Percutaneous wide bore needle biopsy for spinal lesions using the kyphoplasty cannula-a technical note.

PURPOSE: Management of vertebral and discovertebral lesions depends on highly specific modalities like biopsy and histopathology. The transpedicular and transforaminal routes have gained popularity for obtaining samples for diagnosing these lesions. Sample inadequacy plays an important part in lowering the diagnostic accuracy. Present study introduces a technical modification by using a kyphoplasty cannula and pituitary forceps through it thus improving sample adequacy and diagnostic accuracy. METHODS: Seventy-one patients with radiological evidence of spinal lesions from T1 to S1 were included. After obtaining samples via the transpedicular route they were sent for aerobic, anaerobic, acid fast bacilli & fungal cultures, Mycobacterium Tuberculosis/Radio Immuno Frequency (MTB/RIF) Assay and histopathological examination. In lesions with minimal vertebral erosions the transforaminal route was used to obtain samples from the disc space. RESULTS: Sixty-eight patients (95.8%) had a definite diagnosis of which 37 patients (54.4%) tested positive for vertebral osteomyelitis/discitis. All the samples were found to be adequate on histopathological examination. The remaining 3 patients showed chronic inflammation and responded to oral and intravenous antibiotics. None of the patients underwent repeat biopsy. There were no perioperative complications. CONCLUSIONS: Percutaneous transpedicular biopsy has evolved as the intervention of choice in diagnosing radiologically proven vertebral body lesions. Our technique of using a pituitary forceps through a cannula is highly effective in getting an adequate representative sample with excellent accuracy in diagnosis. This procedure is beneficial for soft tissue lesions and for infective pathology especially discitis.

Unplanned return to operation room (OR) following growing spinal constructs (GSCs) in early onset scoliosis (EOS)-a multi-centric study.

PURPOSE: To evaluate the incidence and risk factors associated with the unplanned return to OR in EOS. METHODS: 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. RESULTS: 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.

Management and prognosis of acute traumatic cervical central cord syndrome: systematic review and Spinal Cord Society-Spine Trauma Study Group position statement.

PURPOSE: Spinal Cord Society (SCS) and Spine Trauma Study Group (STSG) established a panel tasked with reviewing management and prognosis of acute traumatic cervical central cord syndrome (ATCCS) and recommend a consensus statement for its management. METHODS: A systematic review was performed according to the PRISMA 2009 guidelines. Delphi method was used to identify key research questions and achieve consensus. PubMed, Scopus and Google Scholar were searched for corresponding keywords. The initial search retrieved 770 articles of which 37 articles dealing with management, timing of surgery, complications or prognosis of ATCCS were identified. The literature review and draft position statements were compiled and circulated to panel members. The draft was modified incorporating relevant suggestions to reach consensus. RESULTS: Out of 37 studies, 15 were regarding management strategy, ten regarding timing of surgery and 12 regarding prognosis of ATCCS. CONCLUSION: There is reasonable evidence that patients with ATCCS secondary to vertebral fracture, dislocation, traumatic disc herniation or instability have better outcomes with early surgery (< 24 h). In patients of ATCCS secondary to extension injury in stenotic cervical canal without fracture/fracture dislocation/traumatic disc herniation/instability, there is requirement of high-quality prospective randomized controlled trials to resolve controversy regarding early surgery versus conservative management and delayed surgery if recovery plateaus or if there is a neurological deterioration. Until such time decision on surgery and its timing should be left to the judgment of physician, deliberating on pros and cons relevant to the particular patient and involving the well-informed patient and relatives in decision making. These slides can be retrieved under Electronic Supplementary Material.

Posterior hemivertebrectomy and short segment fixation-long term results.

OBJECTIVES: The objectives of this study were to study the long-term results of one-stage single and multiple level posterior hemivertebrectomies and to find out the safety and efficacy of the procedure. METHOD: Twenty patients (9 male and 11 female) with mean age of 9.2 years (2 years 4 months-14 years 10 months) with congenital scoliosis (hemivertebrae) were treated with posterior hemivertebrectomy with intraoperative neuromonitoring. Posterior exposure and transpedicular fixation of the adjoining vertebrae was done. The hemivertebra was approached from the convex side, and transpedicular decancellation followed by complete excision was done. Controlled compression at the convexity was done after a cantilever manoeuvre was done for rod capturing on the convexity to achieve the reduction. RESULTS: Average number of hemivertebra removed was 1.46 (1-3). Mean pre-op and post-op coronal Cobb angle was 48.8° (range 22 to 80) and 24.2° (range 7 to 41), respectively (p < 0.001). Mean pre-op and post-op sagittal Cobb angle was 32.1° (range 7 to 76) and 13.6° (range 0 to 23) respectively, (p < 0.005). Mean coronal and sagittal Cobb correction percentage achieved was 50.2 and 51.8%, respectively. Mean follow-up was 62.4 months (range 24-73 months). Mean loss of coronal and sagittal correction at final follow-up was 2.26° (0-8) and 1.55° (0-5), respectively. Maximum correction in both coronal (p = 0.167) and sagittal (p = 0.095) planes was achieved in thoracolumbar vertebrae. Maximum correction was achieved in 3 level hemivertebrae in sagittal (p = 0.9) and 2 level hemivertebrae in coronal plane (p = 0.740). CONCLUSIONS: Posterior hemivertebrectomy is a safe and effective procedure for congenital scoliosis. Not only single but up to 3 level hemivertebrae can be safely removed with good correction of deformity. Long-term follow-up reveals good maintenance of correction.

The effect of metal density in thoracic adolescent idiopathic scoliosis.

PURPOSE: Determine impact of metal density on curve correction and costs in thoracic adolescent idiopathic scoliosis (AIS). Ascertain if increased metal density is required for larger or stiffer curves. METHODS: Multicentre retrospective case series of patients with Lenke 1-2 AIS treated with single-stage posterior only surgery using a standardized surgical technique; constructs using >80 % screws with variable metal density. All cases had >2-year follow up. Outcomes measures included coronal and sagittal radiographic outcomes, metal density (number of instrumented pedicles vs total available), fusion length and cost. RESULTS: 106 cases included 94 female. 78 Lenke 1. Mean age 14 years (9-26). Mean main thoracic (MT) Cobb angle 63° corrected to 22° (66 %). No significant correlations were present between metal density and: (a) coronal curve correction rates of the MT (r = 0.13, p = 0.19); (b) lumbar curve frontal correction (r = -0.15, p = 0.12); (c) correction index in MT curve (r = -0.10, p = 0.32); and (d) correction index in lumbar curve (r = 0.11, p = 0.28). Metal density was not correlated with change in thoracic kyphosis (r = 0.22, p = 0.04) or lumbosacral lordosis (r = 0.27, p = 0.01). Longer fusions were associated with greater loss of thoracic kyphosis (r = -0.31, p = 0.003). Groups differing by preoperative curve size and stiffness had comparable corrections with similar metal density. The pedicle screw cost represented 21-29 % of overall cost of inpatient treatment depending on metal density. CONCLUSIONS: Metal density affects cost but not the coronal and sagittal correction of thoracic AIS. Neither larger nor stiffer curves necessitate high metal density.

Comparing Spinal Cord Drift, Clinical Outcomes and C5 Palsy in Degenerative Cervical Myelopathy: A Study of Cervical Laminoplasty Versus Laminectomy/Fusion.

STUDY DESIGN: Retrospective comparative study. OBJECTIVES: (i)to compare spinal cord drift between laminectomy and fusion(LF) and cervical laminoplasty(LP) for degenerative cervical myelopathy(DCM) treatment,(ii)to study relationship between preoperative cervical alignment, postoperative spinal cord drift, functional outcome, and C5 palsy. METHODS: A cohort of 114 patients who underwent LP or LF for DCM were identified. After propensity-score matching, both groups included 30 patients each.Cobb angle(C2-C7) was used to assess pre-and postoperative cervical spine alignment(at 2-year follow-up).Based on alignment, there were lordotic(L) and straight(S) subgroups.Spinal cord position was measured on sagittal-and axial-T2W MRI of cervical spine pre-and postoperatively at 2-year follow-up and cord drift was measured by subtracting preoperative values from postoperative values.Functional recovery(mJOA score, mJOA recovery rate),and C5 palsy in patients were recorded and compared. RESULTS: LF had higher mean spinal cord drift than LP(2.66 ± .77 vs 2.16 ± .80 mm, P = .049).Lordotic subgroups exhibited greater cord drift than straight subgroups within LP and LF groups.Both groups significantly improved mJOA scores at 2-year follow-up, with no LP-LF difference in mJOA recovery rate(mJOA-RR).Lordotic subgroups had significantly higher mJOA-RR(LP-L vs LP-S,P = .048; LF-L vs LF-S,P = .045).Preoperative cervical alignment, cord drift, and mJOA-RR correlated well(Spearman's ρ .7143 and .6053 respectively).Patients with >2.5 mm cord drift(n = 24) had significantly higher mJOA-RR as compared to <2.5 mm cord drift(n = 18). Substantial clinical difference was seen in C5 palsy risk between LP-S and LF-L, with the LF-L group having 3-fold higher risk. CONCLUSION: LF had a biomechanical advantage in maximizing spinal cord drift in severe DCM cases, while both LP and LF showed significant improvements in neurological function. However, variability in C5 palsy rates highlights the need for individualized patient assessment.

Surgery for deformities in pediatric spinal tuberculosis: single centre review of 51 cases.

PURPOSE: To retrospectively report on the clinical presentation, radiological features, indication, and outcome of surgical management of children with posttubercular spinal deformities with long term outcome. METHODS: This retrospective study was conducted in a single center operated by a single surgeon from 2002 to 2022, and data from an electronic medical record was reviewed. The indications for surgery included failure of medical treatment, to prevent deformity (depending on location, extent of bone loss, stabilization patterns (A, B, or C), and the presence of "Spine at Risk" signs) or correct deformity and in the presence of major neurodeficit. RESULTS: 51 children (< 15 years) of mean age 12.5, and mean follow-up of 7 years (2-15) were included. Pain, deformity/instability, and limb weakness were seen in 34 (66.6%) patients (mean mJOA score was 13.44, which improved to 14.7 and 16.8 at immediate postoperative and latest follow-up), with 17 (33.3%) patients presenting with deformity alone. Dorsal affection was commonest (60.8%), followed by lumbosacral (19.6%) and cervical (19.6%), with multilevel/skip lesions seen in four patients. The mean coronal/sagittal Cobb at presentation was 24.2°/40.96°, which improved to 8.2°/25.6° in the immediate and 8.8°/24.8° at the latest follow-up. Gene Xpert positivity was found in 95%, AFB culture positivity in 84%, and histopathology was positive in 91%. All patients had posterior surgery with an additional anterior reconstruction in 6. The complication rate was 5.8% (N = 3); 2 had implant loosening requiring revision surgery, 1 with prolonged discharging sinus with MDR TB, healed with chemotherapy. CONCLUSION: Pediatric post-tuberculous spinal deformities require identification of those who are likely to worsen, and close follow-up is mandatory. Failure of medical management, major destruction of vertebral bodies, type C stabilization pattern, and worsening deformity/neurodeficit require surgery with a good outcome.

The Management of Intraoperative Spinal Cord Injury - A Scoping Review.

STUDY DESIGN: Scoping Review. OBJECTIVE: To review the literature and summarize information on checklists and algorithms for responding to intraoperative neuromonitoring (IONM) alerts and management of intraoperative spinal cord injuries (ISCIs). METHODS: MEDLINE® was searched from inception through January 26, 2022 as were sources of grey literature. We attempted to obtain guidelines and/or consensus statements from the following sources: American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), American Academy of Neurology (AAN), American Clinical Neurophysiology Society, NASS (North American Spine Society), and other spine surgery organizations. RESULTS: Of 16 studies reporting on management strategies for ISCIs, two were publications of consensus meetings which were conducted according to the Delphi method and eight were retrospective cohort studies. The remaining six studies were narrative reviews that proposed intraoperative checklists and management strategies for IONM alerts. Of note, 56% of included studies focused only on patients undergoing spinal deformity surgery. Intraoperative considerations and measures taken in the event of an ISCI are divided and reported in three categories of i) Anesthesiologic, ii) Neurophysiological/Technical, and iii) Surgical management strategies. CONCLUSION: There is a paucity of literature on comparative effectiveness and harms of management strategies in response to an IONM alert and possible ISCI. There is a pressing need to develop a standardized checklist and care pathway to avoid and minimize the risk of postoperative neurologic sequelae.

Spinal Rosai-Dorfman disease-a report of 2 cases and review of literature.

INTRODUCTION: Rosai-Dorfman Disease (RDD) is a rare benign histiocytic disease that infrequently affects the spine. We report two cases of spinal RDD and review the relevant literature. This report addresses the various diagnostic dilemmas related to the evaluation of Spinal RDD and its treatment. CASE PRESENTATION: Case 1: A 32-year-old male presented with low back pain and left anterior thigh for last 8 months. On examination, there was sensory diminution on inner aspects of the thigh with an absent left knee jerk. CT/MRI scans revealed an extradural lesion at L2/3 with neural compression. PET scan showed several hypermetabolic lesions in ribs, humerus, femur, and vertebrae. He underwent en bloc excision of the extradural mass with L2-3 pedicle screw-rod fixation and was later managed with chemotherapy. Case 2: A 42-year-old male presented with spastic paraparesis with urinary incontinence for the last 4 weeks. On examination, he had a neurological level of T6. MRI scan revealed a lesion in posterior elements of T6-7 compressing the spinal cord. He underwent T6-7 laminectomy with decompression. In both cases, the diagnosis was confirmed by histopathology and further managed by Hemato-oncologist. They both did well at 1-year follow-up with improvement in neurology. DISCUSSION: Spinal RDD to date remains a large diagnostic dilemma with no pathognomonic clinical or radiological features; mimicking many osteolytic lesions in the spine. The diagnosis is purely histopathological and immunological. The lesion's complete surgical excision is the mainstay of treatment with a better prognosis and decreased chances of recurrences.

Delphi-Based Survey for Surgical Indications in Biopsy Proven Active Adult Spinal Tuberculosis.

STUDY DESIGN: Delphi survey. OBJECTIVES: To obtain an expert consensus on various dilemmas in the surgical treatment of adult spinal tuberculosis (TB) patients. METHODS: Stage I included a literature review, stage II the identification of 40 Key Opinion leaders (KOLs) and a set of 46 questions, stage III included analysis of 3 rounds of the Delphi survey, and stage IV had final analysis and recommendations. For each question, the level of agreement needed to reach a consensus was set at greater than or equal to 70.0%. RESULTS: The first and second Delphi survey rounds received 62 and 58 responses, respectively, with 16 questions having more than 70% and two questions having 100% agreement in the first stage. The second stage saw a 70% agreement on six questions. Thus, a consensus was obtained on 22 questions. The recommendations that emerged were as follows: neurodeficit with corresponding radiology and neurological deficit appearing/deteriorating while on anti-tubercular chemotherapy(ATT) are absolute indications for surgery, duration of ATT before neurological deterioration need not be considered, epidural abscess does not need decompression unless concordant clinical neurological findings are present, pain not responding to medical management is not a surgical indication, active pulmonary TB, drug-resistant TB, and tubercular sacroiliitis are not considered as surgical indications, and hemoglobin and other health markers have little contribution to surgical indications. CONCLUSION: In order to resolve several conundrums in the surgical treatment of adult spinal TB, this Delphi survey is the first to achieve a national consensus from spine experts. The final recommendations cover the serological, radiographic, and clinical aspects of spinal TB.

SPINE20 recommendations 2023: One Earth, one family, one future WITHOUT spine DISABILITY.

Introduction: The purpose is to report on the fourth set of recommendations developed by SPINE20 to advocate for evidence-based spine care globally under the theme of "One Earth, One Family, One Future WITHOUT Spine DISABILITY". Research question: Not applicable. Material and methods: Recommendations were developed and refined through two modified Delphi processes with international, multi-professional panels. Results: Seven recommendations were delivered to the G20 countries calling them to:-establish, prioritize and implement accessible National Spine Care Programs to improve spine care and health outcomes.-eliminate structural barriers to accessing timely rehabilitation for spinal disorders to reduce poverty.-implement cost-effective, evidence-based practice for digital transformation in spine care, to deliver self-management and prevention, evaluate practice and measure outcomes.-monitor and reduce safety lapses in primary care including missed diagnoses of serious spine pathologies and risk factors for spinal disability and chronicity.-develop, implement and evaluate standardization processes for spine care delivery systems tailored to individual and population health needs.-ensure accessible and affordable quality care to persons with spine disorders, injuries and related disabilities throughout the lifespan.-promote and facilitate healthy lifestyle choices (including physical activity, nutrition, smoking cessation) to improve spine wellness and health. Discussion and conclusion: SPINE20 proposes that focusing on the recommendations would facilitate equitable access to health systems, affordable spine care delivered by a competent healthcare workforce, and education of persons with spine disorders, which will contribute to reducing spine disability, associated poverty, and increase productivity of the G20 nations.

Neurological recovery in patients of old healed tubercular rigid kyphosis with myelopathy treated with transpedicular decancellation osteotomy.

PURPOSE: The purpose of the study was to find out if transpedicular decancellation osteotomy (TDO) is recommendable for neurological recovery in patients with myelopathy due to tubercular rigid kyphosis. We have analyzed the pattern of recovery seen after the surgery and also made an effort to correlate the neurological recovery with preoperative clinical and radiological features. METHODS: The clinical parameters used were (1) ASIA impairment scale for motor and sensory function, (2) sphincter dysfunction score, (3) time duration from the onset of myelopathy till the date of surgery, and (4) SRS 30 outcomes questionnaire. Radiological parameters used were (1) Cobb's angle in standing/sitting radiographs, (2) levels of gibbus, (3) cord changes in sagittal T2 MRI images, and (4) percentage of cord compression. Assessment was done preoperatively and at 1 month, 3 months, 6 months, 1 year and at 2 years postoperatively. RESULTS: Seventeen patients were included. The follow-up period was 2 years. We had one patient in ASIA A, nine patients in ASIA C and seven patients in ASIA D. Four patients with ASIA C presented with mild sphincter disturbance (score 2) and one presented with severe disturbance (score 1). The ASIA A patient had complete retention (score 0). The ASIA impairment scale improved after surgery, with maximum improvement at 3 months and improvement continuing up to 6 months. 16 (94 %) patients had improvement in lower limb function and 5 (83 %) patients had improvement of sphincter function. 94 % patients had neurological recovery after the operation. The neurological recovery reached a plateau at 6 months with no significant improvement in the further follow-up. Preoperative MRI changes, cord compression and duration from onset of myelopathy to day of surgery were not predictive of the final neurological outcome after surgery. CONCLUSION: TDO gives good results in delayed onset neurological deficits in caries spine with rigid kyphosis. At least, one grade improvement in the neurological status of patients with ASIA C and ASIA D can be expected. Maximum improvement in the neurology is seen in the first 3 months and up to 6 months from the date of surgery, without much improvement thereafter. Level of evidence Level IV.

Subacute Posttraumatic Ascending Myelopathy After Thoracolumbar Spinal Cord Injury.

➢: Subacute posttraumatic ascending myelopathy (SPAM) is defined as neurological deterioration ascending four or more levels above the initial injury level and occurring within the initial days to weeks after spinal cord injury (SCI). ➢: SPAM is a rare complication of spinal cord injury with an incidence of 0.42% to 1% affecting young to middle-aged male patients. ➢: Several hypotheses have been put forth to explain SPAM, but the exact pathomechanism remains elusive. ➢: Treatment guidelines for this rare entity are uncertain and still to be developed. ➢: The current prognosis of SPAM is poor, with a mortality rate of 10.34%.

Delayed Hypoglossal Nerve Palsy After Halo-Vest Immobilization in a Patient With C1-C2 Tuberculosis: A Case Report.

CASE: A 48-year-old man presented with neck pain and torticollis without any neurodeficit. He was diagnosed with C1-C2 tuberculosis with left C1-C2 joint destruction and was immobilized with a halo vest and started on antitubercular treatment (ATT). At the 3-month follow-up, he presented with left hypoglossal nerve palsy (HNP). He responded to ATT with complete healing of C1-C2 lesion and good correction of deformity but persistent left-sided tongue deviation at the 2-year follow-up. CONCLUSION: HNP may occur as a complication of conservative management of craniovertebral junction tuberculosis (CVJ TB). Careful neurological assessment and monitoring must be performed while correcting deformities in CVJ TB using halo-vest immobilization.

Subacute Posttraumatic Ascending Myelopathy: A Rare Complication After Thoracolumbar Spinal Cord Injury: A Case Report.

CASE: A 45-year-old man presented with posttraumatic fracture-dislocation of T11/12 with neurological level T8 AIS A. Sensory level progressed to T4 in the next day morning. He underwent T10, T11, T12, and L1 percutaneous pedicle screw-rod fixation. Postoperatively, there was rapid worsening of his neurology and within 48 hours, he became tetraplegic with neurological level C2 with respiratory paralysis requiring mechanical ventilation. He died on the 14th postoperative day. Clinicoradiological findings were consistent with subacute posttraumatic ascending myelopathy (SPAM). CONCLUSION: Surgeons must be vigilant in days and weeks after spinal cord injury for early recognition and management of SPAM. Treatment guidelines are uncertain and yet to be developed.

Development of Tuberculosis Spine Instability Score (TSIS): An Evidence-Based and Expert Consensus-Based Content Validation Study Among Spine Surgeons.

STUDY DESIGN: An expert-panel consensus-based content validation and case-based clinical validation study. OBJECTIVE: To develop a novel scoring system for diagnosing instability in tuberculosis (TB) spine using an expert-panel consensus followed by clinical validation for validating the content. SUMMARY OF BACKGROUND DATA: Currently, diagnosis of instability is primarily experience-based which may lead to considerable variability and misdiagnosis in the hands of a relatively in-experienced spine surgeon. Considering the potential complications this entity entails, a universally accepted scoring criteria is very important for accurate and uniform diagnosis of instability in TB spine. METHODS: The development of TB spine instability score (TSIS) followed a two-step process, one designing the instrument and the other obtaining judgemental evidence. For judgemental evidence a panel of experts was appointed to make appropriate modifications and content validation for finalizing the scoring instrument. This score was applied on 30 patients of TB spine and receiver operating characteristic (ROC) curves were drawn for sensitivity and specificity analysis. RESULTS: The comprehensive scoring criteria to diagnose instability in TB spine was approved after three rounds of expert panel discussions with an index of content validation more than 0.75 after final round of panel discussion. On case-based validation after plotting ROC curves, sensitivity and specificity for diagnosing stable and potentially unstable lesions at a cut-off score of 6 was 92.9% and 86.8% respectively whereas for diagnosing potentially unstable and unstable lesions at a cut-off score of 10 was 94.3% and 81.9%, respectively. CONCLUSION: TSIS is a comprehensive scoring system integrating demographic, anatomical, clinical, and radiological factors aimed at diagnosing instability in TB spine. The classification determines indications for surgical stabilization in patients with TB spine, with no or little neurological deficit.Level of Evidence: 4.

Deep neural network for automated simultaneous intervertebral disc (IVDs) identification and segmentation of multi-modal MR images.

BACKGROUND AND OBJECTIVE: Lower back pain in humans has become a major risk. Classical approaches follow a non-invasive imaging technique for the assessment of spinal intervertebral disc (IVDs) abnormalities, where identification and segmentation of discs are done separately, making it a time-consuming phenomenon. This necessitates designing a robust automated and simultaneous IVDs identification and segmentation of multi-modality MRI images. METHODS: We introduced a novel deep neural network architecture coined as 'RIMNet', a Region-to-Image Matching Network model, capable of performing an automated and simultaneous IVDs identification and segmentation of MRI images. The multi-modal input data is being fed to the network with a dropout strategy, by randomly disabling modalities in mini-batches. The performance accuracy as a function of the testing dataset was determined. The execution of the deep neural network model was evaluated by computing the IVDs Identification Accuracy, Dice coefficient, MDOC, Average Symmetric Surface Distance, Jaccard Coefficient, Hausdorff Distance and F1 Score. RESULTS: Proposed model has attained 94% identification accuracy, dice coefficient value of 91.7±1% in segmentation and MDOC 90.2±1%. Our model also achieved 0.87±0.02 for Jaccard Coefficient, 0.54±0.04 for ASD and 0.62±0.02 mm Hausdorff Distance. The results have been validated and compared with other methodologies on dataset of MICCAI IVD 2018 challenge. CONCLUSIONS: Our proposed deep-learning methodology is capable of performing simultaneous identification and segmentation on IVDs MRI images of the human spine with high accuracy.

Normal spino-pelvic parameters and correlation between lumbar lordosis (LL) and pelvic incidence (PI) in children and adolescents in Indian population.

PURPOSE: The purpose of this work is to describe normal spino-pelvic parameters for pediatric and adolescent Indian population (and compare it with a cohort of different ethnicity) and to find out the correlation of pelvis incidence (PI) and lumbar lordosis (LL) METHODS: 129 asymptomatic subjects (66 males, 63 females) with age 4-15 years were studied. Pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and lumbar lordosis (LL) were measured on lateral whole-spine standing radiographs using computer software and compared in relation to age, sex, and ethnicity. Using correlation and regression analysis, the association and predictability of LL with PI was studied within the entire sample and then among age groups 4-10 and 11-15 years. RESULTS: Mean PI was 42° ± 8.1°, whereas PT and SS were 12.9° ± 7.8° and 29.3° ± 9.62°, respectively. PI and SS were lower (p < 0.0001), but PT was higher than Caucasians. Overall PI remained unchanged in the age group > 10 years in comparison to the younger age. Mean PT was lower (p = 0.0020), but SS and LL were higher (p = 0.0027 and p = 0.0002 respectively). Angular spino-pelvic parameters were similar between sex groups. Overall correlation between PI and LL was 0.4 (p < 0.0001) which was 0.1 (p = 0.2345) and 0.5 (p < 0.0001) for ages 4-10 and 11-15 years, respectively. Overall, the prediction of PI based on LL is not very accurate with a simple linear term between PI and LL (R2 = 0.1) and only improve marginally with a restricted cubic spline function. CONCLUSIONS: In pediatric and adolescent' population, ethnicity and age-related variations of normal sagittal spino-pelvic parameters exist and should be considered in patient management.

Cervical sagittal alignment in Lenke 1 adolescent idiopathic scoliosis and assessment of its alteration with surgery: a retrospective, multi-centric study.

PURPOSE: To document baseline cervical sagittal characteristics in Lenke 1 adolescent idiopathic scoliosis (AIS) patients and assess the alteration in these parameters with surgery. METHODS: 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 < 20°, TK ≥ 20°). Pre-operative and postoperative values were compared-the change in each radiographic parameter was correlated with the degree of sagittal and coronal correction. RESULTS: At baseline, TK was 29.8° ± 16°, cervical lordosis (CL) was - 1° ± 14°, lumbar lordosis (LL) was - 57.1° ± 21°, C2-C7 sagittal vertical axis (SVA) was 16 ± 14 mm and C7-S1 SVA was - 15 ± 28 mm; 44% of patients had cervical kyphosis. Patients with thoracic hypokyphosis had a significantly lower LL and more kyphotic cervical spine compared to those with thoracic normohyperkyphosis. The effect of surgery on TK depended on pre-operative thoracic sagittal alignment-TK increased in patients with thoracic hypokyphosis, but decreased in patients with thoracic normohyperkyphosis. Neither CL nor C2-C7 SVA changed significantly with surgery; 46% of patients still had cervical kyphosis postoperatively. CONCLUSION: There is a high incidence of cervical kyphosis at baseline in AIS patients-more so in those with pre-operative thoracic hypokyphosis. Unlike TK, CL is not significantly altered with surgery-improvement in CL correlates weakly with sagittal correction of the structural curve.