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To describe a management algorithm for cervicovertebral junction (CVJ) TB based upon disease severity and neurological status at presentation.Retrospective cohort study of 52 patients treated for microbiologically or clinically-diagnosed CVJ TB at a tertiary referral center in a TB endemic area were identified. Data were gathered about presenting symptoms, baseline neurological status, management strategy, and management outcomes. Patients were categorized by a modified Lifeso Stage.Fifty-two patients were included (Mean age 28.5 ± 13.4 yr, 48% male): 18 Lifeso Stage I, 15 Stage II, and 19 Stage III. All presented with pain, 19 (37%) with neurological symptoms, and 5 with inability to ambulate. Stage II and III patients were more commonly myelopathic at presentation (p 0.01) than Stage I patients. Only Stage II/III lesions required traction or surgical intervention; Stage III lesions more commonly required surgery than Stage II lesions (100% vs. 73%; p = 0.03). Among surgically-treated Stage II and III lesions, Stage III lesions had longer symptom prodromes (5.1 ± 2.2 vs. 3.3 ± 1.4mo; p = 0.03), more commonly had lateral mass collapse at presentation (58 vs. 9%; p = 0.02), and more commonly required occipitocervical fusion (68 vs. 9%; p 0.01).Based upon these data, Stage I lesions may be treated conservatively, unless presenting with a neurological deficit. Conversely, Stage III lesions require open reduction and instrumentation due to irrevocable underlying bony damage. Reducible Stage II lesions with absent or mild neurological symptoms can be treated conservatively, but irreducible lesions and those with concomitant neurological deficits merit surgery.

Purpose: Significant number of low back pain is caused by spinal instability. Clinical and radiological tests are used to diagnose lumbar instability, but the practical utility of clinical tests has not been studied extensively. Hence, it was decided to study lumbar rocking test and passive lumbar extension (PLE) clinical tests to identify their accuracy for lumbar instability, in comparison to the radiological assessment. Materials and Methods: This cross-sectional prospective study was conducted in 2017 at an Indian tertiary care center, after Ethics Committee approval. No financial transection involved anywhere at any stage of the study. Patients of 30–65 years having low back pain were included following informed consent. Clinical tests conducted were rocking test and PLE tests. All patients were subjected to a neutral anteroposterior, lateral and flexion-extension X-rays of lumbosacral spine. The association between clinical tests and lumbar instability was represented by Chi-square analysis. The rest of the findings were represented as descriptive statistics. Results: Fifty patients enrolled in the study, of which 28 (56%) were females. On X-rays, the maximum angular rotation and sagittal translation were seen at L5–S1 level. 35 (70%) and 46 (92%) patients showed positive PLE and rocking test, respectively. Significant association (P < 0.05) was seen between rocking test and lumbar instability. The sensitivity of rocking test was 95.56% and positive predictive value as 93.47%. Conclusion: Clinical tests can be used effectively for the diagnosis of lumbar spine instability. Rocking test was found to be accurate and sensitive for detecting subtle lumbar instability.

Study Design Retrospective cohort. Objective To radiographically evaluate Craniovertebral junction (CVJ) tuberculosis infection pathogenesis and to propose a modification to the Lifeso classification. Methods A cohort of patients with radiologically or microbiologically identified CVJ tuberculosis treated at a single tertiary referral center in a TB endemic area was queried for characteristics about clinical presentation, treatment, and radiographic evidence of bone destruction and abscess formation were included. Disease was classified according to the Lifeso grading system and bony lesions were classified as either type 1 (preservation of underlying structure) or type 2 (damage of underlying structure). Results 52 patients were identified (mean age 28.5 ± 13.4yr, 48% male; 14% with a prior history of tuberculosis). All presented with neck pain at presentation, 29% with rotatory pain, and 37% with myelopathy. Comparison by Lifeso type showed Lifeso III lesions had longer symptom durations ( P = .03) and more commonly had periarticular or predental abscess formation ( P < .05), spinal cord compression ( P < .01), and more commonly involved the C2 body and atlanto-dental joint. Underlying bony destruction was more common for lesions of the lateral atlantoaxial joints and atlanto-dental joints in Lifeso III cases than in either Lifeso I or II (all P < .05). Conclusions The radiologic findings of the present series suggest CVJ TB infection may originate in the periarticular fascia with subsequent invasion into the adjacent atlanto-dental and lateral atlantoaxial joints in later disease. To reflect this proposed etiology, we present a modified Lifeso classification to describe the radiologic pathogenesis of CVJ TB.

Spinal tuberculosis is the most common form of extrapulmonnary tuberculosis. It can be managed conservatively as well as by operative intervention. The surgery involves decompression of the focus of infection and stabilisation of the spine. Various approaches have been devised to perform decompression and instrumentation of the spine. This study compares the efficacy and complications of three approaches: Anterior and Posterior, Anterolateral and Only Posterior approach. It is a retrospective study involving 30 patients from October 2013 to October 2015. In our study, we found that the posterior approach was a safer approach with lesser complications and almost equal efficacy as compared to other two approaches. Though there was equally significant improvement in the post-operative neurology in all the three approaches, the posterior approach was associated with lesser morbidity and required relatively lesser time.

Giant cell tumor (GCT) or osteoclastoma is a benign, locally aggressive tumor with a tendency to recur. Involvement of the axial skeleton is very rare and majority of them are seen in the sacrum. The authors report a rare case of a 19-year-old female who presented with a C2 dens GCT with a pathological fracture and atlantoaxial dislocation. The patient was operated in two stages: first stage, with posterior instrumentation and stabilization followed by the second stage, tumor resection by anterior transoral approach. The residual tumor cavity was packed with autologous corticocancellous bone grafts. At a 5-year follow-up, computed tomography scan showed a C1-C2 fusion mass. There was no radiological or clinical evidence of tumor recurrence with the patient having good functional outcome without any neurological deficit.

Objective/Purpose: The objective of this study is to describe our experience with the use of stay sutures and transverse neck incision for anterior cervical spine surgeries involving multiple levels. Summary of Background Data: Transverse incisions on neck usually heal with minimal fibrosis resulting in cosmetically acceptable scars whereas vertical incision, although provides greater exposure, heals with extensive fibrosis resulting in ugly scars. Transverse incision is thus highly recommended. However, the fear of nonextensibility of transverse incision for multilevel fusion has led to the preference of vertical incision, development of techniques for identifying the optimal level of the incision, or has suggested the usage of two transverse incisions. Materials and Methods: Seventy-six patients underwent anterior cervical spine surgeries using a transverse neck incision for single or multilevel discectomy/corpectomy and fusion. Having divided the platysma, dissection was carried down to the anterior surface of the cervical spine between the carotid sheath laterally and the trachea and esophagus medially. Stay sutures were taken through the platysma and subcutaneous tissue, converting the transverse incision into a quadrilateral window providing access for as much as three-level corpectomy or five levels of fixation. Results: All the wounds healed with no evidence of wound-related complications, leaving a cosmetically acceptable scar. Conclusion: Using appropriately placed stay sutures, a transverse neck incision taken in the middle of the field of work can provide enough of a surgical window to perform multilevel fusion surgeries. Its simplicity and cost-effectiveness make it easily implementable, addressing the underlying pathology adequately with best possible cosmetic results.

To present cases of spinal tuberculosis in advanced pregnancy treated on anti-tuberculous drug regimen with successful outcome and proposing alternative paradigm to surgical decompression. A case series of five patients in stages of advanced pregnancy with neurologic deterioration and spinal tuberculosis were reported and treated. Five patients with backache in advanced stages of pregnancy were reported. Patients were diagnosed as cases of spinal tuberculosis on further imaging studies. Patients were treated and followed up till complete clinical and radiological recovery. Four out of five patients were treated conservatively on ATT and rest. One patient underwent decompression without instrumentation. All patients recovered neurologically. There were foetal complications in two cases with foetal demise. One patient who underwent surgical decompression had preterm labour with still birth, apparently due to adverse reactions with anaesthetic drugs. Spinal tuberculosis in pregnancy is a rare occurrence. Hesitation in performing radiographs complicates the outcome with delay in diagnosis and neurological compromise. There are no clear guidelines for treatment of such cases. Conservative treatment with ATT in pregnant patients may be a viable approach. Neurological compromise does not mandate surgical decompression, which in itself is not devoid of complications. Concern of foetal complications is high in surgical treatment.

Single case report. To report multiple level fractures of cervical spine in a patient with osteopetrosis and its management. Osteopetrosis is a rare inherited condition characterized by defective remodeling resulting in hard and brittle bones with diffuse osteosclerosis. Fractures of spine are rare as compared to the common long bone fractures. We report a case of traumatic multiple level fractures of cervical spine in osteopetrosis and its management which has rarely been reported in the literature before, if any. 17-year-old boy presented with severe tenderness in neck and restricted range of motion following a trivial injury to the neck in swimming pool. The neurology was normal and he was diagnosed to have autosomal dominant osteopetrosis on evaluation. Imagining findings, clinical course and the method of treatment are discussed. Radiological evaluation revealed presence of multiple level fractures of cervical vertebrae with end plate sclerosis. Patient was managed with cervical skeletal traction in appropriate extension position for 6 weeks followed by hard cervical collar for another 6 weeks. Follow-up radiographs at 18 months and 2.5 years showed healed fractures with no residual instability or symptoms. The case report discusses rare occurrence of multiple level fractures of cervical spine following trivial injury to the neck in a patient with osteopetrosis and its treatment with conservative management.

Introduction Radiological lumbar spinal instability may exist without obvious spondylolisthesis. We aim to determine the incidence of this non-spondylolisthetic cause of instability in conservatively managed patients and operated groups of patients. We also attempted to study the relationship between instability and its occurrence with respect to age, sex, signs and symptoms. Materials and methods Twenty-three patients treated conservatively (group A) for non-spondylolisthetic backache were studied for radiological evidence of instability by evaluating angular rotation and sagittal translation at each lumbar motion segment. The influence of age, sex, signs and symptoms on the occurrence of instability was studied. A total of 18 patients treated surgically (group B) for non-spondylolisthetic backache in the form of discectomy/decompression were evaluated for occurrence of instability at three months, six months and nine months postoperatively. Results Four out of 23 patients (17.4%) in group A had radiological instability. Angular rotation was found to have negative correlation with age, while sagittal translation did not show any consistent correlation with age. Neither had any significant correlation with sex. The incidence of instability in patients treated with discectomy at three months and six months was 20% which reduced to 10% at nine months while that in patients treated with decompression was about 37.5% over three months, six months and nine months of follow-up. Conclusion If patients with spondylolisthesis were excluded from the study, instability could still result from the rotational component in sagittal plane. Secondary iatrogenic instabilities do result in patients undergoing extensive decompression for spinal stenosis and should always be thought of.

The purpose of the study was to propose a method of prone positioning for posterior cervico-dorsal spine surgeries that is easy to achieve without additional equipment and may reduce complications associated with prone positioning in patients.41 patients underwent posterior spine surgeries using our method of prone positioning on a fluoroscopy compatible conventional operation table, and the technical difficulties and complications associated were noted. After induction under general anaesthesia in supine position, cervical tongs were applied. An assembly of two adequately padded cylindrical bolsters and two lateral brace attachments was set on a conventional operating table. The patient was then positioned prone so that the tongs as well as insertion pins of the tongs rest on the lateral brace attachments, with the face and head suspended freely in between. A neutralisation weight was then applied suspended from the tongs to stabilize the head.The time required for patient positioning was noted and was found to be nearly the same as that required for traditional prone positioning. No problems were noted during patient positioning and with anaesthesia tubing management. All surgeries went well without position related complications except for one patient who developed post-operative macroglossia. All cervical tong pin sites healed without any complications. The fluoroscope easily gained access to the operative areas.Our modification appears simple, versatile and reproducible for posterior approach procedures of the cervical and upper dorsal spine in prone position. Also, the method can be easily implemented in most conventional operating room facilities with minimal surgeon effort and without the need for any additional inventory.

Introduction Traditionally, surgical intervention for patients with a spinal deformity has been considered for cosmetic benefits, but surgical intervention can alter the lung physiology or volumes and in turn leads to increase in physical capacity and exercise tolerance. Therefore, we conducted this to determine whether a surgical correction would restore the lung physiology, physical capacity and exercise tolerance in patients with kyphoscoliosis. Aim To evaluate the usage of six-minute walk test scores and modified Borg scores as tools/measures for exercise tolerance in patients with spinal deformity and to study the effects of surgical correction of spinal deformity on exercise tolerance with above parameters as the measures. Materials and methods Thirty patients with spinal deformity, who had undergone surgery for deformity correction, were evaluated. All patients were investigated pre-operatively with x-rays of the spine (anteroposterior and lateral views). Clinical tests like breath holding time (after full inspiration) in number of seconds, modified Borg scores, six-minute walk test scores (heart rate, respiratory rate, maximum distance walked); were recorded as measures of exercise tolerance. The patients were followed up on the first, third, sixth and twelfth month post-operatively and tested clinically for breath holding time, modified Borg scores, six-minute walk test scores (heart rate, respiratory rate, maximum distance walked) and x-rays of the spine (anteroposterior and lateral views). Results In our study, breath holding time (p-value = 0.001) and modified Borg scores (p-value = 0.012) showed a significant improvement at 12 months post-operatively. We noted similar findings with heart rate, respiratory rate and maximum distance walked after a six-minute walk test. Improvements were noted in all the parameters, especially in the group of patients with greater than 60 degrees of cobb angle. However, the differences between the two groups (pre-operative cobb angle less than 60 degrees and pre-operative cobb angle more than 60 degrees) were not significant. The results were analysed and tested for significance using Student's t-test (paired and unpaired as appropriate) and Wilcoxon signed rank test. Conclusion Surgical correction in cases of spinal deformity improves the cosmetic appearance and balance in the patients. Favourable results of surgical intervention were found in exercise tolerance with improvements in modified Borg scores, six-minute walk test results and breath holding time. The above parameters appear to be good tools for the assessment of physical capacity and exercise tolerance in patients with spinal deformity.

Fractures of the proximal tibia comprise a huge spectrum of injuries with different fracture configurations. The combination of tibia plateau fracture with diaphyseal extension is a rare injury with sparse literature being available on treatment of the same. Various treatment modalities can be adopted with the aim of achieving a well-aligned, congruous, stable joint, which allows early motion and function. We report a case of a 40-year-old male who sustained a Schatzker type VI fracture of left tibial plateau with diaphyseal extension. On further investigations, the patient was diagnosed to have diabetes mellitus with grossly deranged blood sugar levels. The depressed tibial condyle was manipulated to lift its articular surface using K-wire as a joystick and stabilized with an additional K-wire. Distal tibial skeletal traction was maintained for three weeks followed by an above knee cast. At eight months of follow-up, X-rays revealed a well-consolidated fracture site, and the patient had attained a reasonably good range of motion with only terminal restriction of squatting. Tibial plateau fractures with diaphyseal extension in a patient with uncontrolled diabetes mellitus is certainly a challenging entity. After an extended search of literature, we could not find any reports highlighting a similar method of treatment for complex tibial plateau injuries in a patient with uncontrolled diabetes mellitus.

We report a case of posterior atlantoaxial dislocation without a fracture of the odontoid in a 35-year-old woman. There have been nine reported cases of similar injury in the English literature. The integrity of the transverse ligament following posterior atlantoaxial dislocations has not been well documented in these reports. In the present case, MRI revealed an intact transverse ligament, which probably contributed to the stability of the C1-C2 complex following closed reduction.

Recently, it has been demonstrated that anterior release of tight structures via a transoral approach can assist posterior distraction–reduction technique in restoring the cranio-cervical anatomy in irreducible atlantoaxial dislocations. Our aim was to evaluate the radiological and clinical outcome of anterior release and posterior instrumentation for irreducible congenital basilar invagination. A consecutive series of 15 patients (2007–2009) with irreducible congenital basilar invagination were treated with anterior release using transoral approach. A retrospective chart review was performed. All patients presented with myelopathy. Dislocation was treated as irreducible if acceptable reduction was not achieved with traction under general anesthesia and neuromuscular paralysis. The anterior release comprised of transverse sectioning the longus colli and capitis, C1–C2 joint capsular release and intra-articular adhesiolysis with or without anterior C1 arch excision. Cantilever mechanism using posterior instrumentation was used to correct any residual malalignment. Mean age was 21.4 (10–50) years. Average duration of follow-up was 28 (24–40) months. The average preoperative JOA score was 11.4 (8–16), which improved to 15.4 (10–18) after surgery. Anatomical reduction was achieved in thirteen patients. Fusion was documented in all patients. Complications included persistent nasal phonation in one, and superficial wound dehiscence in one. We believe that a significant number of irreducible dislocations can be anatomically reduced with this procedure thus avoiding odontoid excision. Encouraging results from this short series have given us a new perspective in dealing with these challenging problems.

It is a well-know fact that type 2 odontoid fractures frequently go into nonunion. If left untreated, patients may develop irreducible atlantoaxial dislocation (AAD). We describe the surgical management of two patients with neglected odontoid fractures and irreducible AAD treated with single stage anterior release followed by posterior instrumented fusion. Both patients presented with history of neglected trauma and progressive myelopathy. Traction under anesthesia failed to achieve reduction of AAD. Anterior release was done by trans-oral approach in one patient and retrophayngeal approach in the other. Posterior fixation was performed with transarticular screws in both the patients. Both patients had full neurological recovery and demonstrated fusion at follow-up. Anterior release followed by posterior instrumented correction may be an effective alternative to the traditional means of treating irreducible dislocations associated with neglected odontoid fractures.

Study design A retrospective chart review. Objective To describe the presentation and the rationale for management of pathological odontoid fracture and complete odontoid destruction in craniovertebral junction tuberculosis (CVJ TB). Summary of background data Presentation of CVJ TB ranges from minor osteomyelitic changes to severe structural damage leading to instability. Structural damage to the odontoid process is poorly characterized in the literature. Inadequate knowledge about the radiological presentations has led to controversy in the management of CVJ TB. Methods The cohort consisted of 15 consecutive patients with CVJ TB, with structural damage to the odontoid process in the form of either odontoid fracture (n = 7) or complete odontoid destruction (n = 8). These patients presented with pain, neurological deficit, torticollis, dysphagia, or respiratory distress. The cause of neurological deficit was craniocervical instability characterized as anterioposterior (n = 15), rotatory (n = 4), and vertical (n = 6). Displacement reduced anatomically in 13 patients. Apart from antibiotics, all patients were treated surgically by either C1-C2 fusion (n = 7) or occipitocervical fusion (n = 8). Results Average duration of follow-up was 3.6 years (range, 1.5-8 yr). All patients achieved normal neurological status. No complications were noted, except for 1 case, who had a loss of reduction after the use of Hartshill rectangle for occipitocervical fusion. Postoperative computed tomographic scan showed nonunion of odontoid fracture in 2 of 4 patients. No patient of odontoid destruction, of the 5 investigated, revealed structural reformation of the dens. Conclusion CVJ TB can severely damage the odontoid process, resulting in atlantoaxial dislocation. In these patients, surgery restores and maintains the craniocervical alignment and has a predictable outcome compared with conservative therapy. Pathological odontoid fractures have the potential to go into nonunion. Odontoid process once destroyed completely is rarely restored after antibiotic therapy.