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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.

Conventional diagnosis of spinal tuberculosis (TB) is based on a combination of clinical features, laboratory tests and imaging studies, since none of these individual diagnostic features are confirmatory. Despite the high sensitivity of MRI findings in evaluating spinal infections, its efficacy in diagnosing spinal TB is less emphasized and remains unvalidated through tissue studies.We reviewed consecutive patients evaluated for spondylodiscitis with documented clinical findings, MRI spine, and tissue analysis for histopathology, TB culture and genetic TB PCR. MRI features documented include location, contiguous/non-contiguous skip lesions, para/intraosseous abscess, subligamentous spread, vertebral collapse, abscess size/wall, disc involvement, end plate erosion and epidural abscess. Based on the results, patients were divided into two groups-CONFIRMED TB with positive culture/histopathology and NON-TB. The efficacy of MRI findings in accurately diagnosing spinal TB was compared between the two groups.Among 150 patients, 79 patients were TB positive, and 71 were TB negative. Three MRI parameters showed significant differences (p 0.001), namely subligamentous spread (67/79, 84.8%), vertebral collapse 50% (55/79, 69.6%) and large abscess collection with thin abscess wall (72/79, 91.1%) being strongly predictive of TB. Combination of MRI findings had a higher predictive value. 97.5% of TB positive patients had at least one of these three MRI features, 89.8% patients had any two and 58.2% had all three.Our study validated different MRI findings with tissue studies and showed spinal infections with large abscess with thin wall, subligamentous spread of abscess and vertebral collapse were highly suggestive of spinal tuberculosis. These slides can be retrieved under Electronic Supplementary Material.

Single-center retrospective cohort analysis. To analyze the impact of loss of global lumbar lordosis (GLL) on functional outcomes in tuberculosis of the lumbar and lumbosacral spine and to define strategies to restore or preserve the physiological lumbar lordosis. In tuberculosis of lumbosacral spine, loss of lumbar lordosis (LL) leads to altered lumbosacral biomechanics. All available studies have assessed treatment outcomes with respect to physical well-being, neurologic improvement, bone healing, and changes in radiologic parameters. None have studied the correlation between functional outcomes and LL following treatment. We reviewed 63 patients with tuberculosis of lumbar and lumbosacral spine, with an attempt to analyze the impact of loss of GLL on functional outcomes and have defined strategies to restore the same. We retrospectively reviewed 63 patients with lumbar and lumbosacral tuberculosis, treated conservatively (n = 33) or surgically (n = 30) from March 2007 to July 2013. Average follow-up was 43.1±7.2 months. The correlation between posttreatment GLL and the functional outcome (Oswestry Disability Index), measured at 36 months’ follow-up, was analyzed. All patients showed good bone healing (at 8.4±1.5 months), significant improvement in neurology, VAS scores, ESR and CRP, p

This section of the symposium deals with different case scenarios related to cervical spondylotic myelopathy (CSM) which in our daily clinical practice not only act as diagnostic challenges but also test our decision-making abilities. These cases have been handled by different experts and hence help the readers in providing a wider perspective to the problem of cervical myelopathy and its management. This section ends with comments by the authors on key takeaway points from each case scenario, and some literature supported recommendations for the management of CSM.

Different adjuvant local-antibiotic techniques are described in management of surgical-site infections (SSIs). Antibiotic-laden polymethyl methacrylate (PMMA) spacers have been used in peri-prosthetic infections. However, their role in treatment of spinal SSIs is not well-recognised.After approval from Institutional Review Board, we retrospectively evaluated the data of patients aged≥18 years, who were treated for SSIs of lumbo-sacral region (2010-2019). Among them, those who underwent treatment with the placement of cement beads (temporarily/permanently) were identified. This approach was utilised for post-surgical spondylodiscitis patients with significant, associated infection or abscess involving the paraspinal musculature. Only those with≥2 years' follow-up, were included.Patient demographic details, site of infection, details regarding laboratory/radiological investigations, management-protocol followed, pathogen grown, antibiotics used (their dosage and duration of use), complications encountered and outcome were recorded.13 patients [4 males, age:57.3 ± 12.4 years] were included. Seven had co-morbidities. One had upper-lumbar involvement, one sacral and others had lower-lumbar (L4/distally) disease. While 7 had recent-onset infection (≤2 months since primary surgery), 6 had chronic infection. In 2, 8, 2, and 1 patients, primary surgery was microdiscectomy, TLIF, PLF, and adult-deformity surgery, respectively.Nine underwent two-staged intervention and 4 underwent single procedure. Eleven had PMMA beads, while 2 underwent calcium sulphate bead insertion. Culture grew E coli in 3, Pseudomonas in 2; and E fecalis, K pneumoniae, MSSA and MRSA in one patient each. In 4 patients, beads were not removed. All patients underwent 2 weeks of parenteral antibiotics, followed by 8-12 weeks of oral medications. There was complete remission in all patients, except one who required additional VAC therapy.Local antibiotic-laden bead application is an effective adjuvant strategy (along with debridement and systemic antibiotics) for the treatment of spinal SSI, where there is substantial infection involving the paraspinal musculature. It is cost-effective and often necessitates second procedure for bead removal.

Numerous pathologies of the spine, pelvis and hips can present with gluteal pain and pose a challenge to orthopaedic surgeons. We report a unique Case of tuberculous osteomyelitis of the ischium in a young immunocompetent individual presenting as gluteal pain. A high index of suspicion, early diagnosis and prompt management is mandatory to promote early and complete healing and prevent complications.

Purpose The Global Burden of Diseases (GBD) Studies have estimated that low back pain is one of the costliest ailments worldwide. Subsequent to GBD publications, leadership of the four largest global spine societies agreed to form SPINE20. This article introduces the concept of SPINE20, the recommendations, and the future of this global advocacy group linked to G20 annual summits. Methods The founders of SPINE20 advocacy group coordinated with G20 Saudi Arabia to conduct the SPINE20 summit in 2020. The summit was intended to promote evidence-based recommendations to use the most reliable information from high-level research. Eight areas of importance to mitigate spine disorders were identified through a voting process of the participating societies. Twelve recommendations were discussed and vetted. Results The areas of immediate concern were “Aging spine,” “Future of spine care,” “Spinal cord injuries,” “Children and adolescent spine,” “Spine-related disability,” “Spine Educational Standards,” “Patient safety,” and “Burden on economy.” Twelve recommendations were created and endorsed by 31/33 spine societies and 2 journals globally during a vetted process through the SPINE20.org website and during the virtual inaugural meeting November 10–11, 2020 held from the G20 platform. Conclusions This is the first time that international spine societies have joined to support actions to mitigate the burden of spine disorders across the globe. SPINE20 seeks to change awareness and treatment of spine pain by supporting local projects that implement value-based practices with healthcare policies that are culturally sensitive based on scientific evidence.

Detailed radiological analysis by multimodality imaging.To document anatomical changes jeopardizing instrumentation safety in Neurofibromatosis deformity correction surgeries.The apical and 3 adjacent vertebral segments above and below amounting to 70 segments in 10 NF scoliosis were studied by radiographs, CT and MRI. The changes in lamina, pedicle and vertebral body that could jeopardize pedicle screw and sublaminar wire placement were documented and changes were appropriately classified.Extensive anatomical changes were noted. These changes were more severe at the apex and independent of the curve severity. Both laminae were normal in only 36 (Type 1), rest had either gross asymmetry in length and shape (Type 2; 21) or also in sloping (Type 3; 13). Of the 140 pedicles, normal pedicles were found only in 48 (Type 1); while they were divergent (Type 2; 4) or abnormally elongated with only thinning (Type 3a; 26); or with sclerosis (3b; 34); or very curved and wavy (3c; 23) and even fractured or indistinct (Type 4; 5). It was notable that 92 of the 140 pedicles were unsuitable for pedicle screws. A unique phenomenon of body drift was identified in 29 segments which could jeopardize screw placement and rib dislocation into the canal was found in 18 segments.Gross anatomical changes jeopardizing both sublaminar wire strength and trajectory of pedicle screws were common in NF and independent of curve severity. Therefore, detailed preoperative assessment and planning by a 3D CT are essential.

Purpose To analyse the progression of disc degeneration in distal unfused lumbar segments in post-operative Adolescent Idiopathic Scoliosis (AIS) patients; and to evaluate pre-operative and post-operative radiological parameters associated with progressive disc degeneration. Methods A retrospective study of patients, who underwent surgery for AIS between 2006 and 2013 at a tertiary-care spine hospital, was conducted. Only patients aged between 11 and 18 years, who underwent deformity correction surgery with pedicle screw-only constructs, minimum of 6.5 year follow-up, and complete radiological data, and were included. On plain radiographs, coronal cobb's angle (CCA), apical translation, lower instrumented vertebra tilt (LIV tilt), LIV-Sacral angle, and sagittal spinal and pelvic parameters were measured. Disc degeneration was assessed on Magnetic Resonance Imaging (MRI) using Pfirrmann's grading. Total endplate score (TEPS) and facet degeneration (by Fujiwara's grading) were also measured. Based on the difference in progression of disc degeneration, patients were classified as Pfirrmann's grade static (PGS) and Pfirrmann's grade progressive (PGP) groups. Comparison of all pre- and post-operative parameters was made between PGS and PGP groups, and statistically analyzed. Functional evaluation was performed using SRS-22 score. Results A total of 58 patients were finally included. The mean follow-up was 9.1 years. 43 (74.1%) and 15 (25.9%) patients were classified under PGS and PGP groups, respectively. Among the15 patients in PGP group, selected LIV was L4 in 8, L3 in 3, L1 in 3, and L2 in 1. Among them, 11 patients (73.3%) progressed from grade 1 to grade 2. In the remaining 4 (26.6%), Pfirrmann's grade progressed to ≥ 3. The progression of disc degeneration did not correlate with age or sex distribution (p = 0.3), pre-operative and post-operative TEP scores (p = 032), pre-operative disc or facet degeneration (p = 0.52), number of unfused spinal segments (p = 0.56), pre-operative or post-operative coronal (p = 0.42), or sagittal spinal (p = 0.27) or pelvic parameters (p = 0.14). The final functional outcome (SRS-22) was not significantly different between PGS and PGP groups (p = 0.67). Conclusion 74% of AIS patients demonstrated no signs of progressive disc degeneration at an average follow-up of 9.1 years. 26% (15/58) of AIS patients demonstrated progressive disc degeneration, among whom, degeneration progressed by only 1 Pfirrmann's grade in 74% (11/15). In the remaining four patients, disc degeneration progressed to Pfirrmann's grades 3 or greater. There was no correlation between higher grades of disc degeneration and lower instrumented vertebra (LIV) or functional outcomes scores (SRS-22).

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 p =0.002). Sexual drive was normal in 77.7% of patients, and erection and ejaculation were normal in 77.7% and 91.0%, respectively. Overall, 59.1% had resumed sexual intercourse within 6 weeks of surgery.Conclusions: LDH resulted in sexual dysfunction in up to 77% of patients, which significantly improved after surgery. By 6 weeks, the majority had resumed sexual activity without undue discomfort. Therefore, this study supports counseling for patients with LDH about sexual function.

Study Design: A retrospective study. Objective: To identify the prevalence and characteristics of ossified posterior longitudinal ligament (OPLL) in the cervical spine and its association with other spinal ligament ossifications. Method: This study is a retrospective review of whole spine CT scans of polytrauma patients from 2009 to 2018. Patients were screened for cervical OPLL (C-OPLL), thoracolumbar OPLL, thoracic ossified ligamentum flavum (OLF), cervical and thoracolumbar ossified anterior longitudinal ligament (C-OALL AND T-L OALL), ossified nuchal ligament (ONL) and, diffuse idiopathic skeletal hyperostosis (DISH) using CT scans. Their prevalence and distributions were assessed using statistical tools. Chi-square tests were used to determine statistical association between the categorical parameters. Results: Out of 2500 patients, 128 had C-OPLL with a prevalence rate of 5.12% with mean age of 55.89 year. The most commonly affected level was C5, followed by C6, and C4. The segmental OPLL was highest in number (77.7%), followed by localized type (14.8%). While the prevalence rate of thoracic OPLL was 0.56%, OLF was 9.9%. Ossifications that coexisted along with C-OPLL were thoracic OPLL (7.81%), thoracic OLF (36.71%), cervical OALL (29.68%), thoracolumbar OALL (37.5%), DISH (27.34%) and, ONL (7.03%). Conclusion: Our study indicated a prevalence rate of 5.12% for C-OPLL with a predominance of segmental OPLL (77.7%). Among these patients, approximately 36% had coexisting thoracic OLF. In patients with symptomatic OPLL induced cervical myelopathy, MRI analysis of whole spine with relevant CT correlation may help in detecting additional ossification sites of compression.

BACKGROUND CONTEXT: Patients with modic changes (MC) form a distinct clinical subset with reports of higher intensity of pain, poor clinical and surgical outcomes and higher incidence of recurrence. MC also is an independent risk factor for increased post-operative surgical site infection.PURPOSE: This study aimed to investigate the biological changes at molecular level, in discs with MCs. We also aim to identify biological biomarkers and potential targets for molecular therapy.STUDY DESIGN: Experimental analysisMATERIALS AND METHODS: Nucleus pulposus (NP) from 24 patients undergoing microdiscectomy for disc herniation [14 discs with MC and 10 without modic changes (NMC)] were procured. The overall expression of proteins, biological processes, protein-protein and metabolite interactions were analysed and compared. Host defense response proteins (HDRPs) and immunological pathways activated in patients with MC were documented and analysed.RESULTS: Label-free proteomic approach with stringent filters revealed a total of 208 proteins in MC and 193 in NMC groups. 45 proteins were specific to MC; 30 to NMC and 163 common to both. Downregulated proteins in MC belonged to components of extracellular matrix such as collagens (COL-6A1, 6A2, 6A3, 11A1, 12A1, and 20A1), and proteoglycans (versican (VCAN), and biglycan (BGN)). Inflammatory molecules [plasminogen (PLG), angiogenin (ANG), fibroblast growth factor-binding protein 2 (FGFBP2), tetranectin (CLEC3B), cartilage acidic protein 1 (CRTAC1), kininogen (KNG-1), chitinase-3-like protein 2 (CHI3L2), and ferritin (FTL) were expressed only in the MC group. The significantly altered pathways in MC included Fc Fragment of IgG Receptor IIIa (FCGR3A)-mediated phagocytosis, regulation of Toll-like receptors (TLR) by endogenous ligand, neutrophil and platelet degranulation.50 HDRPs were identified in the study, 14 of which were specific to MC and included acute phase reactants, antimicrobial peptides, complement cascade proteins, inflammatory molecule and stress response proteins. Metabolite-protein interaction analysis revealed a significant interaction between 19 proteins, specifically involving ubiquitin mediating proteasome degradative pathway and an association with the metabolite-glutamic acid in the MC group. Accumulation of glutamic acid in MC discs was confirmed by quantitative amino acid analysis using High-performance liquid chromatography.CONCLUSION: Our study confirms that MC represents an intense inflammatory status and activation of host defense response and immunological pathways. Downstream effects leading to ubiquitin mediated proteasomal degradation of ECM proteins and the resulting metabolites such as glutamic acid could cause excessive pain and needs further investigation.CLINICAL SIGNIFICANCE: We have documented the expression of inflammatory molecules, immune mechanisms and host defense response proteins which throw molecular insights into the pathological mechanisms of MC. Further, ubiquitin mediated proteasomal degradation and accumulation of glutamate in discs with MC might serve as targets for molecular therapy. (C) 2021 Elsevier Inc. All rights reserved.

To document baseline cervical sagittal characteristics in Lenke 1 adolescent idiopathic scoliosis (AIS) patients and assess the alteration in these parameters with surgery. Pre-operative and 2-year postoperative radiographs of 82 Lenke 1 AIS patients recruited from five hospitals were analysed. Selected radiographic parameters capturing regional and global sagittal alignment were measured. Comparison was made between groups based on baseline thoracic kyphosis (TK: TK

Objective The optimal timing of surgical intervention of spinal fractures in patients with polytrauma is still controversial. In the setting of trauma to multiple organ systems, an inappropriately timed definitive spine surgery can lead to increased incidence of pulmonary complications, hemodynamic instability and potentially death, while delayed surgical stabilisation has its attendant problems of prolonged recumbency including deep vein thrombosis, organ-sp ecific infection and pressure sores. Methods A narrative review focussed at the epidemiology, demographics and principles of surgery for spinal trauma in poly-traumatised patients was performed. Pubmed search (1995–2020) based on the keywords – polytrauma OR multiple trauma AND spine fracture AND timing, present in “All the fields” of the search tab, was performed. Among 48 articles retrieved, 23 articles specific to the management of spinal fracture in polytrauma patients were reviewed. Results Spine trauma is noted in up to 30% of polytrauma patients. Unstable spinal fractures with or without spinal cord injury in polytrauma require surgical intervention and are treated based on the following principles - stabilizing the injured spine during resuscitation, acute management of life-and limb-threatening organ injuries, “damage control” internal stabilisation of unstable spinal injuries during the early acute phase and, definitive surgery at an appropriate window of opportunity. Early spine fracture fixation, especially in the setting of chest injury, reduces morbidity of pulmonary complications and duration of hospital stay. Conclusion Recognition and stabilisation of spinal fractures during resuscitation of polytrauma is important. Early posterior spinal fixation of unstable fractures, described as damage control spine surgery, is preferred while a delayed definitive 360° decompression is performed once the systemic milieu is optimal, if mandated for biomechanical and neurological indications.

Study Design: Proteomic analysis of human intervertebral discs. Objectives: To compare the characters of scoliotic discs and discs from magnetic resonance imaging (MRI)–normal voluntary organ donors controls used in disc research employing proteomics and establish “true controls” that can be utilized for future intervertebral disc (IVD) research. Methods: Eight MRI-normal discs from 8 brain-dead voluntary organ donors (ND) and 8 scoliotic discs (SD) from 3 patients who underwent anterior surgery for adolescent idiopathic scoliosis were subjected to tandem mass spectrometry, and further analysis was performed. Results: Mass spectrometry identified a total of 235 proteins in ND and 438 proteins in the SD group. Proteins involved in extracellular matrix integrity (Versican, keratins KRT6A, KRT14, KRT5, and KRT 13A1, A-kinase anchor protein 13, coagulation factor XIII A chain, proteoglycan 4) and proteins involved in transcription and DNA repair (Von Willebrand factor A domain-containing 3B, eukaryotic initiation factor 2B, histone H4, leukocyte cell–derived chemotaxin 2) were found to be downregulated in SD. Inflammatory proteins (C3, C1S), and oxidative stress response proteins (peroxiredoxin-2,6, catalase, myeloperoxidase, apolipoprotein E) were found to be upregulated in SD. These changes were reflected at the pathway level also. Conclusion: Findings of our study confirm that scoliotic discs have an abundance of inflammatory, oxidative stress response proteins, which are either absent or downregulated in the ND group indicating that scoliotic discs are not pathologically inert. Furthermore, this study has established MRI-normal discs from voluntary organ donors as the “true” control for molecular studies in IVD research.

Study Design: Randomized controlled trial.Purpose: To compare the functional and radiological outcomes of anterior cervical discectomy and fusion (ACDF) using local graft and allograftOverview 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

Objective Lumbar degenerative spinal ailments are the most important causes for chronic low back pain. Modic changes (MC) are vertebral bone marrow signal intensity changes seen on MRI, commonly in association with degenerative disc disease (DDD). Despite being widely studied, majority of issues concerning MC are still controversial. The current narrative, evidence-based review comprehensively discusses the various aspects related to MC. Literature search An elaborate search was made using keywords “Modic changes”, “lumbar Modic changes”, “Modic changes in lumbar spine”, and “vertebral Endplate Spinal Changes”, on pubmed and google ( scholar.google.com ) databases on the 3rd of March 2020. We identified crucial questions regarding Modic changes and included relevant articles pertaining to these topics for this narrative review. Results The initial search using the keywords “Modic changes”, “lumbar Modic changes”, “Modic changes in lumbar spine”, and “vertebral Endplate Spinal Changes” on pubmed yielded a total of 568, 412, 394 and 216 articles on “pubmed” database, respectively. A similar search using the aforementioned keywords yielded a total of 3650, 3548, 3726 and 21570 articles on “google scholar” database. The initial screening involved exclusion of duplicate articles, articles unrelated to MC, animal or other non-clinical studies, and articles in non-English literature based on abstracts or the titles of articles. This initial screening resulted in the identification of 405 articles. Full manuscripts were obtained for all these selected articles and thoroughly scrutinised at the second stage of article selection. All articles not concerning Modic changes, not pertaining to concerned questions, articles concerning other degenerative phenomena, articles discussing cervical or thoracic MC, case reports or animal studies, articles in non-English language and duplicate articles were excluded. Review articles, randomised controlled trials and level 1 studies were given preference. Overall, 69 articles were included in this review. Conclusion Modic change (MC) is a dynamic phenomenon and its true etiology is still not definitely known. Disc/end plate injury, occult discitis and autoimmune reactions seem to trigger an inflammatory cascade, which leads to their development. Male sex, older age, diabetes mellitus, genetic factors, smoking, obesity, spinal deformities, higher occupational loads and DDD are known risk factors. There is no conclusive evidence on the causative role of MC in chronic low back pain (LBP) or any influence on the long term outcome in patients with LBP or lumbar disc herniations (LDH). Patients with MC have been reported to have less satisfactory outcome following conservative treatment or discectomy, although the evidence is still unclear.

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.

Background: To document the role of sub-clinical infection in disc disorders and investigate the existence of a microbiome in healthy, herniated, and degenerated intervertebral discs (IVD) through next generation genomics tools. Methods: Genomic DNA from 24 lumbar IVDs (8 MRI normal discs (ND) from brain dead yet alive organ donors, 8–Disc herniation (DH), 8–Disc degeneration (DD)) were subjected to 16S rRNA sequencing using the Illumina MiSeq platform for profiling the diversity of human disc microbiome in health and disease. Mass spectrometric analysis was performed to reconfirm the presence of conserved bacterial proteins. The disc microbiome was compared to established human gut and skin microbiomes to identify common microorganisms. Findings: All healthy MRI normal discs from brain dead yet alive organ donors also had a rich bacterial presence. A total of 424 different species (355-ND, 346-DD, and 322-DH) were detected in all 24 samples, with 42·75% OTUs being classified at the Kingdom level, 44% at the Phylum level, 22·62% at the Genus level, and 5·5% at Species level. Varying biodiversity and abundance between the healthy and diseased discs were documented with protective bacteria being abundant in normal discs, and putative pathogens abundant in DD and DH. Propionibacterium acnes had a similar but lower abundance to other pathogens in all three groups ND (3·07%), DD (3·88%), DH (1·56%). Forty-eight bacteria were common between Gut/IVD microbiome, 23 between skin/IVD microbiome, and three common to gut/skin/IVD. Interpretation: Our study challenges the hitherto concept of sterility in healthy IVD and documented an established microbiome even in MRI normal healthy discs. The varying abundance of bacteria between ND, DD, and DH documents ‘Dysbiosis’ as a possible etiology of DD. Many known pathogens were identified in greater abundance than Propionibacterium acnes, and there was evidence for the presence of the Gut- Skin- Spine microbiome axis. Funding Statement: The project was mainly funded by Ganga Orthopaedic Research & Education Foundation (GOREF 2018-08) and partially by the AO Spine (AOSIN(R) 2017-04). Declaration of Interests: The authors declare that they have no conflict of interest. Ethics Approval Statement: The study was performed only after approval of the IRB committee.

Study Design: Review article. Objectives: A review of literature on the epidemiology, diagnosis, and management of spinal tuberculosis (TB). Methods: A systematic computerized literature search was performed using Cochrane Database of Systematic Reviews, EMBASE, and PubMed. Studies published over the past 10 years were analyzed. The searches were performed using Medical Subject Headings terms, and the subheadings used were “spinal tuberculosis,” “diagnosis,” “epidemiology,” “etiology,” “management,” “surgery,” and “therapy.” Results: Tissue diagnosis remains the only foolproof investigation to confirm diagnosis. Magnetic resonance imaging and Gene Xpert help in early detection and treatment of spinal TB. Uncomplicated spinal TB has good response to appropriately dosed multimodal ambulant chemotherapy. Surgery is warranted only in cases of neurological complications, incapacitating deformity, and instability. Conclusions: The incidence of atypical clinicoradiological presentations of spinal TB is on the rise. Improper dosing, inadequate duration of treatment, and inappropriate selection of candidates for chemotherapy has not only resulted in the resurgence of TB but also led to the most dreadful consequence of multidrug resistant strains. In addition, global migration phenomenon has resulted in worldwide spread of spinal TB. The current consensus is to diagnose and treat spinal TB early, prevent complications, promote early mobilization, and restore the patient to his or her earlier functional status.

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.

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 Design: Prospective, observational cohort study. Objective: Selective nerve root block (SNRB) is an effective, standard interventional procedure for failed medical management in lumbar disc herniation (LDH). However, the factors that would predict successful outcomes in patients undergoing SNRB have not been clearly studied. Methods: Patients with failed conservative treatment for acute LDH, treated with SNRB were periodically followed till 1 year. Patients who failed to have pain relief or had recurrent pain after SNRB, underwent surgery. The pattern of radiculogram during SNRB was classified into 4 types—“arm,” “arrow,” “linear,” and “splash.” Various clinical factors, radiological factors, and radiculograms were compared between patients who had consistent pain relief (group A) and those patients who did not (group B). Results: A total of 91 patients underwent SNRB. Sixty-nine had good pain relief maintained till 1 year (75.8% success). Twenty-two patients underwent surgery after failed NRB at a mean of 6.3 weeks. Patients with sensory symptoms ( P = .01), higher mean preinjection Oswestry Disability Index (ODI) score ( P = .02), higher mean postinjection ODI score at 3 weeks ( P = .004), nonmanual job ( P = .01), lumbosacral transitional segment ( P = .00 005), and splash pattern of radiculogram ( P = .005) were predictive of failed NRB. Logistic regression analysis showed that lumbosacral transitional segment at the level of LDH is the most significant factor predicting poor outcome. Conclusions: SNRB is an effective technique to provide consistent symptom relief at least till 1 year in patients with acute LDH. The study identified several factors that predicted poor outcomes of SNRB and such patients can be forewarned about need for later surgery.

A psychometrics study.To determine intra and inter-observer reliability of Allen Ferguson system (AF) and sub-axial injury classification and severity scale (SLIC), two sub axial cervical spine injury (SACI) classification systems.Online multi-national study METHODS: Clinico-radiological data of 34 random patients with traumatic SACI were distributed as power point presentations to 13 spine surgeons of the Spine Trauma Study Group of ISCoS from seven different institutions. They were advised to classify patients using AF and SLIC systems. A reference guide of the two systems had been mailed to them earlier. After 6 weeks, the same cases were re-presented to them in a different order for classification using both systems. Intra and inter-observer reliability scores were calculated and analysed with Fleiss Kappa coefficient (k value) for both the systems and Intraclass correlation coefficient(ICC) for the SLIC.Allen Ferguson system displayed a uniformly moderate inter and intra-observer reliability. SLIC showed slight to fair inter-observer reliability and fair to substantial intra-observer reliability. AF mechanistic types showed better inter-observer reliability than the SLIC morphological types. Within SLIC, the total SLIC had the least inter-observer agreement and the SLIC neurology had the highest intra-observer agreement.This first external reliability study shows a better reliability for AF as compared to SLIC system. Among the SLIC variables, the DLC status and the total SLIC had least agreement. Low-reliability highlights the need for improving the existing classification systems or coming out with newer ones that consider limitations of the existing ones.

Background There is a lack of a classification system providing uniformity in description and guiding management decisions for kyphotic spinal deformities. We developed such a classification based on column deficiency, flexibility of disc spaces, curve magnitude, and correlation with the corrective osteotomy required. Methods A classification was developed based on analysis of 180 patients with thoracolumbar kyphosis requiring osteotomy. The deformity was classified as Type I if the anterior and posterior columns were intact (IA indicated mobile disc spaces and IB, ankylosed segments). Type II indicated deficiency of only 1 column (IIA = anterior column and IIB = posterior column). Type III indicated deficiency of both columns (IIIA = kyphosis of ≤60°, IIIB = kyphosis of >60°, and IIIC = buckling collapse). A prospective analysis of 76 patients was performed to determine interobserver variability and the ability of the classification to guide selection of osteotomies of increasing complexity, including the Ponte osteotomy, pedicle subtraction osteotomy, disc bone osteotomy, single vertebrectomy, multiple vertebrectomies, and anterior in situ strut fusion procedure. Results The mean age of the 76 patients was 21.2 years, the mean kyphosis was 69.9° (range, 26° to 120°), and the mean follow-up duration was 30 months. Six deformities were classified as IA, 5 as IB, 5 as IIA, 2 as IIB, 13 as IIIA, 35 as IIIB, and 10 as IIIC. Four surgeons classifying the deformities had a high agreement rate (kappa = 0.83), with the highest agreement for Types IA, IB, and IIIB. A correlation between the type of deformity and the osteotomy performed demonstrated that the classification could indicate the type of osteotomy required. All 18 patients with Type-I or II kyphosis were treated with Ponte, pedicle subtraction, or disc bone osteotomy. Forty-three (90%) of the 48 patients with Type IIIA or IIIB underwent vertebrectomy (single in 27 [56%] and multiple in 16 [33%]), and only 5 (10%) underwent disc bone osteotomy. Seven of the 10 patients with Type-IIIC kyphosis were treated with multiple vertebrectomies, with 5 of them needing preoperative halo gravity traction; the other 3 patients underwent an anterior in situ strut fusion procedure. Conclusions The proposed classification based on the morphology of column deficiency, flexibility, and curve magnitude demonstrated a high interobserver agreement and ability to guide selection of the appropriate osteotomy. Clinical relevance A novel classification system for kyphosis based on spinal column deficiency, flexibility of disc spaces, and curve magnitude would bring uniformity in management and help guide surgeons in the choice of the appropriate corrective osteotomy.

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 p =0.893), TK (from 24.4° to 22.8°, p =0.145), and LL (from 50.3° to 51.1°, p =0.415). However, subgroup analysis of the hypokyphosis group (40°) showed significant correction of TK (p p =0.0001) and PT (from 15° to 14°, p =0.025).ConclusionsLD strategic pedicle screw fixation provides favorable coronal correction and improves overall sagittal sacro-pelvic parameters. This technique does not cause significant flattening of TK and results in a favorable restoration of TK in patients with hypokyphosis or hyperkyphosis.

STUDY DESIGN A prospective randomized double blind placebo controlled trail. OBJECTIVE To evaluate and compare the efficacy and safety of batroxobin (botropase), tranexamic acid (TXA), and their combination in reduction of perioperative blood loss in lumbar spine single level fusion surgeries. SUMMARY OF BACKGROUND DATA Spinal surgeries are associated with significant blood loss leading to perioperative anemia and increased need for allogenic transfusion. TXA competitively inhibits plasmin and batroxobin converts fibrinogen to fibrin and theoretically their combination is synergistic. Though TXA is widely studied in controlling blood loss, there is little information on use of batroxobin and their combination. Thus, we aimed to study effect and safety of individual drugs and their combination in controlling blood loss in spinal surgery. METHODS Hundred patients were randomized into four groups. Group B received batroxobin, group T received TXA, group BT received batroxobin and TXA and group P received placebo. Outcomes assessed are intraoperative and postoperative blood loss, hematocrit, allogenic blood transfusion, and deep vein thrombosis (DVT), postoperatively. RESULT Mean intraoperative blood loss in Group B, T, BT, and P were 268.32 ± 62.92 mL, 340.72 ± 182.75 mL, 256.96 ± 82.64 mL, and 448.44 ± 205.86 mL, respectively. Postoperative surgical site drain collection in Group B, T, BT, and P were 218.00 ± 100.54 mL, 260.40 ± 100.85 mL, 191.00 ± 87.84 mL, and 320.00 ± 125.83 mL, respectively. Intraoperative blood loss of Group P was statistically higher than Groups B and BT (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 (ppin-situ fusion group PT changed from 26.78° to 11.08°, SFD from 62.9 to 36.99 mm, and LSK from 67.23° to 113.38° (pp>0.05).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.

To develop a classification based on the technical complexity encountered during pedicle screw insertion and to evaluate the performance of AIRO® CT navigation system based on this classification, in the clinical scenario of complex spinal deformity. 31 complex spinal deformity correction surgeries were prospectively analyzed for performance of AIRO® mobile CT-based navigation system. Pedicles were classified according to complexity of insertion into five types. Analysis was performed to estimate the accuracy of screw placement and time for screw insertion. Breach greater than 2 mm was considered for analysis. 452 pedicle screws were inserted (T1–T6: 116; T7–T12: 171; L1–S1: 165). The average Cobb angle was 68.3° (range 60°–104°). We had 242 grade 2 pedicles, 133 grade 3, and 77 grade 4, and 44 pedicles were unfit for pedicle screw insertion. We noted 27 pedicle screw breach (medial: 10; lateral: 16; anterior: 1). Among lateral breach (n = 16), ten screws were planned for in–out–in pedicle screw insertion. Among lateral breach (n = 16), ten screws were planned for in–out–in pedicle screw insertion. Average screw insertion time was 1.76 ± 0.89 min. After accounting for planned breach, the effective breach rate was 3.8% resulting in 96.2% accuracy for pedicle screw placement. This classification helps compare the accuracy of screw insertion in range of conditions by considering the complexity of screw insertion. Considering the clinical scenario of complex pedicle anatomy in spinal deformity AIRO® navigation showed an excellent accuracy rate of 96.2%.

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.

Purpose Surgical reduction of uni and bi-facetal dislocations of the cervical spine (AO type C injuries) can be performed by posterior, anterior or combined approaches. Ease of access, low infection rates and less risks of neurological worsening has popularized anterior approach. However, the reduction of locked cervical facets can be intricate through anterior approach. We analyzed the safety, efficacy and outcomes at a minimum 1 year, of a novel anterior reduction technique for consecutively treated cervical facet dislocations. Materials and methods Patients with single level traumatic sub-axial cervical dislocation (n = 39) treated by this modified anterior technique were studied. The technique involved standard Smith-Robinson approach, discectomy beyond PLL, use of inter-laminar distracter to distract while Caspar pins were used as "joysticks" (either flexion-extension or lateral rotation moments are provided), to reduce the sub-luxed facets. Among 51 patients with cervical type C injury treated during the study period, 4 patients who had spontaneous reduction and 8 treated by planned global fusion were excluded. Results 39 patients of mean age 49.9 years were studied. The levels of injury included (C3-4 = 2, C4-5 = 5, C5-6 = 20, C6-7 = 12). 18 were bi-facetal and 21 were uni-facetal dislocation. One facet was fractured in 17 and both in 5 patients. 30% (n = 13) had a concomitant disc prolapse. The neurological status was as follows: 9 ASIA A, 9 ASIA C, 13 ASIA D and 8 ASIA E. All the patients were successfully reduced by this technique and fixed with anterior locking cervical locking plates. No supplemental posterior surgery was performed. 22 patients with incomplete deficit showed recovery. The mean follow-up was 14.3 months and there was no implant failure except one patient who had partial loss of the reduction. Conclusion Patients with traumatic sub-axial cervical dislocation (AO type C injuries) can be safely and effectively reduced by this technique. Other advantages include minimal blood loss, less risks of infection, shorted fusion zone, good fusion rate and neurological recovery.

Late onset neurological deficit is a rare complication of spinal tuberculosis. Reactivation of the disease and compression by internal gibbus are the common causes for late onset neurological deficit. We report a rare cause of late onset paraplegia in a patient with post tubercular kyphotic deformity. The late onset neurological deficit was due to the adjacent segment degeneration proximal to the kyphotic deformity. Posterior hypertrophied ligamentum flavum and anterior disc osteophyte complex caused the cord compression. The increased stress for prolonged period at the end of the deformity was the reason for the accelerated degeneration. Patient underwent posterior decompression, posterolateral and interbody fusion. Deformity correction was not done. To our best knowledge, this is only the second report of this unusual cause of late onset paraplegia.

(1) To analyze peculiarities of presentation and prognosis of tubercular spondylodiscitis (TBS) in elderly. (2) To assess if associated co-morbidities and risks lead to poorer outcome (3) To observe if different management strategy needs to be implemented in them. Retrospective analysis of 66 consecutive elderly TBS patients (>60 years) treated conservatively or surgically between January 2010 and July 2013 was performed. Details regarding clinical presentation (general health, ambulatory status, co-morbidities), neurological status, medical or surgical complications and outcome measurements [visual analog score, clinico-radiological evidence of healing and lumbar lordosis in lumbar (L) or lumbo-sacral (LS) or focal kyphosis in thoracic (T) or thoraco-lumbar (TL) disease] were analysed. Of 66 patients (mean age 67.9 years), 85% had at least one medical co-morbidity and only 45% were community ambulators. Mean delay in presentation was 132 days and lumbar disease was commonest. 35% had neuro-deficit. Most patients had stage 2 (38%) or 3 (42.4%) disease. 19 patients were conservatively managed, while others underwent surgery. Significant complications occurred in 23 patients, most common being liver dysfunction (9 patients). Five patients (8%) expired during treatment: three succumbed to multi-focal tubercular disease, while two expired secondary to medical illnesses. Mean loss of lordosis in conservatively treated (CG) L/LS disease was 8°, while lordosis was restored by 11.6° in operative group (OG). In T/TL disease, sagittal alignment correction by 12.6° was observed in OG as against 5.7° kyphotic collapse in CG patients. 92% patients were cured with no recurrences. The final VAS scores in operative and conservative groups were not significantly different (OG 1.4 ± 0.6, CG 1.9 ± 0.7). TBS in elderly differed from that in younger by having a higher co-morbidities, later presentation, higher neuro-deficit, greater mortality and increased complications. Nevertheless, in those who survived, clinico-radiological outcomes of both conservative and surgical treatments were good.

To document a rare complication of a delayed ‘chance fracture pattern’-type injury through the proximal end of a pedicle screw construct in the clinical scenario of skeletal fluorosis. A 72-year-old man with fluorosis presented following a fall which resulted in a T12–L1 fracture. Investigations revealed an unstable three-column injury, so the patient was treated with surgical stabilisation using pedicle screw fixation from T11 to L2. He presented 1 month following surgery with worsening back pain. Investigations revealed a fracture through T11 in a ‘chance fracture pattern’ along the pedicle screw tracts at the proximal end of the construct. An extension of fixation was performed proximally to T8 and he made an uneventful recovery showing fusion at 20-month follow-up. Complication of delayed pedicle fractures, in a ‘chance fracture pattern’ at the ends of a pedicle screw fixation constructs are a rarely reported in the literature. The occurrence of such a complication in a hyperostotic spine associated with fluorosis makes this a unique clinical scenario which is previously unreported to the best of our knowledge. This report highlights a very rare complication of chance fracture pattern injury in the clinical scenario of fluorosis. A hyperostotic stiff spine, poor quality of bone and extension of pedicle screw tracts to anterior cortex during primary surgery may have resulted in the occurrence of this rare complication.

Study Design: Prospective survey-based study. Objectives: The AO Spine thoracolumbar injury classification has been shown to have good reproducibility among clinicians. However, the influence of spine surgeons’ clinical experience on fracture classification, stability assessment, and decision on management based on this classification has not been studied. Furthermore, the usefulness of varying imaging modalities including radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) in the decision process was also studied. Methods: Forty-one spine surgeons from different regions, acquainted with the AOSpine classification system, were provided with 30 thoracolumbar fractures in a 3-step assessment: first radiographs, followed by CT and MRI. Surgeons classified the fracture, evaluated stability, chose management, and identified reasons for any changes. The surgeons were divided into 2 groups based on years of clinical experience as 10 years (n = 29). Results: There were no significant differences between the 2 groups in correctly classifying A1, B2, and C type fractures. Surgeons with less experience had more correct diagnosis in classifying A3 (47.2% vs 38.5% in step 1, 73.6% vs 60.3% in step 2 and 77.8% vs 65.5% in step 3), A4 (16.7% vs 24.1% in step 1, 72.9% vs 57.8% in step 2 and 70.8% vs 56.0% in step3) and B1 injuries (31.9% vs 20.7% in step 1, 41.7% vs 36.8% in step 2 and 38.9% vs 33.9% in step 3). In the assessment of fracture stability and decision on treatment, the less and more experienced surgeons performed equally. The selection of a particular treatment plan varied in all subtypes except in A1 and C type injuries. Conclusion: Surgeons’ experience did not significantly affect overall fracture classification, evaluating stability and planning the treatment. Surgeons with less experience had a higher percentage of correct classification in A3 and A4 injuries. Despite variations between them in classification, the assessment of overall stability and management decisions were similar between the 2 groups.

Late onset paraplegia is a rare complication of spinal tuberculosis. Disease reactivation and cord compression by internal gibbus are the common causes for neurological deficit. We report a patient with post-tubercular kyphotic deformity in whom the late onset paraplegia is caused by ossified ligamentum flavum above the level of kyphotic deformity. The deficit was attributable to the ossified ligamentum flavum and she recovered completely following posterior decompression and instrumented posterolateral fusion. To the best of our knowledge, this is the first report of this unusual cause of late onset paraplegia.

To analyse the clinic-radiological factors associated with neurological deficit following lumbar disc herniation. A prospective, cross-sectional study was performed in 140 cases of micro-discectomy following lumbar disc herniation. Group 1 included 70 consecutive patients with motor deficit and group 2 (controls) included 70 patients with intact neurology. Motor deficit was defined as the occurrence of motor power ≤3/5 in L2–S1 myotomes. Multiple clinical and radiological parameters were studied between the two groups. Patients with diabetes (p 0.004), acute onset of symptoms (p 0.036), L3–4 discs (p 0.001), sequestrated discs (p 0.004), superiorly migrated discs (p 0.012) and central discs (p 0.004), greater antero-posterior disc dimension (p 0.023), primary canal stenosis (p 0.0001); and greater canal compromise (p 0.002) had a significant correlation with the development of neurological deficit. The presence of four or more of these risk factors showed a higher chance of the presence of motor deficit (sensitivity of 74%, specificity of 77%). Age, sex, previous precipitating events, severity of pain, smoking, and number of herniations levels did not affect the occurrence of deficit (p > 0.05 for all). Patients with or without bladder symptoms were similar with respect to all clinico-radiological parameters. However, the time delay since the occurrence of deficit was significantly shorter in patients with bladder involvement (p 0.001). Patients with diabetes, acute presentation, central, sequestrated and superiorly migrated discs, high lumbar disc prolapse, and greater spinal canal compromise are predisposed to the presence of motor deficit.

Proteomic and 16S rDNA analysis of disc tissues obtained in vivo. To address the controversy of infection as an aetiology for disc disorders through protein profiling. There is raging controversy over the presence of bacteria in human lumbar discs in vivo, and if they represent contamination or infection. Proteomics can provide valuable insight by identifying proteins signifying bacterial presence and, also host defence response proteins (HDRPs), which will confirm infection. 22 discs (15-disc herniations (DH), 5-degenerate (DD), 2-normal in MRI (NM) were harvested intraoperatively and immediately snap frozen. Samples were pooled into three groups and proteins extracted were analysed with liquid chromatography-tandem mass spectrometry (LC–MS/MS). Post identification, data analysis was performed using Uniprotdb, Pantherdb, Proteome discoverer and STRING network. Authentication for bacterial presence was performed by PCR amplification of 16S rDNA. LC–MS/MS analysis using Orbitrap showed 1103 proteins in DH group, compared to 394 in NM and 564 in DD. 73 bacterial specific proteins were identified (56 specific for Propionibacterium acnes; 17 for Staphylococcus epidermidis). In addition, 67 infection-specific HDRPs, unique or upregulated, such as Defensin, Lysozyme, Dermcidin, Cathepsin-G, Prolactin-Induced Protein, and Phospholipase-A2, were identified confirming presence of infection. Species-specific primers for P. acnes exhibited amplicons at 946 bp (16S rDNA) and 515 bp (Lipase) confirming presence of P. acnes in both NM discs, 11 of 15 DH discs, and all five DD discs. Bioinformatic search for protein–protein interactions (STRING) documented 169 proteins with close interactions (protein clustering co-efficient 0.7) between host response and degenerative proteins implying that infection may initiate degradation through Ubiquitin C. Our study demonstrates bacterial specific proteins and host defence proteins to infection which strengthen the hypothesis of infection as a possible initiator of disc disease. These results can lead to a paradigm shift in our understanding and management of disc disorders.

Bardet–Biedl syndrome (BBS) is a rare, autosomal-recessive, debilitating genetic disorder, which can present with multitudinous systemic clinical features including rod-cone dystrophy, polydactyly, Frohlich-like central obesity, mental retardation, hypogonadism, and renal anomalies. Diverse neuromuscular manifestations in patients afflicted by this heterogeneous disorder include ataxia, cervical, and thoracic canal stenoses, presenting as spastic quadriparesis and other gait disturbances. We report a young patient with BBS, who had presented with acute flaccid paraparesis due to severe primary lumbar canal stenosis. She underwent immediate lumbar decompression and discectomy following which she recovered significantly. Acute cauda equina syndrome due to primary lumbar canal stenosis has not been reported as a clinical feature of BBS previously.

STUDY DESIGN Prospective observational cohort study. OBJECTIVE The aim of this study was to analyze the efficacy of diffusion tensor imaging (DTI) anisotropy indices in predicting the postoperative recovery in cervical spondylotic myelopathy (CSM) patients and to describe postoperative changes in the DTI indices based on neurological recovery after surgery. SUMMARY OF BACKGROUND DATA Surgical results of CSM are unpredictable and cannot be estimated based on preoperative MRI. DTI indices were found to have good sensitivity to detect changes in CSM, but their efficacy in predicting postoperative recovery and postoperative changes in DTI indices has not been studied before. METHODS Thirty-five patients who underwent surgical decompression for cervical spondylotic myelopathy underwent DTI evaluation preoperatively and postoperatively at 12 months. DTI indices-fractional anisotropy, apparent diffusion coefficient (ADC), relative anisotropy, volume ratio, and eigen vectors (E1, E2, and E3)-were obtained and clinical evaluations were made preoperatively and 12 months postoperatively. RESULTS Twenty-six patients were available for final follow-up at 12 months. Twenty patients showed improvement by at least 1 Nurick grade, five maintained the preoperative Nurick grade status and one patient was noted to have deterioration by 1 grade. The preoperative DTI values could not predict neurological recovery patterns postoperatively. Although conventional MRI showed adequate decompression in all patients irrespective of the clinical outcome, DTI indices showed variable results. There were significant improvements in postoperative DTI indices for ADC (P = 0.002), E1 (P

To document the role of sub-clinical infections in disc disorders and investigate the existence of microbiome in intervertebral discs (IVD). Genomic DNA from 24 lumbar IVDs [8—MRI normal discs (ND) from brain dead yet alive organ donors, 8—disc herniation (DH), 8—disc degeneration (DD)] was subjected to 16SrRNA sequencing for profiling the diversity of human disc microbiome in health and disease. The disc microbiome was further compared to established human gut and skin microbiomes. All healthy MRI normal discs from brain dead yet alive organ donors also had a rich bacterial presence. A total of 424 different species (355-ND, 346-DD, and 322-DH) were detected, with 42.75% OTUs being classified at kingdom level, 44% at the phylum level, 22.62% at genus level, and 5.5% at species level. Varying biodiversity and abundance between healthy and diseased discs were documented with protective bacteria being abundant in normal discs, and putative pathogens abundant in DD and DH. Propionibacterium acnes had a similar but lower abundance to other pathogens in all three groups ND (3.07%), DD (3.88%), DH (1.56%). Fifty-eight bacteria were common between gut and IVD microbiomes, 29 between skin and IVD microbiomes, and six common to gut/skin/IVD. Our study challenges the hitherto concept of sterility in healthy IVD and documented a microbiome even in MRI normal healthy discs. The varying abundance of bacteria between ND, DD, and DH documents ‘dysbiosis’ as a possible etiology of DD. Many known pathogens were identified in greater abundance than Propionibacterium acnes, and there was evidence for the presence of the gut/skin/spine microbiome axis.

To evaluate the incidence and risk factors associated with the unplanned return to OR in EOS.Medical records of 51 patients of EOS operated at three different centres using various types of GSCs were evaluated for complications requiring unplanned surgeries. Data were analysed to find out rate of unplanned surgeries in relation to the aetiology, age and Cobb angle at index surgery, type of implant, cause of unplanned surgery, and management required.Out of 51 patients, three did not meet inclusion criteria. Forty-eight patients of EOS operated by GSCs with a mean age of 6.7 years (range 2-12 years) with an average follow-up of 67.3 months were studied. There were 30 congenital, 10 idiopathic, 4 syndromic, and 4 neuromuscular cases. Thirty-nine out of 48 patients had one or more unplanned surgeries on follow-up (81.25%). Out of total 248 surgeries following index procedure, 82 were unplanned surgeries (33.06%), including 53 implant revisions, 12 implant-removal, 14 debridement, and 2 flaps. The common complications were 24.14% rod/screw breakage, 42.53% anchor pull-out, 16.09% infections, 6.90% wound dehiscence, and 4.6% neuro deficits. Unplanned surgeries were significantly higher in syndromic (58.8%) and neuromuscular (52.9%) than congenital (27.2%) and idiopathic (37.8%) cases (p 0.05). Age at index procedure 5 years had higher unplanned surgeries than age 5 years (2.5 and 1.23 per patient, respectively, p 0.05). Type of implant and initial Cobb angle did not significantly affect the rate of unplanned surgeries (p 0.05) CONCLUSION: GSCs in EOS require a frequent revisit to operation room which should be well understood by the surgeon and parents.

Cauda equina syndrome following transforaminal lumbar interbody fusion (TLIF) is very rare, and the causes implicated include inadequate decompression, retained disc fragments, epidural haematoma, gel foams, fat pad grafts, retained sponges, intradural masses and ischaemia of conus. This is a rare case report of pseudoaneurysm of dorsal branch of lumbar artery presenting with delayed onset incomplete cauda equina syndrome following TLIF. To describe the very rare case of lumbar artery pseudoaneurysm causing delayed onset incomplete cauda equina syndrome following TLIF and its management with endovascular embolisation. An 80-year-old female presented with incomplete cauda equina syndrome on 14th post-operative day following TLIF. On evaluation, computed tomography (CT) scan and magnetic resonance imaging (MRI) revealed haematoma with heterogeneous signal intensity, which was pulsatile in ultrasonogram. Doppler and contrast-enhanced CT revealed pseudoaneurysm from posterior branch of left lumbar L4 artery, which was managed with endovascular embolisation. After endovascular embolisation, the patient had immediate relief from radiating pain in left lower limb and regained full motor power and perianal sensation at the end of 3 weeks. Post-procedure ultrasonography done on the tenth day revealed complete resolution of the pseudoaneurysm. This case presentation shows the necessity of diagnosing epidural haematomas due to vascular aneurysm in patients with post-operative radiculopathy and neurodeficit and the effectiveness of endovascular embolisation in treating such a threatening condition.

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.

Introduction Some of the most common developmental malformations of the axis include anomalies of the odontoid, for example, hypoplasia or aplasia. Isolated anomalies of the posterior arch of the axis rarely occur. This study reports a unique case of congenital anomaly of the neural arch of the axis vertebra, which manifested clinically as progressive hemiparesis. Case presentation A 33-year-old man presented with progressive weakness of the right upper and lower limbs that had lasted 18 months. The patient reported loss of right-hand dexterity in the 6 months period before he consulted us. Plain radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) revealed C5-C6 block vertebra, primary canal stenosis and spino-laminar anomaly of the axis, along with invagination of the lamina into the canal causing severe cord compression. Discussion The anomalous posterior element of the axis was excised, and the cord was decompressed. The presence of congenital stenosis and block vertebrae at the C5-C6 level necessitated decompression and instrumentation between C2-C6. Simultaneous occurrence of a posterior arch anomaly, primary canal stenosis, and block vertebra has not been previously described. A cervical spine anomaly presenting as hemiparesis is uncommon in clinical practice. Information enabling clinicians to identify causative anomaly and determine the appropriate surgical intervention is useful, and can facilitate a good clinical outcome.