Post-tubercular Lumbosacral Kyphotic Deformity in a 11-Year-Old Child: A Case Report.

CASE: An 11-year-old girl with intact neurology presented with a lumbosacral kyphotic deformity due to healed tuberculosis. Radiological imaging showed sagittal balanced spine with compensatory thoracic lordosis and cervical kyphosis. She underwent L4 and L5 posterior vertebral column resection (PVCR) with posterior instrumentation from L2 to pelvis. The patient demonstrated immediate correction of compensatory curves postoperatively. At 3-year follow-up, she returned to her activities of daily living with Oswestry Disability Index and Scoliosis Research Society scores of 12 and 4.8% respectively. CONCLUSION: Pediatric post-tubercular deformities in the lumbosacral region are rare. They can cause secondary changes in other regions, such as the loss of thoracic kyphosis or cervical lordosis. These deformities should be addressed at an early age to prevent structural changes in compensatory curves.

Proximal Junctional Kyphosis after Pediatric Angular Kyphotic Deformity Correction: Are we Missing Something?

PURPOSE: Corrective maneuvers in an angular kyphotic deformity have its own problems including early complications such as neurological deficit and late complications such as proximal junctional kyphosis (PJK) and proximal junctional failure (PJF). This article discusses the probable mechanisms, leading to PJK in pediatric severe angular kyphotic deformities and preventive strategies for the same. We will also assess natural course of untreated PJK and its devastating consequences. MATERIALS AND METHODS: Three patients, two 13-year males presented with progressive, painless thoracolumbar kyphoscoliotic deformity, with segmental kyphosis 100° and 140° and scoliosis of 33° and 78°, respectively, and one 14-year-old female presented with angular kyphotic deformity of 60° with apex at D11-12 level. RESULTS: Posterior vertebral column resection with segmental deformity correction with good coronal and sagittal balance was done. In the follow-up, PJF was seen. Second surgery was done with the extension of instrumentation to D4 along with deformity correction in both the male patients. The female patient did not opt for a revision surgery, and we are following the natural history of this case. CONCLUSION: In severe thoracolumbar angular kyphotic deformities with normal or negative sagittal balance, it might be a safer option to select the sagittal stable vertebra as upper instrumented vertebra based on the C2 plumb line on the preoperative standing lateral radiographs. However, a study with a larger sample size is needed to validate our hypothesis.

EDF Casting for Early Onset Scoliosis: What We Learned From 175 Castings.

STUDY DESIGN: IRB approved prospective case series. OBJECTIVES: This study attempts to determine the effects of elongation, derotation, and flexion (EDF) casting on pulmonary function. We also attempted to define prognostic factors and determine the ideal amount of traction for casting in patients with early onset scoliosis (EOS). SUMMARY OF BACKGROUND DATA: No literature on effects of serial casting on pulmonary parameters in EOS, or on the ideal amount of traction to be used for EOS Casting. METHODS: Fifty consecutive children with EOS treated by the senior author using EDF casting were studied prospectively. Traction and lung function parameters (compliance, tidal volume, peak inspiratory pressure, and resistance) were measured at different periods during cast application. Etiology, age, weight, Cobb angles, and RVAD were monitored. RESULTS: All lung function parameters decline during cast application but rise to near baseline levels at the time of next cast application. Near full curve correction was achieved in every patient with (A) idiopathic scoliosis who (B) presented prior to 20 months of age with (C) a moderate main curve at presentation (<45°) and in those (D) without a phase II rib-vertebral relationship at presentation. The best response to casting was seen with 1 pound traction per pound body weight during application. CONCLUSION: EDF casting can delay progression or improve curves in patients with larger curves, nonidiopathic scoliosis, and older patients. Idiopathic patients, moderate curve sizes, and younger patients had a better response to casting. Even though lung function declines during cast application, it returns to near baseline levels at the time of the next cast application, suggesting that EDF casting may not have any long-term effects on lung function, and also may protect pulmonary function in EOS from its natural history of progressive deterioration.Level of Evidence: 4.

Is VCR necessary to correct very severe deformity? case report and review of literature.

Background: Management of severe scoliotic deformities is challenging. Deformity correction may need three column osteotomies that may be associated with significant morbidity. Staged procedure and use of Halo gravity traction is a useful strategy in such cases.Case Description: A thirty-year-old woman presented with complaint of progressive deformity over the back for the past few years. She was very frail as per the adult spine deformity frailty index (ASD-FI), and her BMI was less than 18. Her Cobb angle measured 180 degrees of main thoracic curve. Her pulmonary function was compromised and had dyspnea on exertion. Management options in these deformities are limited and fraught with risk of major complications. To correct these deformities, a 2-3 level vertebral column resection (VCR) is required using an all-posterior approach. This patient was treated by anterior release followed by halo-gravity traction (HGT) for two weeks, which was then followed by posterior release and correction. The Cobb angle was reduced from 180° to 55° at final follow up of 2 years.Conclusion: Anterior release and traction can help in obviating the vertebral column resection in these severe rigid U-shaped deformities.

Varicella-Zoster Radiculitis Mimicking Sciatica: A Diagnostic Dilemma.

Varicella-zoster virus (VZV) presenting as a radicular pain in the thoracic region is not uncommon, but the presentation in the lumbar and thigh region is not frequently seen. Characteristic segmental vesicular-bullous rash in a dermatomal distribution associated with pain and allodynia is a prominent feature. The pain appears before rash. It is not uncommon for clinicians to misdiagnose radicular pain caused by VZV due to prolapsed disc. We report two patients who presented to us with complaints of back pain with leg radiculopathy that were initially treated for discogenic radiculopathy and rash was wrongly attributed to hot fomentation. This case report emphasizes the importance of including varicella-zoster radiculitis in the differential diagnosis of radicular pain and clinical examination of every rash. Physical examination is must if the patient complains of rash. Appropriate and timely diagnosis can prevent unnecessary investigations.

Ligamentum Flavum Cyst: Rare Presentation Report and Literature Review.

Ligamentum flavum cysts (LFC) are uncommon and their differentiation from other Juxta-facetal cysts & epidural cystic lesions is difficult based on imaging techniques. We present one such rare case of ligamentum flavum cyst with relevant review of the literature. An eighty-eight years male presented with progressively worsening radicular symptom in the left lower limb. His neurological examination was unremarkable. Magnetic resonance imaging of lumbar spine revealed an epidural cystic lesion narrowing the left lateral recess. Intra-operatively, a mass was found originating from ventral surface of ligamentum flavum. Pathological examination was suggestive of fibro-collagenous tissue without synovial lining. The exact pathogenic mechanism for the formation of LFCs is not well understood. Association with segmental instability and degenerative conditions of spine is postulated. They are commonly seen at the mobile junctional levels of the spine. Persistent micro-traumatic events with abnormal movement maybe contributory to their origin. They present either with radiculopathy or neurogenic claudication symptoms owing to compressive effect on adjacent neural structure. LFC should be considered as a differential in patients with radicular pain or claudication symptoms with epidural cystic lesion seen on MRI. Complete excision of such lesion provides excellent pain relief in symptomatic individuals.

Spinal osteoid osteoma: Surgical resection and review of literature.

BACKGROUND: Osteoid osteoma (OO) is a rare benign tumor of the spine that involves the posterior elements with 75% tumors involving the neural arch. The common presenting symptoms include back pain, deformity like scoliosis, and rarely radiculopathy. METHODS: From 2011 to 2017, we evaluated cases of OO managed by posterior surgical resection while also reviewing the appropriate literature. RESULTS: We assessed five patients (three males and two females) averaging 36.60 years of age diagnosed with spinal OOs. Two involved the lumbar posterior elements, two were thoracic, and one was in the C3 lateral mass. All patients underwent histopathological confirmation of OO. They were managed by posterior surgical resection with/without stabilization. No lesions recurred over the minimum follow-up period of 24 months. CONCLUSION: Surgical excision is the optimal treatment modality for treating spinal OOs. The five patients in this study demonstrated good functional outcomes without recurrences. Further, the literature confirms that the optimal approach to these tumors is complete surgical excision with/without radiofrequency ablation.

Spinal Injury in Indian Children: Review of 204 Cases.

STUDY DESIGN: Retrospective study. OBJECTIVE: The purpose of the study was to analyze the epidemiological parameters and associated factors after spinal cord injury (SCI) in children, in the last 14 years admitted at a tertiary care center (Indian Spinal Injury Centre [ISIC], New Delhi, India). METHOD: The demographic and injury-related data was analyzed descriptively. The incidence, type, and level of injury were compared across the age groups using a χ2 test. Wherever appropriate, Fisher exact test was used. RESULTS: There were 1660 pediatric trauma cases admitted at ISIC from 2002 to 2015, where 204 cases presented with spine injuries. The average age of children sustaining spine injury was 15.69 years (3-18 years of range). There were 15 patients in the age group 0 to 9 years, 27 patients in the age group 10 to 14 years, and 162 patients in the age group 15 to 18 years. This difference in spine injury incidence among the age groups was statistically significant. Fall from height was a common mode of injury. In our sample, boys were 3 times more likely to be injured than girls. Burst fractures were common among the type of injuries. CONCLUSION: Our study confirms the predominance of cervical spine injury and the high incidence of multilevel contiguous with a lesser percentage of noncontiguous multilevel spinal involvement. SCIWORA (spinal cord injury without radiological abnormality) incidences were in a similar context to the literature available. There was a very low incidence of death. Neurological improvement was seen in 8 operated cases and 4 conservatively treated cases.

Evolution of casting techniques in early-onset and congenital scoliosis.

Casting is being utilized as a therapeutic strategy in some mild to moderate cases obviating surgical intervention for management of early-onset scoliosis (EOS). Bracing, another conservative modality, applies comparable correcting forces on chest wall and axial skeleton. But cast application carries additional advantage of sustained restorative force which bypasses issue of compliance seen with brace wear. There is no specific blanket treatment, conservative or surgical, for the early-onset spinal deformities. Serial cast application provides near total correction of less severe curves (less than 500 to 600) if treatment is initiated before age of 2 yrs. In this review article, we will assess the evolution of plaster cast application in management of EOS and also describe technique of EDF (Elongation- Derotation- Flexion) casting.

Use of Topical Tranexamic Acid to Reduce Blood Loss in Single-Level Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Nonrandomized, prospective, and case-controlled study. PURPOSE: To evaluate the efficacy and cost-effectiveness of topically applied tranexamic acid (TXA) during different phases of spine surgery. OVERVIEW OF LITERATURE: Perioperative blood loss is the leading cause of postoperative anemia associated with prolonged stays in hospital and long recovery times. The direct and indirect costs involved pose a significant economic challenge in developing countries. There is no consensus for topical use of tranexamic acid in spine surgery. METHODS: Patients requiring a single-level TLIF were divided into two groups. In the TXA group (n=75), the wound surface was soaked with TXA (1 g in 100 mL saline solution) for 3 minutes after exposure, after decompression, and before wound closure, and in the control group (n=175) using only saline. Intraoperative blood loss drain volume was recorded on each of the first 2 days immediately after surgery. An estimated cost analysis was made on the basis of the length of hospital stay and the blood transfusion. RESULTS: IBL for the control group was 783.33±332.71 mL and for intervention group 410.57±189.72 mL (p<0.001). The operative time for control group was 3.24±0.38 hours and for intervention group 2.99±0.79 hours (p<0.695). Hemovac drainage on days 1 and 2 for control group was 167.10±53.83 mL and 99.33±37.5 mL, respectively, and for intervention group 107.03±44.37 mL and 53.38±21.99 mL, respectively (p<0.001). The length of stay was significantly shorter in the intervention group (4.8±1.1 days) compared to control group (7.0±2.3 days). The cost of treatment in the intervention group was US dollar (USD) 4,552.57±1,222.6 compared with that in the control group USD 6,529.9±1,505.04. CONCLUSIONS: Topical TXA is a viable, cost-effective method of decreasing perioperative blood loss in major spine surgery with fewer overall complications than other methods. Further studies are required to find the ideal dosage and timing.

Clinico-Radiological Outcome of Single-Level and Hybrid Total Disc Replacement with Spineart Baguera®-C for Cervical Myeloradiculopathy: Minimum 2-Year Follow-Up Study in Indian Population.

CONTEXT: Cervical radiculopathy and myelopathy is one of the most frequent ailments encountered by spine surgeon. Motion-preserving surgeries in cervical spine is a standard of care due to its certain advantages such as biomechanical anatomical conformity, reduced chances of adjacent segment degeneration, and revision surgeries. While there is abundant data from some centers, data from developing countries are still limited. AIMS: The aim was to study the clinico-radiological outcome of single-level and hybrid total disc replacement (TDR) with Spineart Baguera®-C cervical prosthesis for cervical myeloradiculopathy. SETTINGS AND DESIGN: Retrospective study. MATERIALS AND METHODS: Retrospective analysis of the 29 consecutive patient undergoing single level TDR and hybrid fixation (i.e., TDR with anterior cervical discectomy and fusion) with Spineart Baguera®-C cervical prosthesis for myeloradiculopathy from January 1, 2014 to December 31, 2017, was done. Radiological features and outcome were studied from data collected on Insta-picture archiving and communication system. STATISTICAL ANALYSIS USED: SAS 9.4 was used for all computations. Results on continuous measurements were presented as mean and standard deviation (min-max) and results on categorical measurements were presented as numbers (n) and percentages. RESULTS: Twenty-nine patients were included in the study. The mean age was 43.31 ± 9.04 years with 14 males and 15 females. The most common level of TDR was C5-C6 (72.41%). The mean follow-up duration was 3.14 years ± 1.13 years (2-5 years). The mean hospital stay was 4.93 ± 2.12 days. The mean neck disability index (NDI) at admission was 27.24 ± 7.66 which decreased to 6.41 ± 4.29 at final follow-up. CONCLUSIONS: Two-year data on treatment with Spineart Baguera®-C cervical prosthesis shows significantly improved NDI, visual analog scale (arm) with maintenance of movement of the prosthesis.

Surgical Trend Analysis for Use of Cement Augmented Pedicle Screws in Osteoporosis of Spine: A Systematic Review (2000-2017).

STUDY DESIGN: Systematic review. OBJECTIVES: (1) Study indications for cement-augmented pedicle screws (CAPS) in patients with osteoporosis. Have they changed over the years (2000-2017)? Are there any differences in usage of CAPS based on the geographical region? (2) What were the outcome of the studies? (3) What are the complications associated with this technique? METHODS: Electronic database and reference list of desired articles were searched from the database (2000-2017). Articles were selected discussing indications, clinical and radiological outcomes, and complications in cases of preexistent osteoporosis treated surgically using CAPS. RESULTS: Seventeen studies were identified; 3 were comparative studies and had a control arm (cemented vs noncemented screws). Most studies originated from Europe (10) or Asia (7). Painful vertebral fracture with or without neurological deficit, Kummell's lesion, deformity and failure to respond to conservative treatment are the common indications for cement augmentation. Visual analogue scale score was the most commonly used to assess pain and average improvement after surgery was 6.1. Average improvement in kyphosis was 13.21° and average loss of correction at the end of the study was 3°. Cement leak was the most common complication observed and pulmonary cement embolism was the most dreaded complication. Nevertheless, majority of cement leaks discussed in studies were asymptomatic. CONCLUSION: CAPS are being increasingly used in osteoporotic spine. Pain scores, functional quality of life, and neurological function indices were studied. CAPS improved anchorage in osteoporotic vertebra and helped improve/maintain clinical and radiological improvement. Common risks of cement leak were observed.

Floating lumbar spine: proposed mechanism with review of literature.

Hyperextension injuries of lumbar spine resulting in lumbosacral dislocation are a rare entity. We report a case of a 60-year-old male who presented to us in outpatient department with history of trivial fall from bicycle with fracture through the pedicles extending from L2 to L5 with lumbosacral dislocation with free floating posterior elements with intact neurology. This is the first case report of 4 level extension compression injury with lumbosacral dislocation leading to floating lumbar spine to the best of author's knowledge. Treatment consists of reduction of the lumbosacral dislocation first and fusion of the disc space followed by reduction of the other fractures proximally. These injuries may present with a trivial trauma in spondylotic spine in elderly patients. MRI and CT scan should be done early to identify it, reduce and fix it, as in many cases with trivial trauma there may be no neural deficit.

Feasibility of Sub-Axial Cervical Laminar Screws, Including C7, in the Indian Population: A Study on 50 Patients Using Computed Tomography-Based Morphometry Measurements.

STUDY DESIGN: Observational study of computed tomography (CT) data. PURPOSE: We performed a CT-based radiographic analysis of sub-axial cervical lamina in the Indian population to assess the feasibility of laminar screws. OVERVIEW OF LITERATURE: Morphometric studies have been performed for populations of various ethnic groups, but none exist for Indian populations. METHODS: Cervical spine CT scans of 50 adults with a minimum slice thickness of <2 mm (0.5-2 mm) were obtained from the database of a single center in northern India. Measurements (e.g., length, thickness, and height) were taken in millimeters along the axial, coronal, and sagittal planes. Three measurements were made to assess laminar anatomy, namely, the translaminar/screw length, laminar thickness, and sagittal laminar height. RESULTS: The final sample comprised 500 laminae in 50 patients, resulting in 1,500 measurements. The mean translaminar lengths of the C3, C4, C5, C6, and C7 laminae were 19.48 mm, 19.60 mm, 19.61 mm, 20.49 mm, and 22.85 mm, respectively. The mean thick- , 19.60 , 19.60 mm, 19.61 mm, 20.49 mm, and 22.85 mm, respectively. The mean thick- mm, 19.61 mm, 20.49 mm, and 22.85 mm, respectively. The mean thick- , 19.61 , 19.61 mm, 20.49 mm, and 22.85 mm, respectively. The mean thick- mm, 20.49 mm, and 22.85 mm, respectively. The mean thick- , 20.49 , 20.49 mm, and 22.85 mm, respectively. The mean thick- mm, and 22.85 mm, respectively. The mean thick- , and 22.85 mm, respectively. The mean thick , and 22.85 mm, respectively. The mean thicknesses of these cervical laminae were 3.12 mm, 2.62 mm, 2.56 mm, 3.47 mm, and 5.20 mm, respectively. The mean sagittal heights of these laminae were 9.38 mm, 9.80 mm, 10.12 mm, 11.31 mm, and 13.84 mm, respectively. Except for the C7 vertebrae, all other levels had a success rate of <10% in the Indian population using the criteria of a laminar height of at least 9 mm and thickness of 4.5 mm. Limited success was achieved at the C5, C6, and C3 levels. CONCLUSIONS: To the best of our knowledge, the present study is the only series on the feasibility of laminar screws in the sub-axial cervical spine in the Indian population. We found that Indian patients have smaller anatomical dimensions and thus, are not suitable for laminar screws in the sub-axial cervical spine, barring C7, which is contrary to findings for populations in western and south Asian countries.

A New Search Algorithm for Reducing the Incidence of Missing Cottonoids in the Operating Theater.

STUDY DESIGN: Retrospective study. PURPOSE: Missing cottonoids during and after spinal surgery is a persistent problem and account for the most commonly retained surgical instruments (RSIs) noticed during a final cottonoid count. The aim of this study was to enumerate risk factors and describe the sequence to look out for misplaced cottonoids during spinal surgery and provide an algorithm for resolving the problem. OVERVIEW OF LITERATURE: There are only a few case reports on RSIs among various surgical branches. The data is inconclusive and there is little evidence in the literature that relates to spinal surgery. METHODS: This retrospective study was conducted at Indian Spinal Injuries Centre. The data was collected from hospital records ranging from January 2013 to December 2017. The surgical cases in which cottonoid counts were inconsistent during or after the procedure were included in the study. The case files along with operating theater records were thoroughly screened for selecting those in which there was confirmed evidence of such an event. RESULTS: There were 7,059 spinal surgeries performed during the study period. Fifteen cases of miscounts were recorded with an incidence of one in every 471 cases. Cottonoids were most commonly lost under the shoes of the surgeon or assistants. In two instances, cottonoids were found in the surgical field and trapped in the interbody cage site. Based on these locations, a systematic search algorithm was created. CONCLUSIONS: This study enumerates RSI risk factors in spinal surgical procedures and describes steps that can be followed to account for any missing cottonoids. The incidence of missing cottonoids can be decreased using a goal-oriented approach and ensuring that surgical teams work in collaboration.

Bladder Recovery Patterns in Patients with Complete Cauda Equina Syndrome: A Single-Center Study.

STUDY DESIGN: Retrospective case series. PURPOSE: Cauda equina syndrome (CES) is associated with etiologies such as lumbar disc herniation (LDH) and lumbar canal stenosis (LCS). CES has a prevalence of 2% among patients with LDH and exhibits variable outcomes, even with early surgery. Few studies have explored the factors influencing the prognosis in terms of bladder function. Therefore, we aimed to assess the factors contributing to bladder recovery and propose a simplified bladder recovery classification. OVERVIEW OF LITERATURE: Few reports have described the prognostic clinical factors for bladder recovery following CES. Moreover, limited data are available regarding a meaningful bladder recovery status classification useful in clinical settings. METHODS: A single-center retrospective study was conducted (April 2012 to April 2015). Patients with CES secondary to LDH or LCS were included. The retrieved data were evaluated for variables such as demographics, symptom duration, neurological symptoms, bladder symptoms, and surgery duration. The variable bladder function outcome during discharge and at follow-up was recorded. All subjects were followed up for at least 2 years. A simplified bladder recovery classification was proposed. Statistical analyses were performed to study the correlation between patient variables and bladder function outcome. RESULTS: Overall, 39 patients were included in the study. Majority of the subjects were males (79.8%) with an average age of 44.4 years. CES secondary to LDH was most commonly seen (89.7%). Perianal sensation (PAS) showed a significant correlation with neurological recovery. In the absence of PAS, bladder function did not recover. Voluntary anal contraction (VAC) was affected in all study subjects. CONCLUSIONS: Intactness of PAS was the only significant prognostic variable. Decreased or absent VAC was the most sensitive diagnostic marker of CES. We also proposed a simplified bladder recovery classification for recovery prognosis.

Infected charcot spine arthropathy.

BACKGROUND: Charcot spinal arthropathy (CSA), a destructive spinal pathology, is seen in patients with impaired sensation. Superimposed infection in the affected spinal segments can lead to a challenge in the diagnosis and management. Spinal cord injury (SCI) is the leading cause of CSA as persons with SCI have significantly impaired sensation. Though infection of the CSA is rare, SCI persons are prone to superimposed infection of the Charcot spine. We report atypical presentations of three cases of CSA with superimposed infection. CASE DESCRIPTIONS: A 47-year-old male with complete T7-8 SCI developed symptoms suggestive of infection and CSA. He was managed with a posterior vertebral column resection (PVCR) of T12 and intravenous antibiotics as the intraoperative culture showed the growth of E. coli and Pseudomonas. A 26-year-old male with T12 complete paraplegia, post status post open reduction and internal fixation with subsequent implants removal developed infection and CSA over the pseudo-arthrotic lesion with destruction of T12 and L1 vertebrae and an external fistulous track. He was managed with debridement and anterior column T11-L1 reconstruction with a Titanium cage and four-rod pedicle screw stabilization construct. A 25-year-old male with complete paraplegia with CSA at L4-S1. He underwent PVCR of L5 and L3-S2 posterior stabilization. The intraoperative culture and histopathology were suggestive of tuberculous infection. CONCLUSION: Pyogenic or tubercular infection of CSA should be considered as a diagnostic possibility in persons with SCI who are more prone to infections. The management includes aggressive debridement and circumferential fusion along with appropriate medications to control the infection.

Sclerosing Epithelioid Fibrosarcoma of the Coccyx: A Case Report and Review of Literature.

Coccydynia in adult patients is not uncommon and is frequently neglected. Coccydynia is mostly associated with fall on buttocks. In long-standing cases, coccydynia can be debilitating. Rarely coccydynia can be due to more sinister causes and surgeons should be aware of all differential diagnosis. We present a case of an elderly female who presented with a complaint of pain over coccyx which was not subsiding with conventional treatment methods. Biopsy was done and a diagnosis of sclerosing epitheloid fibrosarcoma was made. We describe an unusual case of coccydynia secondary to this tumour with the histopathology finding and surgical management.