Management of congenital craniovertebral anomalies: a single-centre experience of 71 cases by an algorithmic approach.

STUDY DESIGN: Retrospective study. OBJECTIVE: Congenital craniovertebral (CV) anomalies include a wide variety of conditions involving basilar invagination (BI), atlantoaxial dislocation (AAD), bony congenital anomalies and Chiari malformation. The management of these disorders is more surgeon dependent rather than based on clear guidelines. This study aims to provide a step-by-step algorithmic approach to the management of congenital CV anomalies to achieve good CV alignment, neural recovery and long lasting stability. MATERIALS: The study retrospectively analyses 71 patients of congenital CV anomalies treated by our algorithmic approach. Clinical assessment was done with the help of Nurick's grading pre- and post-operatively. Radiological outcome was assessed by plain radiographs, and computed tomographic scan was done at 12-month follow-up. RESULTS: Mean age at presentation was 17.9 years (6-41 years). Mean Nurick score pre-operatively was 3.8 which was reduced to 1.3 at a mean follow-up of 13.6 months. Sixty-one patients had type I BI, 6 had type II BI, and 4 patients had os odontoideum. Most common symptom at presentation was weakness in limbs, neck pain and difficulty in walking. Patients of isolated AAD with os odontoideum required posterior atlantoaxial fixation and fusion only. Thirty-two patients of type I BI and 4 patients of type II BI required anterior release procedures prior to occipitocervical instrumentation. Bony fusion was achieved in 96% (68) cases with the help of autologous bone grafting. Three patients of occipitocervical fusion developed pseudoarthrosis. CONCLUSION: Our retrospective analysis demonstrates that the algorithm is effective in ensuring long lasting results in all types congenital CV anomalies.

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.

Long-term operative outcome of giant calcified thoracic disc herniation - A retrospective analysis of 24 patients.

Background: Thoracic disc herniations (TDHs) are rare (0.15-4%) and often cause significant myelopathy (70-95%). They are defined as "Giant" if they occupy >40% of the spinal canal. Further, they are ossified/calcified in 42% of cases, with a 70% incidence of intradural extension. Here, we reviewed our experience resecting 24 giant thoracic discs utilizing a posterolateral surgical approach. Methods: Over a 2-year period, we evaluated the outcomes for 24 patients averaging 40 years of age undergoing posterolateral resections of giant ossified/calcified TDH. We evaluated multiple clinical and radiographic parameters; demographics, Frankel grades, surgical time, perioperative complications, and number of levels involved. In addition, utilizing magnetic resonance/computed tomography studies, we documented that the most commonly involved level was T11-T12, and the average canal occupancy ratio (i.e., degree of canal encroachment) was 58.2 ± 7.72%. Results: Neurological improvement was seen in 22 of the 24 patients; none experienced neurological deterioration over the average 2-year post-operative period. Six complications occurred; three dural tears and three suture site infections. Conclusion: The posterolateral approach proved to be safe and effectively for resecting 24 giant ossified/calcified TDH with minimum complications.

Is only Anterior Stabilization Enough in Three-Column Injury of Subaxial Cervical Spine? - A Long-Term Retrospective Analysis of 78 Patients.

STUDY DESIGN: This was a retrospective study. PURPOSE: The purpose was to retrospectively evaluate long-term outcome of anterior stabilization in three-column injury of the subaxial cervical spine. OVERVIEW OF LITERATURE: Literature shows varied results regarding the approach to be chosen. Most studies prefer a combined approach since biomechanically forms more stable construct. The isolated posterior approach is preferred by many as it is easy to reduce and fix three-column injuries. There are very few studies which show the isolated anterior approach to be better than the other two. MATERIALS AND METHODS: Seventy-eight patients of three-column injury operated by anterior approach with follow-up of atleast 2 years were included and retrospectively analyzed. Clinical data included age, sex, time to surgery, methods of reduction, postoperative mobilization, and neurological evaluation using the ASIA scale. Radiological data included pre- and postreduction X-ray, computed tomography, and magnetic resonance imaging (MRI). X-rays taken post-operatively at 1,3, 6 months, 1yr and 2yrs. Variables like fracture type (AO Classification), overall alignment, localized kyphosis, time for fusion and grade of fusion mass were noted. RESULTS: Of 78 patients, 61 had bifacetal dislocation and 17 unifacetal. The most common site was C5-6, followed by C3-4 and C6-7. The mean patient age was 35.98 years with 60 males and 18 females. The mean time to surgery was 4.4 days. Forty dislocations were reduced by closed method and 38 by open anterior approach. Fifty-six percent of patients had traumatic disc injury on MRI. All are managed by single-level anterior cervical discectomy and fusion with iliac crest autograft for fusion. The mean preoperative lordosis: 4.44° (range -13.4° to 25°) and mean postoperative lordosis: 28.57° (P < 0.0001) mean loss of alignment: 2.59° by 2 years, 100% fusion with mean time - 22.82 weeks, neurological recovery in 34.6% with atleast one grade improvement in ASIA scale. No neurological worsening or need for revision surgery was observed. CONCLUSION: The goal of surgery in cervical injury is bony stabilization and fusion using a least morbid approach and one with good long-term outcome. Above study concludes that only anterior stabilization after reduction of three-column injury would suffice with good long-term outcome, thereby obviating need for global fusion.

Functional outcome of surgically treated patients of ossified posterior longitudinal ligament of cervical and dorsal spine in Indian population - A single center retrospective analysis of 40 patients.

AIMS: The aim of the study was to retrospectively evaluate the neurological outcome in operated patients of ossified posterior longitudinal ligament (OPLL) of cervical and/or dorsal spine using modified Japanese orthopedic association (mJOA) score and find out the factors affecting the outcome. SETTINGS AND DESIGN: The study design was a retrospective study. MATERIALS AND METHODS: Forty operated patients of cervical and/or dorsal spine OPLL were included in the study. Neurological examination was conducted and analyzed using mJOA score pre- and postoperatively at 1, 6, and 12 months. Improvement in the mJOA score based on age, sex, type of OPLL, duration of symptoms, type of surgical procedure, and radiological parameters were calculated, analyzed, and compared with previous records of the patient. RESULTS: Significant improvement in mJOA scores with mean preoperative being 12.27 ± 1.95 with 1-year postoperative 13.85 ± 2.02 (P < 0.0001) noted. There is a significant difference in mean mJOA scores in posterior approach with instrumentation (P < 0.0001) as compared with laminoplasty group (P < 0.005). Patients with occupancy ratio <60% had better results (P < 0.0001) as compared to those with occupancy ratio of >60% (P = 0.003). Patients with duration of symptoms >1 year had poorer results compared to those of <1 year duration. Mean ossification kyphosis angle was 19.4° ± 5.73°. CONCLUSION: OPLL is a progressive disease which causes severe neurological deficit if left untreated. OPLL in a young patient with short duration of symptoms, low occupancy ratio, and low ossification kyphosis had better chances of neurological recovery. Type of OPLL and sex of patient do not affect the recovery. OPLL managed early and surgically has better results irrespective of anterior or posterior approach with significant improvement in mJOA score. Decompression with fusion has better results than decompression alone.

Comparative Analysis of Long-Term Outcome of Anterior Reconstruction in Thoracic Tuberculosis by Direct Anterior Approach versus Posterior Approach.

STUDY DESIGN: Retrospective study. AIM: To retrospectively evaluate and compare the long-term outcome of anterior vertebral body reconstruction in tuberculosis (TB) of the dorsal spine by direct anterior-versus-posterior approach. MATERIALS AND METHODS: A total of 127 patients operated by posterior approach, 118 by anterior for TB-thoracic spine with at least 1-year follow-up were included and retrospectively analyzed. Patients were assessed clinically, radiologically and data regarding age, sex, levels involved, surgical approach, operative time, blood loss, neurological recovery using Frankel grade, pre- and post-operative kyphosis, % correction of kyphosis, time for fusion, fusion grading using Bridwell criteria, % loss of correction, mobilization time and complications if any were collected, analyzed, compared in anterior-v/s-posterior approaches. RESULTS: The mean age in anterior-approach was 36.03 and 39.83 years in posterior. Mean operative time in anterior-approach was 6.11 and 5 h in posterior. Mean blood loss of 1.6 L in anterior approach and 1.11 L in posterior. Mean preoperative kyphosis angle in posterior-approach was 34.803°and 11.286° (P < 0.001) at 3 months postopandtotal correction of 67.216%. Mean preoperative kyphosis angle in anterior-approach was 41.154° and 9.498° at 3 months postopandtotal correction of 77.467% (P < 0.001). Mean loss of correction at 1 year was 4.186°in posterior-approach and 6.184°in anterior. The mean time for fusion was 4.69 months in anterior-approach while 6.34 months in posterior as per Bridwell criteria. Meantime for mobilization in posterior-approach was 1.18 and 2.51 weeks in anterior. Significant improvement in neurology was seen in patients operated by either approach, slightly better in anterior. Complications were more in posterior-approach. CONCLUSIONS: Anterior-approach allows for thorough debridement, neural decompression, better anterior column reconstruction, and deformity correction under direct vision than posterior. Direct cord visualization while correcting kyphosis reduces the chances of neurological complications significantly. Both approaches have unique advantages and limitations. Though the posterior approach is easy to master, results shown by the anterior cannot be overseen. To conclude, better functional outcome and significantly better kyphosis correction are seen with anterior-approach, which are strong pointers favoring it.

Computed Tomography- and Radiography-Based Morphometric Analysis of the Lateral Mass of the Subaxial Cervical Spine in the Indian Population.

STUDY DESIGN: This was a double-blinded cross-sectional study, which obtained no financial support for the research. PURPOSE: To obtain a detailed morphometry of the lateral mass of the subaxial cervical spine. OVERVIEW OF LITERATURE: The literature offers little data on the dimensions of the lateral mass of the subaxial cervical spine. METHODS: We assessed axial, sagittal, and coronal computed tomography (CT) cuts and anteroposterior and lateral X-rays of the lateral mass of the subaxial cervical spine of 104 patients (2,080 lateral masses) who presented to a tertiary care public hospital (King Edward Memorial Hospital, Mumbai) in a metropolitan city in India. RESULTS: For a majority of the parameters, males and females significantly differed at all levels (p<0.05). Females consistently required higher (p<0.05) minimum lateral angulation and lateral angulation. While the minimum lateral angulation followed the order of C5

Roentgenographic and computerized tomography based morphometric analysis of cervical spinal canal diameters to establish normative measurements in an Indian population.

Compressive cervical myelopathy secondary to degenerative changes in the cervical spine is a common cause of neurologic morbidity in the elderly. Identification of canal stenosis and addressing it surgically in addition to the obvious compressive lesions is essential to obtain satisfactory results. We attempt to define the saggital and transverse diameters in a normal adult population presenting at our centre with head injuries. We found that the values were lower than those reported in comparable studies for a western population, and also that the dimensions in women are significantly lower than in men.

C3-C4 spondyloptosis without neurological deficit-a case report.

BACKGROUND CONTEXT: Traumatic spondyloptosis of the cervical spine is usually associated with a complete, or rarely a partial, neurological deficit. Traumatic spondyloptosis with bipedicular fracture of the C3 vertebra is uncommon. To the best of the authors' knowledge, there is no report in the literature of bipedicular fracture of C3 with spondyloptosis of C3 over C4 with no neurological deficit. Literature is not clear about the role of preoperative traction in neurologically intact patients, and most authors advise both anterior and posterior fixation for cervical spondyloptosis. PURPOSE: To report a case of C3-C4 spondyloptosis with C1 and C2 posterior arch fractures with no neurological deficit and its management strategy and underline the fact that closed reduction and limited anterior fusion can preserve the motion segment of cervical spine at other fractured levels and give a stable cervical column with good long-term results. STUDY DESIGN: A case report with review of the literature. METHODS: A 35-year-old man fell from a height with hyperextension-compression injury to the cervical spine. The patient suffered fracture of the posterior elements of C1-C3 along with spondyloptosis of C3 over C4 without any neurological deficit. The patient was treated with an awake nasotracheal intubation with gradual cervical traction under fluoroscopic guidance to acceptable alignment followed by anterior cervical fusion at C3-C4. RESULTS: At 24 months' follow-up, the C3-C4 level fused completely with fracture healing at C1 and C2. The patient remained asymptomatic with normal neurological examination and near complete cervical motion. The patient returned to his preinjury job and recreational activities. CONCLUSIONS: A case of C3-C4 spondyloptosis with associated C1-C2 posterior arch fracture is reported. The patient can present without neurological deficit if associated with a fracture of the posterior elements. Spondyloptosis without neurological deficit can be treated with gradual reduction under fluoroscopic guidance. A limited anterior-only fusion at the spondyloptosis level can provide good long-term results with preservation of other motion segments.