Spontaneous Lumbar Interbody Fusion Following Posterolateral Fusion Surgery: A Retrospective Analysis of 5-Year Data.

Background: Posterolateral fusion (PLF) surgery is frequently performed for a range of spinal disorders. However, spontaneous lumbar interbody fusion (SLIF) following PLF surgery is yet to be reported. Thus, we evaluated the incidence and characteristics of SLIF among patients that underwent PLF surgery. Methods: This retrospective study involved review of electronic medical records of 121 adult patients who underwent primary lumbar decompression with instrumented PLF between 2006 and 2011. The available radiographs of L2-S1 region were assessed for SLIF and PLF. At 1 year, modified Lee's and Lenke's criteria were used to assess SLIF and PLF, respectively. Differences between the patients in the fusion and non-fusion groups were evaluated. Results: At 1-year follow-up, 28.93 and 87.61% patients had SLIF and PLF, respectively. Moreover, 27.27% patients had both SLIF and PLF. L4-L5 (n = 13) was the most common segment involved in SLIF. SLIF rate was significantly greater among young adults (p value = 0.001), and those with no pre-operative instability (p value = 0.003) as well as who underwent pedicular fixation instrumented PLF surgery (p value < 0.0001). While, PLF was significantly greater in patients who did not undergo discectomy (p value = 0.049). SLIF was not significantly associated with sex, age groups, discectomy status, and level of PLF surgery (all p values > 0.05). PLF was not significantly associated with sex, age groups, pre-operative instability, type of instrumentation, and level of PLF surgery (all p values > 0.05). There was no significant association between patients with SLIF and PLF (p value = 0.155). Conclusions: More than a quarter of patients developed SLIF and majority of them had PLF. SLIF was significantly associated with younger age at surgery and use of pedicular fixation instruments.Level of Evidence III; retrospective cohort study.

Epidemiology of pain in back and extremities in rural population: A community-based estimation of age- and sex-specific prevalence, distribution, duration and intensity of pain, number of painful sites and seasonality of pain during twelve months in rural Gadchiroli, India.

BACKGROUND: Population-based estimates of the burden of pain in back and extremities (PBE) by sex, age, intensity, seasonality and site are lacking from rural India. METHODS: Two villages were randomly selected from a cluster of 39 villages in Gadchiroli district in India. All residents'≥20 years of age were surveyed in January 2010 by trained surveyors by making household visits. Information on PBE in the 12 months prior to survey was obtained using a structured, pretested questionnaire. RESULTS: The 12-month period prevalence of PBE was 75% (95% confidence interval CI = 72.54-77.73) in men and 91% (95% CI = 88.66-92.13) in women. The prevalence of PBE in the participants >50 years was 94% while that in the age group 20 to 50 years was 79% (P < 0.05). The site with the highest prevalence of pain was low back (women 80%, men 59%). The mean number of painful sites per person was 5.42 (95% CI = 5.17-5.67) in women, 3.68 (95% CI = 3.45-3.90) in men, 3.89 (95% CI = 3.71-4.07) in participants aged 20 to 50 years and 6.48 (95% CI = 6.11-6.85) in those >50 years. Among participants across the age and sex groups, the prevalence of mild pain was higher than severe pain at all the anatomical sites. Among various seasons, the highest prevalence of pain was in the rainy season (14%). CONCLUSION: The prevalence and the number of painful sites were higher among women and in those >50 years of age. The public health interventions for PBE need to focus on these two high risk groups.

Burden of pain in back and extremities in rural population: A community-based estimation of 12-month prevalence, distribution and duration of pain in rural Gadchiroli, India.

BACKGROUND: Population based estimates of the burden of pain in back and extremities (PBE) are lacking from rural India. We estimated this burden, measured as a) 12-month prevalence, b) site specific prevalence c) total number of painful sites per adult, d) severity of pain and e) duration of pain in the rural adult population in Gadchiroli, India, over a period of 12 months. METHODS: This population-based, cross-sectional study was conducted in two villages randomly selected from a cluster of 7 eligible villages in Gadchiroli district of India. All adults ≥20 years in these villages were surveyed by the trained community health workers in January 2010 by making household visits. The data were collected using a structured, pretested questionnaire on the history of pain in back and extremities (PBE) at various anatomical sites and its features during the previous 12 months. RESULTS: Out of 2535 eligible adults in two villages, 2259 (89%) were interviewed, of which 1876 (83%) had an episode of PBE in the preceding 12 months. The period prevalence of pain was 76% in back (including lower back, thoracic and neck) and 71% in the extremities. Highest site specific prevalence was at lower back (70%), knee (46%), neck (44%), leg/calf (39%) and mid-back (39%). The mean number of painful sites per adult was 4.57 (standard deviation (SD) = 4.17). The prevalence of severe pain was 15%. The mean number of painful days due to PBE was 166 days. Female gender (odds ratio (OR) = 2.8, 95% confidence interval (CI) = 2.1-3.6), farming/labour occupation (OR = 1.8, 95% CI = 1.4-2.4), increasing age (more than 60 years OR = 6.3, 95% CI = 3.3-11.9) were significantly associated with the risk of PBE. CONCLUSION: Nearly five out of six adults in rural Gadchiroli suffered from pain in back or extremities during the preceding 12 months. Pain was at multiple sites and was present on a mean 166 days in the year. Female gender, farming / manual labor as occupation and increasing age were the key risk factors identified. The pain in back and extremities emerges as a public health priority in rural communities.

Activity limitation and disability due to pain in back and extremities in rural population: A community-based study during a period of twelve months in rural Gadchiroli, India.

BACKGROUND: Population based estimates of the extent of the activity limitation due to back pain and disability due to musculoskeletal pains are lacking from rural India. We estimated this burden as a) extent of activity limitation due to back pain, b) disability due to musculoskeletal pains, c) grading of the limitation of each activity due to back and musculoskeletal pain in the rural adult population in Gadchiroli, India. METHODS: This population-based, cross-sectional study was conducted in two villages randomly selected from a cluster of 7 eligible villages in Gadchiroli district of India. All adults ≥20 years in these villages were surveyed by the trained community health workers in January 2010. Disability due to back pain was evaluated using newly developed questionnaire for women and men which assessed limitations in the gender-specific daily household and occupational activities in a rural area. Disability due to pain in extremities was assessed using the Health Assessment Questionnaire (HAQ). RESULTS: The total population of the two villages was 3735 out of which 2535 (67.9%) were adults ≥20 years of age and were eligible to participate in the study. Of these, 2259 (89%) were interviewed and 1247 participants (55%) had any pain on the day of the survey. Activity limitation questionnaire was filled for 716 (91.4%) out of 783 patients with back pain. HAQ scale was filled for 524 (85.2%) out of 615 patients with pain in extremities. Among men with back pain, respectively 11%, 19%, 60% and 11% had no, mild, moderate to severe difficulty or were completely unable to perform agrarian work, while among women, respectively 6%, 20%, 69% and 4% had no, mild, moderate to severe difficulty or were completely unable to perform household activities. Based on the HAQ score, respectively 1%, 67%, 18% and 14% of the participants had no, mild, moderate to severe disability or were completely unable to perform the activities. CONCLUSIONS: This community-based study in rural Gadchiroli demonstrates significant mild to moderate disability and activity limitation, due to pain in back and extremities in a population involved in hard manual work, especially agricultural and underlines the need to address the problem through appropriate interventions. The study also employs for the first time an indigenously developed questionnaire to identify activity limitation due to back pain, and demonstrates the method as well as the questionnaire.

Clinical patterns and their prevalence among adult population with back pain: A community-based cross-sectional study in rural Gadchiroli, India.

BACKGROUND: Evaluating clinical patterns and their prevalence of back pain, a common problem in rural areas, can help develop treatment strategies to address this leading cause of disability. METHODS: We conducted a population-based study in rural Gadchiroli, India. In this, two-phase study, trained surveyors conducted a door to door survey (Phase 1) to identify individuals with pain in the back and extremities in two villages randomly selected using pre-defined criteria. Those with pain were evaluated by a team of spine surgeons and rheumatologists to diagnose clinical conditions among these patients (Phase 2). RESULTS: Of the 2535 eligible adults, 2259 (89%) were screened, 1247 (55%) reported pain in back and limb and were referred to the specialist clinic. Out of the 906 (73%) participants who attended the clinics, 783 (89%) had back/neck pain. The point prevalence of back/neck pain among adults was 49% (95% confidence interval (CI) = 49%-51%), non-specific low back pain 45% (95% CI = 43.4%-47.5%); non-specific neck pain 21% (95% CI = 18.9-22.4), radiculopathy 12 (95% CI = 10.4-13.1), myelopathy 0.4 (95% CI = 0.1-0.7) and other serious spinal disorders 0.2 (95% CI 0.048-0.45). The prevalence of non-specific back/neck pain and radiculopathy was higher among females. CONCLUSIONS: Non-specific back and neck pain are the commonest diagnoses among those with pain in the back and extremities, followed by radiculopathy. Serious disorders are rare. Given the high prevalence of non-specific back and neck pain, community health workers and physicians working in rural areas need to be trained systematically to manage these conditions.

A 2-Year Outcomes and Complications of Various Techniques of Lumbar Discectomy: A Multicentric Retrospective Study.

OBJECTIVES: Various techniques of performing lumbar discectomy are prevalent, each having its rationale and claimed benefits. The authors ventured to assess the perioperative factors, outcomes, and complications of each procedure and compare among them with 946 patients contributed by 10 centers and operated by experienced surgeons. METHODS: This was a retrospective study of patients operated using open discectomy, microdiscectomy, microendoscopic discectomy, interlaminar endoscopic lumbar discectomy, transforaminal endoscopic lumbar discectomy, and Destandau techniques with a follow-up of minimum 2 years. The inclusion criteria were age >18 years, failed conservative treatment for 4-6 weeks, and the involvement of a single lumbar level. RESULTS: There was a significant improvement in the visual analog scale score of back, leg, and Oswestry Disability Index scores postoperatively across the board, with no significant difference between them. Minimally invasive procedures (microendoscopic discectomy, interlaminar endoscopic lumbar discectomy, transforaminal endoscopic lumbar discectomy, and Destandau techniques) had shorter operation time, hospital stay, better cosmesis, and decreased blood loss compared with open procedures (open discectomy and microdiscectomy). The overall complication rate was 10.1%. The most common complication was recurrence (6.86%), followed by reoperation (4.3%), cerebrospinal fluid leak (2.24%), wrong level surgery (0.74%), superficial infection (0.62%), and deep infection (0.37%). There were minor differences in incidence of complications between techniques. CONCLUSION: Although minimally invasive techniques have some advantages over the open techniques in the perioperative factors, all the techniques are effective and provide similar pain relief and functional outcomes at the end of 2 years. The various rates of individual complications provide a reference value for future studies.

Does Segmental Kyphosis Affect Surgical Outcome after a Posterior Decompressive Laminectomy in Multisegmental Cervical Spondylotic Myelopathy?

STUDY DESIGN: Retrospective analysis. PURPOSE: To compare results of laminectomy in multisegmental compressive cervical myelopathy (CSM) with lordosis versus segmental kyphosis. OVERVIEW OF LITERATURE: Laminectomy is an established procedure for decompression in CSM with cervical lordosis. However in patients with segmental kyphosis, it is associated with risk of progression of kyphosis and poor outcome. Whether this loss of sagittal alignment affects functional outcome is not clear. METHODS: We retrospectively reviewed 68 patients who underwent laminectomy for CSM from 1998 to 2009. As per preoperative magnetic resonance images, 36 patients had preoperative lordosis (Group 1) and 32 had segmental kyphosis (Group 2). We studied age at the time of surgery, duration of preoperative symptoms, recovery rate, magnitude of postoperative backward shifting of spinal cord and loss of sagittal alignment. RESULTS: Mean follow up was 5.05 years (range, 2-13 years) and mean age at the time of surgery 61.88 years. Group 1 had 20 men and 16 women and Group 2 had 19 men and 13 women. Mean recovery rate in Group 1 was 60.32%, in Group 2 was 63.7% without any statistical difference (p-value 0.21, one tailed analysis of variance). Two patients of Group 1 had loss of cervical lordosis by five degrees. In Group 2 seven patients had progression of segmental kyphosis by 5-10 degrees and two patients by more than 10 degrees. Mean cord shift was more in Group 1 (mean, 2.41 mm) as compared to Group 2 (mean, -1.97 mm) but it had no correlation to recovery rate. Patients with younger age (mean, 57 years) and less duration of preoperative symptoms (mean, 4.86 years) had better recovery rate (75%). CONCLUSIONS: Clinical outcome in CSM is not related to preoperative cervical spine alignment. Thus, lordosis is not mandatory for planning laminectomy in CSM. Good outcome is expected in younger patients operated earliest after onset of symptoms.

Hydatid disease of spine: Multiple meticulous surgeries and a long term followup.

We present a long term followup (13 years) of spinal hydatid disease with multiple recurrences and intradural dissemination of the disease at the last followup. Intradural extension of the disease in our case was supposedly through the dural rent which has not been reported in English literature. An early followup of the same case has been reported previously by the authors. A 53 year-old female came with progressive left leg pain and difficulty in walking since 2 months. On examination, she had grade four power of ankle and digit dorsiflexors (L4 and L5 myotomes) on the left side (Medical Research Council grade). There was no sensory loss, no myelopathy and sphincters were intact. Plain radiographs showed consolidation at D10-D11 (old operated levels) with stable anterior column and there were no implant related problems. Magnetic resonance imaging showed a cystic lesion at L3-L4, signal intensity same as of cerebrospinal fluid in T2 and T1, displacing the cauda equina roots. The proximal extent of the lesion could not be identified because of artifacts from previous stainless steel instrumentation. Computed tomography myelogram showed complete block at L3-L4 junction with "meniscus sign". This is the longest followup of hydatid disease of the spine that has ever been reported. Hydatid disease should always be included in the differential diagnosis of destructive or infectious lesions of the spine. Aggressive radical resection whenever possible and chemotherapy is the key to good results. Recurrence is known to occur even after that. Disease can have long remission periods. Possibility of intradural dissemination through dural injury is highly likely. Hence, it should always be repaired whenever possible.

Non-surgical management of cord compression in tuberculosis: a series of surprises.

STUDY DESIGN: Prospective study. PURPOSE: We present a series of 50 patients with tuberculous cord compression who were offered systematic non-surgical treatment, and thereby, the author proposes that clinico-radiological soft tissue cord compression is not an emergency indication for surgery. OVERVIEW OF LITERATURE: Spinal cord compression whether clinical or radiological has usually been believed to be an indication for emergency surgery in spinal tuberculosis. METHODS: Fifty adults were prospectively studied at our clinic for spinal cord compression due to tuberculous spondylitis, between May 1993 and July 2002. The inclusion criteria were cases with clinical and/or radiological evidence of cord compression (documented soft tissue effacement of the cord with complete obliteration of the thecal sac at that level on magnetic resonance imaging scan). Exclusion criteria were lesions below the conus level, presence of bony compression, severe or progressive neurological deficit (

Spinal loop rectangle and sub laminar wiring as a technique for scoliosis correction.

BACKGROUND: Most literature popularizes the efficacy of third generation instrumentation in the surgical correction of spinal deformities. A cheap and effective scoliotic deformity correction method is reviewed in this article. The aim of this study is to evaluate the efficacy of spinal loop rectangle and sub laminar wires as a modality for spinal deformity correction and its co-relation with patients' satisfaction and clinical outcome. MATERIAL AND METHODS: Thirty six patients of scoliotic spinal deformities with various etiologies (congenital-4, idiopathic- 25, neurofibromatosis-3, neuromuscular-2 and 'syndromic'-3) with ages ranging from 8 to 23 years underwent corrective posterior spinal arthrodesis with stainless steel Hartshill loop rectangle and sublaminar wires. Clinicoradiological evaluation was done at an average follow-up of 6 (1/2) years (min-2 (1/2), years). Along with clinicoradiological outcome, patient satisfaction (as per the SRS 24), was accounted. RESULTS: Average preoperative Cobb's angle were 73.25 degrees in the entire group and 66.48 degrees in the idiopathic group. Average percentage correction was 64.34% in the entire group and the (average degree of correction was 47.13). In the idiopathic group, the respective values were 69.19% and 46 degrees . Loss of correction in the whole group was 2.2 degrees at two year follow up. Sagittal profiles, truncal balance were well corrected too; minimal complications were seen. Patient satisfaction results were encouraging in 36 patients as per - SRS24). About 80.2% patients were ready to undergo the same surgery if required. (SRS24). CONCLUSION: Segmental spinal fixation with locally made spinal loop rectangle and sublaminar wires is comparable as a modality to correct scoliotic spinal deformities.

Spinal instability in ankylosing spondylitis.

BACKGROUND: Unstable spinal lesions in patients with ankylosing spondylitis are common and have a high incidence of associated neurological deficit. The evolution and presentation of these lesions is unclear and the management strategies can be confusing. We present retrospective analysis of the cases of ankylosing spondylitis developing spinal instability either due to spondylodiscitis or fractures for mechanisms of injury, presentations, management strategies and outcome. MATERIALS AND METHODS: In a retrospective analysis of 16 cases of ankylosing spondylitis, treated surgically for unstable spinal lesions over a period of 12 years (1995-2007); 87.5% (n=14) patients had low energy (no obvious/trivial) trauma while 12.5% (n=2) patients sustained high energy trauma. The most common presentation was pain associated with neurological deficit. The surgical indications included neurological deficit, chronic pain due to instability and progressive deformity. All patients were treated surgically with anterior surgery in 18.8% (n=3) patients, posterior in 56.2% (n=9) patients and combined approach in 25% (n=4) patients. Instrumented fusion was carried out in 87.5% (n=14) patients. Average surgical duration was 3.84 (Range 2-7.5) hours, blood loss 765.6 (+/- 472.5) ml and follow-up 54.5 (Range 18-54) months. The patients were evaluated for pain score, Frankel neurological grading, deformity progression and radiological fusion. One patient died of medical complications a week following surgery. RESULTS: Intra-operative adverse events like dural tears and inadequate deformity correction occurred in 18.7% (n=3) patients (Cases 6, 7 and 8) which could be managed conservatively. There was a significant improvement in the Visual analogue score for pain from a pre-surgical median of 8 to post-surgical median of 2 (P=0.001), while the neurological status improved in 90% (n=9) patients among those with preoperative neurological deficit who could be followed-up (n =10). Frankel grading improved from C to E in 31.25% (n=5) patients, D to E in 12.5% (n=2) and B to D in 12.5% (n=2), while it remained unchanged in the remaining - E in 31.25% (n=5), B in 6.25% (n=1) and D in 6.25% (n=1). Fusion occurred in 11 (68.7%) patients, while 12.5% (n=2) had pseudoarthrosis and 12.5% (n=2) patients had evidence of inadequate fusion. 68.7% (n=11) patients regained their pre-injury functional status, with no spine related complaints and 25% (n=4) patients had complaints like chronic back pain and deformity progression. In one patient (6.2%) who died of medical complications a week following surgery, the neurological function remained unchanged (Frankel grade D). Persistent back pain attributed to inadequate fusion/ pseudoarthrosis could be managed conservatively in 12.5% (n=2) patients. Progression of deformity and pain secondary to pseudoarthrosis, requiring revision surgery was noted in one patient (6.2%). One patient (6.2%) had no neurological recovery following the surgery and continued to have nonfunctional neurological status. CONCLUSION: In ankylosing spondylitis, the diagnosis of unstable spinal lesions needs high index of suspicion and extensive radiological evaluation Surgery is indicated if neurological deficit, two/three column injury, significant pain and progressive deformity are present. Long segment instrumentation and fusion is ideal.

Giant cell tumor of the spine: A review of 9 surgical interventions in 6 cases.

BACKGROUND: Giant cell tumor (GCT) of the spine is uncommon but most aggressive benign tumor of the spine with unpredictable outcome. We present our observation on six cases of GCT of the spine. We treated six patients with giant cell tumors (GCT) of the spine between 1993 and 2006. A total of nine surgical interventions were carried out. Four interventions were carried out in patients presented as 'new' cases, while five on recurrences from past GCT resections. All presented with cord compression and neurological deficits of varying grades. All patients also presented with clinical as well as radiological instability. Preoperative tissue diagnosis was available only in the five recurrences (tissue from the old resection). Posterior only (n=2), anterior only (n=4) and single-stage back and front (n=3) surgeries were carried out depending on the nature of the tumor. RESULTS: Overall results were satisfactory, as all patients were symptom-free postoperatively. Two out of our four new patients had tumor recurrence and both needed repeat resection. Both have been disease-free at last follow-up. CONCLUSION: Surgical intervention is mandatory. Close follow up is needed for early diagnosis of recurrences.