic factors in the etiology of MCs has been evaluated. However, studies with a larger patient subset are lacking, and candidate genes involved in other disc degeneration phenotypes have not been evaluated. We studied the prevalence of MCs and genetic association of 41 candidate genes in a large Indian cohort.Overview of LiteratureMCs are vertebral endplate signal changes predominantly observed in the lumbar spine. A significant association between MCs and lumbar disc degeneration and nonspecific low back pain has been described, with the etiopathogenesis implicating various mechanical, infective, and biochemical factors.MethodsWe studied 809 patients using 1.5-T magnetic resonance imaging to determine the prevalence, patterns, distribution, and type of lumbar MCs. Genetic association analysis of 71 single nucleotide polymorphisms (SNPs) of 41 candidate genes was performed based on the presence or absence of MCs. SNPs were genotyped using the Sequenome platform, and an association test was performed using PLINK software.ResultsThe mean age of the study population (n=809) was 36.7±10.8 years. Based on the presence of MCs, the cohort was divided into 702 controls and 107 cases (prevalence, 13%). MCs were more commonly present in the lower (149/251, 59.4%) than in the upper (102/251, 40.6%) endplates. L4–5 endplates were the most commonly affected levels (30.7%). Type 2 MCs were the most commonly observed pattern (n=206, 82%). The rs2228570 SNP of VDR (p=0.02) and rs17099008 SNP of MMP20 (p=0.03) were significantly associated with MCs.ConclusionsGenetic polymorphisms of SNPs of VDR and MMP20 were significantly associated with MCs. Understanding the etiopathogenetic mechanisms of MCs is important for planning preventive and therapeutic strategies.

Study DesignRetrospective case series.PurposeTo assess safety and efficacy of single stage, posterior stabilisation and anterior cage reconstruction through the transforaminal or lateral extra-cavitary route for Andersson lesions.Overview of LiteraturePseudoarthrosis in ankylosing spondylitis (Andersson lesion, AL) can cause progressive kyphosis and neurological deficit. Management involves early recognition and surgical stabilisation in patients with instability. However, the need and safety of anterior reconstruction of the vertebral body defect remains unclear.MethodsTwenty consecutive patients with AL whom presented with instability back pain and or neurological deficit were managed by single stage posterior approach with long segment pedicle screw fixation and anterior vertebral reconstruction. Radiological evaluation included- the regional kyphotic angle, measurement of anterior defect in computed tomography (CT) scan and the spinal cord status in magnetic resonance imaging. Radiological outcomes were assessed for fusion and kyphosis correction. Functional outcomes were assessed with visual analogue scale (VAS), ankylosing spondylitis quality of life (ASQoL) and Oswestry disability index (ODI).ResultsThe mean age of the patients was 50.1 years (male, 18; female, 2). The levels affected include thoracolumbar (n=12), lower thoracic (n=5) and lumbar (n=3) regions. The mean level of fixation was 6.2±2.4 vertebrae. The mean anterior column defect was 1.6±0.6 cm. The mean surgical duration, blood loss and hospital stay were 112 minutes, 452 mL and 6.2 days, respectively. The mean followup was 2.1 years. At final follow up, VAS for back pain improved from 8.2 to 2.4 while ODI improved from 62.7 to 18.5 (p

Introduction. Osteolipomas are uncommon variants of lipoma. These lesions have been usually reported to arise from the oral cavity, brain, and neck and scarcely from the knee and thigh. Intraspinal osteolipomas are rare. A single case of intraspinal osteolipoma has been reported in the cervical and thoracic spine in the literature. To our knowledge, there is no report of osteolipomas in the lumbar spine. Case Presentation. We report a very rare case of a solitary lumbar intraspinal osteolipoma, presenting as a cauda equina syndrome. The intraspinal osteolipoma was excised en bloc and fusion was performed as it required partial resection of the facet joint within 24 hours of presentation. He has since then improved neurologically, and there has been no recurrence of the lesion so far. The clinical presentation, radiological characteristics, treatment course, and histopathological features of this lesion along with the clinical outcomes and a pertinent literature review were done and have been discussed. Discussion. The heterogeneous signal intensity of the lesion in MRI differentiates it from other dural-based lesions, and this should raise suspicion of an osteolipoma, which warrants a CT. Although intraspinal osteolipomas are benign lesions and generally have good prognosis, they need to be removed en bloc as they may result in rapid neurological deterioration.

A 55-year-old gentleman was presented to our clinic two months after a trivial fall with persistent pain, gibbus at the thoraco-lumbar junction and intact neurology. Radiological and laboratory investigations suggested osteoporotic fracture or metastasis. Due to unremitting pain, a plan was made to do transpedicular biopsy and kyphoplasty. Biopsy needles were inserted into both pedicles and an attempt at aspiration was made. Since the aspirate was dry, 5 to 6 mL of saline was injected through one needle and an attempt at aspiration was made through the other. Three-millilitres of sero-sanguineous material mixed with pus came out and kyphoplasty was deferred. After extubation, the patient developed severe bronchospasm and was transferred to the intensive care unit. Investigations confirmed multiple septic pulmonary emboli and the patient recovered completely after treatment. This report highlights that confirmation of the diagnosis is essential before performing any procedure that increases the intravertebral pressure and the place should have appropriate facilities to manage complications.

This section of the symposium brings to the reader seven case scenarios with regard to adolescent idiopathic scoliosis (AIS). These are the common curve patterns which a spine surgeon encounters in his practice. They have been contributed by different spine surgeons and highlight the varied approaches taken by them to achieve a satisfactory outcome. Each scenario highlights the proper workup required for such cases along with planning of the levels of fusion.