Congenital Stenosis of the Spine-A Cross-Sectional Study of 1019 Whole-Spine Computed Tomography Scans to Determine Prevalence and Association Among Multilevel, Tandem, and Triple Region Stenosis.

BACKGOUND: Patients with congenital stenosis of the spine (CSS) present with clinical symptoms at an early age and fewer degenerative hypertrophic changes than the more common degenerative cohort. Literature is lacking in the true prevalence of CSS affecting the 3 segments of the spine in isolation, as well as in tandem in the Indian subcontinent. METHODS: Anteroposterior spinal canal diameter in axial plane computed tomography at the midvertebral level was measured in asymptomatic patients with whole-spine computed tomography. Spinal canal stenosis was defined as a diameter of <12 mm for the cervical region, <12 mm for the thoracic region, and <13 mm for the lumbar region. Single-level and multilevel stenosis, as well as tandem and triple-region stenosis, were evaluated. RESULTS: The results show the prevalence of CSS as 16.6%, 11.5%, and 20.1% involving the cervical, thoracic, and lumbar spine, respectively. Single-level stenosis affected 90.6%, 94%, and 79.8% of the patients with cervical, thoracic, and lumbar CSS, respectively. Tandem stenosis affected 10.4% of the population (n = 104), with cervicolumbar stenosis being the most prevalent (n = 51, 5%). The presence of CSS in any one segment of the spine was significantly associated with the presence of stenosis at one of the other segments (P < 0.05). Triple-region stenosis was seen in 0.3% (n = 3) patients. CONCLUSIONS: The prevalence of cervical, thoracic, lumbar and tandem stenosis from our study is established at 16.6%, 11.5%, 20.1%, and 10.4%. Additionally, our study demonstrates the association between stenosis of the different regions of the spine.

The disc-endplate-bone-marrow complex classification: progress in our understanding of Modic vertebral endplate changes and their clinical relevance.

BACKGROUND CONTEXT: The disc, endplate (EP), and bone marrow region of the spine form a single anatomical and functional interdependent unit; isolated degeneration of any one structure is rare. Modic changes (MC), however, are restricted to the subchondral bone alone and based on only T1 and T2 sequences of MRI. This results in poor reliability in differentiating fat from edema and hence may give a false impression of disease inactivity. PURPOSE: To study the changes in disc, endplate, and bone marrow as a whole in degeneration and propose a classification based on the activity status of this complex with the addition of STIR MRI sequences. STUDY DESIGN: Observational cohort. PATIENT SAMPLE: Patients with isolated brain, cervical, or thoracic spine injury and patients with low back pain (LBP) who underwent MRI formed the control and study groups, respectively. OUTCOME MEASURES: Demographic data, the prevalence of MC and disc-endplate-bone marrow classification (DEBC) changes, EPs undergoing reclassification based on DEBC, and comparison of the prevalence of MC, DEBC, H+modifier and DEBC with H+concordance between control and LBP group. The study determined the risk of LBP patients undergoing surgery as well as the incidence of postoperative infection based on DEBC changes. Significance was calculated by binomial test and chi-square test with the effect size of 0.3 to 0.5. Prevalence and association of outcome were calculated by Altman's odds ratio with the 95% CI and the scoring of z statistics. Logistic expression was plotted for independent variables associated with each class of both Modic and DEBC against dependent variables surgery and nonsurgery. METHODS: Lumbar segments in both groups were assessed for MC types. The DEBC classification was developed with the addition of STIR images and studying the interdependent complex as a whole: type-A: acute inflammation; type-B: chronic persistence; type-C: latent and type-D: inactive. Modifier H+ was added if there was disc herniation. The classification was compared with MC and correlated to clinical outcomes. RESULTS: A total of 3,560 EPs of 445 controls and 8,680 EPs in 1,085 patients with LBP were assessed. Four nonMC, 560 MC-II, and 22 MC-III EPs were found to have previously undetected edema in STIR (n=542) or hyperintensity in discs (n=44) needing reclassification. The formerly undescribed type-B of DEBC, representing a chronic persistent activity state was the most common (51.8%) type. The difference between the control and LBP of H+(12% vs 28.8%) and its co-occurrence with DEBC type 1.1% vs 23.3%) was significant (p<.0001). The odds ratio for the need for surgery was highest (OR=5.2) when H+ and DEBC type change co-occurred. Postoperative deep infection (as determined by CDC criteria) was 0.47% in nonDEBC, compared with 2.4% in patients with DEBC (p=.002), with maximum occurrence in type-B. CONCLUSION: Classification based on the classic MC was found to need a reclassification in 586 EPs showing the shortcomings of results of previous studies. Considering the DEBC allowed better classification and better predictability for the need for surgical intervention and incidence of postoperative infection rate than MC.

Arthroscopic capsular release versus manipulation under anaesthesia for treating frozen shoulder - a prospective randomised study.

PURPOSE: Arthroscopic capsular release (ACR) and Manipulation under anaesthesia(MUA) have been widely used in the treatment of frozen shoulder (FS). However, there is only limited Level-I evidence to prefer ACR over MUA. The purpose of our study was to conduct a randomised trial comparing ACR versus MUA to assess the difference in outcome, complications and cost-effectiveness of both procedures. METHODS: From May 2020 to June 2021, patients presenting with FS were randomised into two groups ACR (n = 44) and MUA (n = 41). Patients with arthritis, full-thickness cuff tears, history of trauma/previous surgery around the shoulder were excluded from the study. Range of movement (ROM), pain grading using visual analogue scale (VAS), functional scores- UCLA, CONSTANT and EuroQol-5D scores were measured pre-operatively and post-operatively. MRI was done at three weeks post-operatively for screening complications of either procedure. Quality-adjusted life years (QALY) was used for cost-analysis. RESULTS: Post-operatively, patients had significant improvement in pain, ROM and functional scores in both groups (P < 0.001) with no significant difference between groups at 24 weeks of follow-up. Diabetic patients undergoing ACR had lesser improvement in abduction and external rotation when compared to non-diabetic patients. Labral tears in MUA group and bone bruises in ACR group were the most common complications noted on the post-operative MRI. For ACR cost per QALY gained was 896 USD while that for MUA was 424 USD. CONCLUSION: Both ACR and MUA resulted in good improvement in pain and shoulder function. Good outcomes, simple technique and better cost-effectiveness would still make MUA an attractive option over ACR for treating FS.