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Juvenile ossifying fibroma (JOF) is a rare benign fibro-osseous tumour occurring in craniofacial bones of children and young adults. An 8-year-old girl presented with low back pain since 10 months. Plain radiographs revealed a vertebra plana-like lesion of L3 vertebra. CT scan showed an osteolytic lesion with areas of ground-glass appearance interspersed with bone flecks involving the entire body, pedicles and laminae of L3 with well-circumscribed cortical margins. Biopsy was done-histopathological findings showed cellular fibrous stroma with bony trabeculae-which, on corroboration with clinical and radiological findings noted previously, confirmed the diagnosis of JOF. The patient underwent preoperative angioembolisation, curettage and posterior stabilisation. At follow-up of 15 months, the patient was asymptomatic-imaging revealed residual tumour in pedicles-which however did not progress radiologically. The case raises the importance of including this rare condition as a differential diagnosis in children and reports successful outcome with subtotal resection., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To present a radiographic analysis of the anatomy of the lumbar plexus and retroperitoneal blood vessels with respect to psoas morphology and safe working zones (SWZ) for LLIF., Methods: A retrospective radiographic analysis of 158 MRI scans was performed. Selected morphometric measurements were performed at L1-L2, L2-L3, L3-L4 and L4-L5 levels: disc anteroposterior distance, psoas anteroposterior distance, lumbar plexus-anterior disc distance, lumbar plexus-anterior psoas distance, vena cava-anterior disc distance and calculation of SWZ in psoas on both left and right sides. The morphometric measurements were analysed for differences with sex and the level., Results: All the morphometric parameters differed significantly at all levels between males and females. The SWZ was significantly wider on the left side compared to the right-at L2-L3, L3-L4 and L4-L5 levels in females and at L3-L4 and L4-L5 levels in males. The SWZ at L4-L5 was narrowest on both left and right sides-and significantly reduced compared to other levels. 6.9% patients had a SWZ > 20 mm on the left side, and 44.9% patients had SWZ < 20 mm on the right side. With caudal progression of levels, the lumbar plexus and psoas muscle migrated anteriorly and the vena cava/right iliac vein migrated posteriorly., Conclusion: A detailed study of preoperative MRI scans should be carried out in patients planned for LLIF-particularly, at L4-L5 level and in females. A left-sided trans-psoas approach is safer to perform compared to the right side-a right-sided approach should be avoided at L4-L5 considering the narrow SWZ at that level.

Oncogenic osteomalacia (OO) is an uncommon paraneoplastic syndrome occurring due to the presence of a tumour that oversecretes fibroblast growth factor-23, which impairs renal phosphate handling. In most cases, the tumour is a morphologically distinct entity called 'phosphaturic mesenchymal tumour' (PMT). Spinal tumours causing OO are exceedingly rare. A 55-year-old man presented with multiple bone pain and proximal muscle weakness in the lower limbs. The constellation of biochemical findings (hypophosphataemia, normocalcaemia, increased alkaline phosphatase, low-normal serum vitamin D and hyperphosphaturia) with radiographical rarefaction of the skeleton and pseudofractures led us to consider OO as a possibility. Functional imaging ( 68 Ga DOTA-NOC positron emission tomography/CT scan) localised the tumour to the D2 vertebra. Complete surgical resection led to resolution of symptoms, improved ambulatory status, normalisation of biochemical parameters and healing of pseudofractures. PMT should be considered in the differential diagnosis of hypophosphataemic osteomalacia with hyperphosphaturia. Tumour localisation with functional imaging and complete surgical resection produces satisfactory outcome., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Study Design: Prospective, comparative., Purpose: To compare the histopathological and electron microscopic changes in the ligamentum flavum (LF) between degenerative lumbar canal stenosis (LCS) and lumbar disk herniation (LDH)., Overview of Literature: The LF has been implicated as a key structure in the pathogenesis of LCS. With aging, the LF undergoes morphological changes-a decrease in the elastic component and an increase in the collagen component, in addition to other focal changes. By comparing the histopathological and electron microscopic picture of the LF in elderly patients with LCS with that in young patients with LDH, the role of this ligament in the pathogenesis of LCS may be clarified., Methods: Forty patients were prospectively recruited and divided into two groups: group 1 included 20 patients with degenerative LCS aged >55 years and group 2 included patients with LDH aged <35 years. The ligament flava were collected during the patients' surgery. The features noted on histopathological examination included the fibrosis score, the loss of elastic fibers, calcification, chondroid metaplasia, mucinous degeneration, vascularization, long septa, clefts, granulation tissue, and ganglion-like cysts. The features noted on electron microscopic examination included the elastic fiber thickness, the quality of elastic fibers, the elastic:collagen ratio, calcification, melanin fibers, remnants of necrotic cells, and electron-dense material in the LF. All parameters were compared between group 1 and group 2., Results: On histopathological examination, the two groups exhibited significant differences regarding three parameters: chondroid metaplasia, long septa, and ganglion-like cysts. On electron microscopy examination, significant differences were observed between the two groups regarding two parameters: the quality of elastic fibers and the elastic:collagen ratio., Conclusions: Characteristic morphological changes may be noted on histopathological and electron microscopic examination that mark the degenerative changes in the LF that contribute to the occurrence and pathogenesis of degenerative LCS.

Purpose: To investigate whether intraoperative neuromonitoring (IONM) may be avoided in growing rod lengthening procedures in early onset scoliosis (EOS)., Methods: A total of 636 primary growing rod surgeries and lengthening procedures were performed in 112 patients with EOS. Traditional growing rods (TGR) or magnetically controlled growing rods (MCGR) were implanted and subsequent lengthening procedures were done at stipulated intervals. Combined multi-modality IONM was used in all index surgeries-but was only used in lengthening procedures in patients with existing spinal cord abnormality or a history of neurosurgical procedure for the same, patients with prior history of a neuromonitoring alert in their index surgery and when lengthening was accompanied by an implant exchange/revision. All the remaining growing rod lengthening procedures were carried out without IONM. Hospital records and operation notes were retrospectively reviewed with focus on details of neurological events/complications., Results: In 112 primary growing rod applications (TGR = 96, MCGR = 16) and 524 lengthening procedures (TGR = 444, MCGR = 80), intraoperative neuromonitoring 'alerts' were encountered in 6/112 index surgeries and temporary postoperative neurological deficits were seen in 2/112 index surgeries. No intraoperative neuromonitoring event or postoperative neurological complication was encountered in 524 lengthening procedures-irrespective of whether they were carried out along with implant exchange, or in patients with spinal cord abnormality or prior neuromonitoring event during index surgery., Conclusion: While IONM should be used in primary growing rod application surgeries, its use may be avoided in lengthening and implant exchange procedures in a resource-limited setting., Level of Evidence: Level 3.

Background: Treatment of distal radius fractures has seen a paradigm shift since the use of volar locking plates became popular. However, there is a subset of fractures, which includes extreme distal volar rim fractures, that is often not amenable to fixation by volar locking plates as there is insufficient bone mass to put screws. These fractures as such are quite rare but carry a huge morbidity due to frequent lack of anatomical reduction and fixation. A number of different techniques like hook plates, specially designed distal volar locking plates and loop wire techniques have been described for these fractures, but they have been found to be less helpful when the fracture fragments are very small., Methods: Herein, we describe our experience on 6 patients, using a novel surgical technique for fixation of distal radius volar rim fractures which works equally well even when the fragments are quite small (2-3 mm). The technique uses low cost and readily available implants (K wire and conventional volar locking plate) without the need of any special implants., Results: The total of 6 cases of distal radius volar rim fractures (AO/OTA Type B3 = 4, Type C1 = 2) were operated. The mean age was 50.83 years (range: 31-72). The mean follow-up duration was 43.3 months (range: 26-66). The mean size of the volar fragment was 3.66 mm (range: 2-5). The mean pronation and supination were 72.5° (60-80) and 74.2° (60-85). The main flexion and extension were 52.5° (40-75) and 58.3° (50-80) respectively. The mean grip strength was 19.8 kg (4-38) and it was mean 79.3% (40-130%) compared to uninjured side. The mean PRWE score was 12.3 (2-31). One patient developed symptoms of Complex Regional Pain syndrome 1 (CRPS 1) which resolved with conservative management and no other complications were noted., Conclusion: Our technique offers an indigenous, cost-effective way for fixation of extreme volar rim fracture fragments which can be easily adopted and used by surgeons in developing countries., Competing Interests: Dr. Bhavuk Garg, Dr. Tungish Bansal and Dr. Nishank Mehta declare that they have no conflict of interest., (© 2020 Delhi Orthopedic Association. All rights reserved.)

Competing Interests: Dr. Bhavuk Garg and Dr. Nishank Mehta declare that they have no conflict of interest.

Background: The choice of surgical procedure in severe (Bayne and Klug types 3 and 4) radial longitudinal deficiency (RLD) is contentious. Existing studies have reported varying results with both centralization and radialization procedures. The purpose of this study was to compare the clinical and radiologic outcome of radialization and centralization procedures at a short-to-intermediate-term follow-up for the treatment of types 3 and 4 RLD., Methods: Fourteen patients with 17 affected limbs having types 3 or 4 RLD were recruited in this prospective, randomized, controlled trial. After initial application of successive casts for soft tissue distraction, patients were randomized to 2 wrist alignment procedures-centralization and radialization. Clinical and radiologic parameters recorded at stipulated intervals until a final follow-up of 24 months included hand-forearm angle, ulnar bow, forearm length, arm length, total angulation, and range of motion at elbow, wrist, and fingers., Results: Centralization was performed in 9 affected limbs, whereas radialization was performed in 8 affected limbs. Nine affected limbs had type 4 RLD, and 8 affected limbs had type 3 RLD. There was no significant difference in the hand-forearm angle in the immediate postoperative period. At 3 months, the radiologic hand-forearm angle increased to 19 degrees in the centralization group, while the radialization group showed an average increase to 4 degrees. This increase in the hand-forearm angle continued at 6-, 12-, and 24-month follow-up assessments. Worsening of the deformity was more in the centralization group, as compared with the radialization group. The forearm length also significantly differed in the 2 groups at 6-, 12-, and 24-month follow-up; however, when adjusted for preoperative lengths, the difference was significant only at 12- and 24-month follow-up., Conclusions: At a short-to-intermediate-term follow-up, radialization fares better than centralization in terms of recurrence of deformity and in terms of affecting the forearm length. Longer follow-up with a larger sample size is needed to draw definitive conclusions., Level of Evidence: Level I.

Study Design: Cross-sectional, observational., Objectives: (i) To develop a cross-culturally adapted Hindi translation of the Scoliosis Research Society (SRS)-22r (refined) questionnaire and (ii) validate it in Hindi-speaking Indian patients with adolescent idiopathic scoliosis (AIS)., Background Data: Health-related quality of life (HRQoL)-based questionnaires have superseded objective clinical and radiological measurements as tools to assess the outcome of health-related interventions. The SRS-22r is an extensively validated HRQoL-based questionnaire for AIS patients and has been adapted and translated in other languages., Methodology: A Hindi version of SRS-22r was developed in accordance with standard guidelines for cross-cultural adaptation. The final Hindi version was administered to 108 AIS patients. Subsequently, 58/108 patients answered the Hindi version again after 10-14 days. Another 50/108 bilingual patients answered the original English version after 10-14 days. In addition, 52/108 patients answered a previously validated Hindi version of Short Form (SF)-36 health survey. Content analysis, floor/ceiling effects, internal consistency, test/retest reproducibility and concurrent validity with the English version and the SF-36 questionnaire were determined for the Hindi version of SRS-22r., Results: High ceiling effect was noted for the pain and satisfaction with management domains of Hindi version of SRS-22r. Overall internal consistency was good (Cronbach α = 0.77)-all domains, except the function domain (α = 0.61) had good or excellent internal consistency. The test/retest reliability for all domains was excellent (intraclass coefficient/ICC > 0.80). The concurrent validity with the English version showed an excellent correlation for all domains (ICC > 0.80). Concurrent validity with SF-36 showed good correlation between relevant domains of SRS-22r and SF-36, except for the self-image and satisfaction with management domains of SRS-22r., Conclusion: Based on the results proving its reliability and validity, the adapted Hindi version of SRS-22r can be effectively used in Hindi-speaking, Indian AIS patients., Level of Evidence: 3.

Background Context: Posterior vertebral column resection (PVCR) has several advantages over a combined anterior-posterior procedure for management of severe, rigid spinal deformities. The technique, described by Suk et al., has a high complication rate. Modifications of the technique which can reduce this complication rate might make this challenging procedure safer., Purpose: To report the results of PVCR in severe, rigid spinal deformity; to describe a modified technique for PVCR and compare its results with the conventional technique., Study Design: Retrospective cohort., Patient Sample: A total of 38 patients who underwent PVCR for severe, rigid spinal deformities., Outcome Measures: Mean correction of deformity (sagittal and/or coronal), estimated blood loss, operation time, neurological and non-neurological complications, patient-reported outcome score (SRS-22r)., Methods: Thirty-eight patients underwent PVCR for severe, rigid spinal deformities. These patients had a deformity in excess of 90° and a flexibility index <20%. Twenty-one of 38 patients (Group 1) underwent PVCR by the technique reported by Suk et al.; 17 patients (Group 2) underwent a modified PVCR technique. Our technique involves retaining the posterior elements until the other steps of PVCR are completed, which prevents ventral settling and allows for less handling of an already tight spinal cord. The results and complications were compared between the two groups., Results: The mean operating time was 251 minutes and the mean blood loss was 1,251 mL. Mean coronal correction of 50% and a mean sagittal correction of 52.4% were achieved. Intraoperative loss of motor evoked potentials was seen in eight patients while there were two instances of permanent postoperative deficit, both occurring with the conventional PVCR technique. The average operating time, mean correction and blood loss did not differ between the two techniques. There was, however, a reduction in the occurrence of neurological complications with the authors' modified technique., Conclusions: Our retrospective study with a small cohort suggests that the authors' modified technique of PVCR, wherein the posterior elements are preserved until just prior to attempting to correct the deformity, may be safer in terms of neurological complications when compared with the conventional technique. However, larger studies are warranted to conclusively establish this., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The endeavour to make spine surgery safe with reproducible, consistent outcomes has led to growing interest and research in the field of intraoperative imaging, navigation and robotics. The advent of surgical robot systems in spine surgery is relatively recent - with only a few systems approved for commercial use. At present, pedicle screw insertion remains the primary application of robotic systems in spine surgery. The purported advantages of robot-assisted pedicle screw insertion over other conventional techniques are its increased accuracy, reproducible consistency and reduced radiation exposure. Many of these claims have been supported or refuted by individual studies - and high quality evidence for the same is lacking. Robotic spine surgery also has its share of limitations which include increased operative time, considerable learning curve and technical pitfalls unique to the robotic systems. The applications of robotic spine surgery are evolving and expanding to spinal deformity, spine oncology and needle-based interventional treatments. This review provides an overview of the evolution and current status of robotic spine surgery along with an evidence-based discussion of its current applications in spine surgery., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© 2020 Delhi Orthopedic Association. All rights reserved.)

EOS® imaging is a proprietary imaging technology that was launched in 2007. Based on a gaseous particle detector with a multi-wire proportional chamber, it offers several advantages over other imaging modalities: low dose of radiation, ability to create 3D reconstructions, ability to conduct whole body imaging, high reproducibility in measuring various parameters of alignment and faster imaging time. EOS® imaging is slowly gaining widespread acceptance as its applications in various disorders continue to evolve. It has been found to be particularly useful and has opened up new avenues of research in the field of spinal deformities. This narrative review seeks to provide an overview of the proprietary technology behind EOS® imaging, compare it to existing imaging modalities, summarize its current applications in various spinal disorders and outline its limitations., (© 2020 Delhi Orthopedic Association. All rights reserved.)

Study Design: Case series., Objectives: To describe a novel surgical strategy for severe, rigid post-tubercular cervical kyphosis with treatment outcomes in two patients., Background Data: Spinal tuberculosis is a common cause of kyphotic deformity in the developing world with 3-5% of non-operatively managed patients ending up with kyphosis exceeding 60°. Ventral, dorsal and combined approaches have been described for cervical kyphosis, but there is no established surgical strategy for severe, rigid post-tubercular cervical kyphosis., Methods: We operated on two girls with severe, rigid cervical kyphosis with preoperative kyphosis measuring 98° and 62°. Our surgical strategy included a three-step approach in the same sitting-(1) An anterior approach to osteotomize the fused vertebral body mass, decompress the spinal cord ventrally and place a temporary cage to stabilize the spine, (2) A posterior approach to osteotomize the fused facets and decompress the cord dorsally. With the completion of the osteotomy, a combination of pedicle screws and lateral mass screws was used to correct the deformity via an anterior opening, posterior closing type of osteotomy. This was followed by, (3) An anterior approach to replace the corpectomy cage with a larger one supplemented with an anterior cervical plate., Results: Our 540° approach achieved a substantial improvement in each of the clinical and radiological parameters we measured, viz. C2-C7 lordosis angle, C2-C7 sagittal vertical axis, neck tilt and Neck Disability Index., Conclusion: For severe, rigid post-tubercular cervical spine kyphosis, a three-step, anterior-posterior-anterior procedure can be used for achieving acceptable correction, improving symptoms and avoiding further progression., Level of Evidence: IV.

Minimal access surgery has revolutionized most surgical disciplines and spine surgery is no exception. Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) was devised to reduce the approach-related morbidity of open TLIF and has flourished in the last decade. With expanding indications, standardization of technique and equipment, publication of more studies on its results and complications being brought to light - an update of the existing knowledge on MI-TLIF is imminent. We provide a review of the indications, technique, results and complications of MI-TLIF while also highlighting its variations and utility in special situations., (© 2019 Delhi Orthopedic Association. All rights reserved.)

Osteoporosis and fragility fractures have become a major healthcare challenge globally in the recent years. However, this problem has only recently been accorded its due importance in developing countries such as India. India is a model case study for the management of osteoporosis and fragility fractures in a resource-limited setting, as it harbors a large geriatric population and has the highest prevalence of osteopenia globally. It is imperative to identify the myriad factors contributing to poor bone health and understand the many hurdles encountered to tackle this healthcare problem in a developing country. Innovative methods for managing fragility fractures are commonly seen. Collaborative multidisciplinary care and structured, evidence-based management has finally found its place in India with the establishment of a regional fragility fracture network. This chapter outlines the current status of management of fragility fractures in India by focusing on the disease burden, hurdles, innovative treatment methods, and the challenges lying ahead., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Three-dimensional printing (3DP) is one of the latest tools in the armamentarium of the modern spine surgeon. The yearning to be more precise and reliable whilst operating on the spine has led to an interest in this technology which has claimed to achieve these goals. 3D printing has been used pre-operatively for surgical planning and for resident or patient education. It has also found its way to the operation theatre where it is used to fabricate customized surgical tools or patient-specific implants. Several authors have highlighted significant benefits when 3D printing is used for specific indications in spine surgery. Novel applications of this technology in spine surgery have also been described and though still in a nascent stage, these are important for this technology to sustain itself in the future. However, major limitations have also come to light with this technology in use. This article seeks to review the current status and applications of 3D printing in spinal surgery and its major drawbacks while briefly describing the essentials of the technology. It is imperative that the modern spine surgeon knows about this important innovation and when and how it can be applied to improve surgical outcomes.

Isolated traumatic brachialis muscle tears are uncommonly reported - leading to occasional misdiagnosis and misdirected treatment. The rarity of brachialis muscle tear may promote misdiagnosis or mistreatment of this injury. We report an isolated brachialis muscle tear in a young female, possibly caused by strenuous exercise in the gymnasium. The diagnosis was made clinically and confirmed by magnetic resonance imaging. The patient was subsequently managed adequately with conservative treatment. We herein present a 35-year-old woman who was diagnosed with an acute brachialis muscle tear being diagnosed with a combination of clinical signs and imaging and successfully managed non-operatively. A chronologically arranged review of literature is also presented.