Efficacy and Safety of Ultrasound Guided Inter-semispinal Plane Block for Postoperative Analgesia in Posterior Cervical Laminectomy - A Prospective Randomised Controlled Study.

STUDY DESIGN: Prospective, randomized controlled study. OBJECTIVE: To assess the safety and efficacy of an ultrasound-guided ISP block for postoperative analgesia in posterior cervical laminectomy. METHODS: 88 patients requiring posterior cervical laminectomy were randomized into two groups, those who underwent ISP block with multimodal analgesia (ISPB group) and those with only multimodal analgesia (control group). Demographic details, intraoperative parameters (blood loss, duration of surgery, perioperative total opioid consumption, muscle relaxants used), and postoperative parameters (numeric rating scale, satisfaction score, mobilization time, and complications) were recorded. RESULTS: The total opioid consumption (128.41 + 39.65vs 284.09 + 140.92mcg; P < .001), muscle relaxant usage (46.14 + 6.18 mg vs 59.32 + 3.97 mg; P < .001), surgical duration (128.61 + 26.08/160.23 + 30.99mins; P < .01), and intra-operative blood loss (233.18 + 66.08 mL vs 409.77 + 115.41 mL; P < .01) were significantly less in the ISPB group compared to the control. In the postoperative period, the control group's pain score was significantly higher (P < .001) in the initial 48 hours. The Modified Observer Alertness/Sedation Score (MOASS) score and satisfaction scores were significantly better in the ISPB compared to the control (P < .001). The mean time required to ambulate was statistically less in ISPB (4.30 + 1.64hours) when compared to controls (9.48 + 3.07hours) (P < .001). CONCLUSION: In patients undergoing posterior cervical laminectomy, ISP block is a safe and effective technique with better outcomes than standard multi-modal analgesia alone, in terms of reduced intra-operative opioid requirements and blood loss, better postoperative analgesia, and early mobilization.

Does Magnetic Resonance Imaging Predict Neurological Deficit in Patients with Traumatic Lower Lumbar Fractures?

STUDY DESIGN: A retrospective cohort study. PURPOSE: This study aimed to understand the role of magnetic resonance imaging (MRI) in predicting neurological deficits in traumatic lower lumbar fractures (LLFs; L3-L5). OVERVIEW OF LITERATURE: Despite studies on the radiological risk factors for neurological deficits in thoracolumbar fractures, very few have focused on LLFs. Moreover, the potential utility of MRI in LLFs has not been evaluated. METHODS: In total, 108 patients who underwent surgery for traumatic LLFs between January 2010 and January 2020 were reviewed to obtain their demographic details, injury level, and neurology status at the time of presentation (American Spinal Injury Association [ASIA] grade). Preoperative computed tomography scans were used to measure parameters such as anterior vertebral body height, posterior vertebral body height, loss of vertebral body height, local kyphosis, retropulsion of fracture fragment, interpedicular distance, canal compromise, sagittal transverse ratio, and presence of vertical lamina fracture. MRI was used to measure the canal encroachment ratio (CER), cross-sectional area of the thecal sac (CSAT), and presence of an epidural hematoma. RESULTS: Of the 108 patients, 9 (8.3%) had ASIA A, 4 (3.7%) had ASIA B, 17 (15.7%) had ASIA C, 21 (19.4%) had ASIA D, and 57 (52.9%) had ASIA E neurology upon admission. The Thoracolumbar Injury Classification and Severity score (p =0.000), CER (p =0.050), and CSAT (p =0.019) were found to be independently associated with neurological deficits on the multivariate analysis. The receiver operating characteristic curves showed that only CER (area under the curve [AUC], 0.926; 95% confidence interval [CI], 0.860-0.968) and CSAT (AUC, 0.963; 95% CI, 0.908-0.990) had good discriminatory ability, with the optimal cutoff of 50% and 65.3 mm2, respectively. CONCLUSIONS: Based on the results, the optimal cutoff values of CER >50% and CSAT >65.3 mm2 can predict the incidence of neurological deficits in LLFs.

Functional and Radiological Outcomes of All-Posterior Surgical Correction of Dystrophic Curves in Patients with Neurofibromatosis Type 1.

STUDY DESIGN: A retrospective cohort study. PURPOSE: To determine outcomes following all-posterior surgery using computed tomography navigation, hybrid stabilization, and multiple anchor point techniques in patients with neurofibromatosis type 1 (NF-1) and dystrophic scoliosis. OVERVIEW OF LITERATURE: Previous studies favored antero-posterior fusion as the most reliable method; however, approaching the spine anteriorly was fraught with significant complications. With the advent of computer assisted navigation and multiple anchor point method, posterior only approach is reporting successful outcomes. METHODS: This study included patients who underwent all-posterior surgical deformity correction for dystrophic NF-1 curves. Coronal and sagittal Cobbs angles, apical rotation, and the presence of dystrophic features were evaluated before surgery. Postoperatively, sagittal, coronal, and axial correction, implant position, and implant densities were evaluated. The decline in curve correction and implant-related complications were evaluated at follow-up. Clinical outcomes were evaluated using the Scoliosis Research Society-22 revised index. RESULTS: This study involved 50 patients with a mean age of 13.6 years and a mean follow-up duration of 5.52 years. With a mean coronal flexibility of 18.7%, the mean apical vertebral rotation (AVR), preoperative coronal Cobb angle, and sagittal kyphosis were 27.4°, 64.01°, and 47.70°, respectively. The postoperative mean coronal Cobb angle was 30.17° (p <0.05), and the sagittal kyphosis angle was 25.4° (p <0.05). The average AVR correction rate was 41.3%. The correction remained significant at the final mean follow-up, with a coronal Cobb angle of 34.14° and sagittal kyphosis of 25.02° (p <0.05). The average implant density was 1.41, with 46% of patients having a high implant density (HID). The HID had a markedly higher mean curve correction (29.30° vs. 38.05°, p <0.05) and a lower mean loss of correction (5.7° vs. 3.8°, p <0.05). CONCLUSIONS: Utilizing computer-assisted navigation, hybrid instrumentation, and multiple anchor point technique and attaining high implant densities, this study demonstrates successful outcomes following posterior-only surgical correction of dystrophic scoliosis in patients with NF-1.

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.

Active tuberculosis of spine: Current updates.

Background: Spinal tuberculosis (TB) is the most common extrapulmonary form of tuberculosis. In both developing and developed countries, TB has been on the rising trend due to factors such as increasing HIV coinfection, multidrug resistance of the organism, and global migration. Spinal TB, which most often affects the lower thoracic and thoracolumbar area, accounts for 50% of all musculoskeletal tuberculosis. Methods: Using the Cochrane Database of Systematic Reviews, EMBASE, and PubMed, a systematic computerized literature search was performed. Analyses of studies published within the past 10 years were conducted. The searches were performed using Medical Subject Headings terms, with "spinal tuberculosis," "diagnosis," "epidemiology," and "etiology","management," "surgery," and "therapy" as subheadings. Results: Progressive collapse, kyphosis, and neurological deficiency are hallmarks of the disease because of its destructive effect on the intervertebral disc and adjacent vertebral bodies. The condition may be identified using laboratory testing and distinctive imaging features, but the gold standard for diagnosis is tissue diagnosis using cultures, histology, and polymerase chain reaction. Uncomplicated spinal TB is today a medical condition that can be adequately treated by multidrug ambulatory chemotherapy. Surgery is reserved for individuals who have instability, neurological impairment, and deformity correction. Debridement, deformity correction, and stable fusion are the cornerstones of surgical treatment. Conclusions: Clinical results for the treatment of spinal TB are generally satisfactory when the disease is identified and treated early. However, the major health issue and the biggest obstacle in achieving the goals of the "End TB strategy" is the recent rise in the emergence of drug resistance. Hence strict vigilance and patient perseverance in the completion of the treatment is the main need of the hour.

Comparison Between Relative Efficacy of Erector Spinae Plane Block and Caudal Epidural Block for Postoperative Analgesia in Lumbar Fusion Surgery- A Prospective Randomized Controlled Study.

STUDY DESIGN: Prospective, randomized controlled double-blinded study. OBJECTIVE: To compare the relative efficacy of ultrasound-guided ESPB and CEB for postoperative analgesia after a single-level lumbar fusion surgery and compared it with conventional multimodal analgesia. METHODS: 81 patients requiring single-level lumbar fusion surgery were randomly allocated into 3 groups (ESPB group, CEB group, and the control group). Demographic and surgical data (blood loss, duration of surgery, perioperative total opioid consumption, muscle relaxants used) were assessed. Postoperatively, the surgical site pain, alertness scale, satisfaction score, time to mobilization, and complications were recorded. RESULTS: The total opioid consumption in the first 24 hours was significantly lower in both the block groups than in the control group (103.70 ± 13.34 vs 105 ± 16.01 vs 142.59 ± 40.91mcg; P < .001). The total muscle relaxant consumption was also significantly less in block groups compared to controls (50.93 ± 1.98 vs 52.04 ± 3.47 vs 55.00 ± 5.29 mg; P < .001). The intraoperative blood loss was significantly less in both the block group (327.78 ± 40.03 mL, 380.74 ± 77.80 mL) than the control group (498.89 ± 71.22 mL) (P < .001). Among the block groups, the immediate postoperative pain relief was better in the CEB group, however, the ESPB group had a longer duration of postoperative pain relief. CONCLUSION: Both ESPB and CEB produce adequate postoperative analgesia after lumbar fusion however the duration of action was significantly longer in the ESPB group with relatively shorter surgical time and lesser blood loss compared to the CEB group.

Current trends and advancements in spine surgery.

In recent years, spine surgery has undergone remarkable advancements, revolutionized the field, and transformed patient care. This special issue of the Journal of Orthopedics provides the best possible knowledge for its readers about the current trends and recent innovations in the field of spine surgery and supports clinicians and surgeons in their daily practice and decision-making process. It covers various topics like artificial intelligence in spine surgery, 3D printing, minimally invasive spine surgery. It also provides needed information on modic changes, management of eary onset scoliosis and recent trends in spinal cord injury management.

Giant Anomalous Cervical Spinous Process Causing Dynamic Cord Compression: An Unusual Cause for Myelopathy: A Case Report.

CASE: A 47-year-old male patient presented with progressively worsening gait instability caused by a giant anomalous, free-floating C5 spinous process resulting in dynamic cord compression and myelopathy. The patient was successfully managed with a C5 laminectomy and total excision of the anomalous spinous process with a good functional outcome at the final follow-up. CONCLUSION: Anomalies of the posterior arch of the subaxial cervical spine are relatively uncommon and asymptomatic. This case is being reported for its rarity and to highlight the role of dynamic imaging in patients presenting with congenital anomalies of the cervical spine presenting with compressive myelopathy.

Vancomycin Flushing Syndrome After the Use of Vancomycin-Impregnated Bone Graft During Spine Surgery: A Case Report.

CASE: Intrawound vancomycin in spine surgery is a common clinical practice. We report a case of a 14-year-old adolescent girl undergoing surgery for scoliosis correction who developed features of vancomycin flushing syndrome after the use of vancomycin-impregnated bone graft. After resuscitation, she was extubated and had an uneventful postoperative recovery. At 1-year follow-up, she is back to her routine without any sequelae of the intraoperative event. CONCLUSION: The use of intrawound vancomycin can result in life-threatening reactions. With the increase in its use, the anesthetist and the surgeon must be aware of such complications.

Ralstonia mannitolilytica as a rare cause of spondylodiscitis following endoscopic lumbar discectomy- A report of two cases.

Ralstonia mannitolilytica is a low-virulence, gram-negative bacillus which causes opportunistic infections in immunosuppressed patients. Postoperative spondylodiscitis by R. mannitolilytica has not been reported so far. We report the management of two cases of postoperative spondylodiscitis caused by Ralstonia mannitolilytica presenting to our center within a span of one month following endoscopic lumbar discectomy at a different center. They were managed successfully by surgical debridement and appropriate antibiotics. In these two cases of R.mannitolilytica spondylodiscitis, prompt detection, and intensive treatment resulted in satisfactory outcomes in terms of fulfilling the purpose of the original surgery.

Propensity matched outcome analysis following microdiscectomy versus interlaminar endoscopic discectomy for L5-S1 disc herniation.

Purpose: The main purpose of the study is to perform a propensity-matched functional outcome analysis following microdiscectomy (MD) versus interlaminar endoscopic lumbar discectomy (IELD) for L5-S1 disc herniation. Although many studies have compared endoscopic lumbar discectomy and microdiscectomy, few have compared the outcomes of microdiscectomy (MD) and interlaminar endoscopic discectomy (IELD) at the L5-S1 level. Methods: This is a propensity-matched analysis of 100 patients (50 MD patients, 50 IELD patients) based on baseline covariates with a minimum of one-year follow-up. Patient-reported outcome measures were obtained from EMR during follow-up visits. Back pain and sciatic pain were assessed by the Visual Analogue Scale (VAS-B and VAS-L). Functional outcome was assessed using Oswestry Disability Index (ODI) Score and 12-item Short Form Survey (SF-12) score. Data were obtained at baseline (pre-op) and at 0, 1, 3, and 12 months post-operatively. Results: Mean operative time was significantly lower (p < 0.001) in the IELD group (44 min) compared to the MD group (59 min). Mean VAS-B at the immediate and 1-month postoperative period was significantly (p < 0.001) lower in the IELD group (0.36, 0.24) when compared with the MD group (1.74, 1.16). There was no significant difference between IELD and MD groups with regard to improvement in sciatic pain (VAS-L). ODI scores at 1 month and 3 months post-operative period were significantly (p < 0.001) lower in the IELD group (30.1, 23.2) when compared with the MD group (41, 27.5). However, there was no significant difference between the two groups with regards to VAS-B, ODI, and SF-12 at 1-year follow-up. Conclusion: Our findings indicate that the IELD group achieved better immediate and early postoperative outcomes despite no significant difference at one-year follow-up.

Dural injury following elective spine surgery - A prospective analysis of risk factors, management and complications.

Incidental dural tears being a familiar complication in spine surgery could result in dreaded postoperative outcomes. Though the literature pertaining to their incidence and management is vast, it is limited by the retrospective study designs and smaller case series. Hence, we performed a prospective study in our institute to determine the incidence, surgical risk factors, complications and surgical outcomes in patients with unintended durotomy during spine surgery over a period of one year. The overall incidence in our study was 2.3% (44/1912). Revision spine surgeries in particular had a higher incidence of 16.6%. The average age of the study population was 51.6 years. The most common intraoperative surgical step associated with dural tear was removal of the lamina, and 50% of the injuries were during usage of kerrison rongeur. The most common location of the tear was paramedian location (20 patients) and the most common size of the tear was about 1 mm-5mm (31 patients). We observed that the dural repair techniques, placement of drain and prolonged post-operative bed rest didnot significantly affect the post-operative outcomes. One patient in our study developed persistent CSF leak, which was treated by subarachnoid lumbar drain placement. No patients developed pseudomeningocele or post-operative neurological worsening or re-exploration for dural repair. Wound complications were noted in 4 patients and treated by debridement and antibiotics. Based on our study, we have proposed a treatment algorithm for the management of dural tears in spine surgery.

"Are we barking up the wrong tree? Too much emphasis on Cutibacterium acnes and ignoring other pathogens"- a study based on next-generation sequencing of normal and diseased discs.

BACKGROUND: The majority of literature on bacterial flora in the disc stands disadvantaged in utilizing traditional culture methods and targeting a single bacterium, Cutibacterium acnes. PURPOSE: Our objective was to document the diversity in the bacterial flora between normal and degenerated discs for shortlisting potential pathogens using next-generation genomic tools. STUDY DESIGN: Experimental case-control study. METHODS: Researchers employed 16S metagenome sequencing to profile bacterial diversity in magnetic resonance imaging normal healthy discs from brain-dead organ voluntary donors (n=20) and 40 degenerated disc samples harvested during surgery (Modic [MC]=20 and non-Modic [NMC]=20). The V3-V4 region was amplified using universal bacterial primers 341F and 806R, and the libraries were sequenced using Illumina NovoSeq 6000 platform. Statistical significance was set at bacteria with a minimum of 100 operational taxonomic unit (OTU) and present in at least 70% of the samples. The quality check-filtered reads were processed using the QIIME-2 pipeline. The OTU clustering and taxonomic classification were carried out for the merged reads using the Greengenes/SILVA reference database. Validation was done by identification of bacterial metabolites in samples using the liquid chromatography-mass spectrometry approach. RESULTS: Abundant bacteria differing widely in diversity, as evidenced by Alfa and Beta diversity analysis, were present in all control and degenerative samples. The number of bacterial genera was 27 (14-gram-positive: 13-gram-negative) in the control group, 23 (10-gram-positive: 11-gram-negative) in the Modic group, and 16 (11-gram-positive: 5-gram-negative) in the non-Modic group. In the Modic group, gram-negative bacteria OTUs were found to be predominant (more than 50% of the total bacteria identified), whereas in control and non-Modic groups the OTUs of gram-positive bacteria were predominant. Species-level analysis revealed an abundance of opportunistic gram-negative pathogens like Pseudomonas aeruginosa, Sphingomonos paucibacillus, and Ochrobactrum quorumnocens in the discs with Modic changes, more than in non-Modic discs. The presence of bacterial metabolites and quorum-sensing molecules like N-decanoyl-L-homoserine lactone, 6-hydroxynicotinic acid, 2-aminoacetophenone, 4-hydroxy-3-polyprenylbenzoate, PE (16:1(9Z)/18:0) and phthalic acid validated the colonization and cell-cell communication of bacteria in disc ruling out contamination theory. Cutibacterium acnes was not the predominant bacteria in any of the three groups of discs and in fact was in the 16th position in the order of abundance in the control discs (0.72%), seventh position in the Modic discs (1.41%), and 12th position (0.53%) in the non-Modic discs. CONCLUSION: This study identified a predominance of gram-negative bacteria in degenerated discs and highlights that Cutibacterium acnes may not be the only degeneration-causing bacteria. This may be attributed to the environment, diet, and lifestyle habits of the sample population. Though the study does not reveal the exact pathogen, it may pave the way for future studies on the subject. CLINICAL SIGNIFICANCE: These findings invite further investigation into causal relationships of bacterial profile with disc degeneration phenotypes as well as phenotype-driven clinical treatment protocols.

Analysis of Postoperative Clinical Outcomes in Cervical Myelopathy due to Ossification of Posterior Longitudinal Ligament Involving C2.

STUDY DESIGN: Retrospective study. PURPOSE: To investigate the radiological phenotype, patient and surgery-related risk factors influencing postoperative clinical outcome for cervical myelopathy caused by ossification of the posterior longitudinal ligament involving C2 following posterior instrumented laminectomy and fusion. OVERVIEW OF LITERATURE: Ossified posterior longitudinal ligament (OPLL) is caused by ectopic ossification of the posterior longitudinal ligament. It can cause neurological impairment and severe disability. For multilevel cervical OPLL, studies have shown good neurological recovery following cord decompression via either an anterior or posterior approach. There is, however, a lacunae in the literature regarding the outcomes of patients with OPLL extending to C2 and above (C2 [+]). METHODS: We retrospectively studied 61 patients with C2 (+) OPLL who had posterior instrumented laminectomy and fusion at Ganga Hospital, Coimbatore between July 2011 and January 2021, with a minimum follow-up of 2 years. Data on demographics, clinical outcomes, radiology, and post-surgical outcomes were gathered. RESULTS: Among 61 patients, 56 were males and five were females. The OPLL pattern was mixed in 32 cases (52.5%), continuous in 26 cases (42.6%), segmental in two cases (3.3%), and circumscribed in one patient (1.6%). All of our patients showed signs of neurological improvement after a 24-month follow-up. The mean preoperative modified Japanese Orthopaedic Association (mJOA) score was 10.6 (range, 5-11) and the postoperative mJOA score was 15.8 (range, 12-18). The recovery rate was >75% in 27 patients (44.6%), >50% in 32 patients (52.5%), and >25% in two patients (3.3%). The average recovery rate was 71% (range, 33%-100%). The independent risk factor for predicting recovery rate is the preoperative mJOA score. CONCLUSIONS: In C2 (+) OPLL, posterior instrumented decompression and fusion provide a relatively safe approach and satisfactory results.

Ultrasonic bone scalpel in spine surgery.

Background: Spine surgery has always been considered technically demanding even in the hands of the most experienced surgeon on account of close proximity of vital soft tissue structures. Technical advancements over the last few decades have been crucial for the progress of this complex speciality which not only increased the surgical accuracy, but patient safety as well. Ultrasonic devices are one such innovation based on piezoelectric vibrations, patented by Fernando Bianchetti, Domenico Vercellotti, and Tomaso Vercellotti in 1988. Methods: We did an extensive literature search on ultrasonic devices and their applications in the field of spine surgery. Results: We present the various ultrasonic bone devices available including their physical, technologic and clinical aspects in spine surgery. We also attempt to cover the limitations and future advances of Ultrasonic bone scalpel (UBS) in particular, which would be interesting and informative for any spine surgeon who is novice in this field. Conclusion: UBS has been found to be safe and effective in all forms of spine surgeries offering distinct advantages over conventional instruments, although limited by an inherent learning curve.

Surgical Approach to Cervical Fractures in Ankylosing Spondylitis Patients: Rationale and Surgical Strategy.

BACKGROUND: Current literature lacks objective criteria to determine surgical management in patients with ankylosing spondylitis who sustain cervical fractures. The purpose of our study was to analyze the determinants for stratifying surgical approach, evaluate the outcome in patients, and postulate a management strategy. METHODS: This was a retrospective study of patients with ankylosing spondylitis who underwent surgery for cervical spine injury with a minimum follow-up of 2 years. Neurological recovery, fracture pattern including translation and angulation, surgical duration, blood loss, and postoperative complications were recorded, and a comparative analysis of these factors with anterior, posterior, and combined surgical approaches was performed. RESULTS: The study included 43 men with a mean age of 57 years; 49% underwent anterior-only stabilization, 16% underwent posterior-only stabilization, and 35% underwent combined anteroposterior stabilization. Mean operative time was significantly lower in anterior-only (81.4 minutes; P < 0.05) and posterior-only (124 minutes; P < 0.05) approaches compared with combined approach (266.6 minutes). Mean blood loss was significantly lower in anterior-only (87.5 mL, P < 0.05) approach compared with posterior-only (714.7 mL) and combined (912.7 mL) approaches. Mean translation was 1.8 mm, 1.7 mm, and 3.7 mm in anterior, posterior, and combined approaches (P < 0.05), respectively. CONCLUSIONS: Our study provides insights into management of cervical spine fractures in ankylosing spondylitis patients. A fracture displacement ≤2 mm may be successfully managed by an anterior approach, while the posterior approach may be beneficial in similar fractures warranting instrumentation extending to the thoracic spine. All other fractures warrant a combined surgical approach.

Bacteria in human lumbar discs - subclinical infection or contamination? Metabolomic evidence for colonization, multiplication, and cell-cell cross-talk of bacteria.

BACKGROUND CONTEXT: The accumulating evidence associating sub-clinical infection with disc degeneration (DD) and the controversy of contamination versus infection mandates a further understanding of the microbial activity in the disc and host-microbiome interaction. PURPOSE: To utilize a novel approach of metabolomics to probe the presence of bacterial metabolites involved in colonization, survival, and replication in human lumbar intervertebral discs (LIVD). STUDY DESIGN: An observational case-control study. PATIENT SAMPLE: Nucleus pulposus from the LIVD of three brain-dead voluntary organ donors (MRI normal and classified as controls) and of three patients undergoing surgery for disc degeneration (DD) (cases) were utilized. METHODS: Untargeted metabolite profiling was carried out in six discs (3-controls and 3-cases) after extraction using methanol: acetonitrile: water (2:2:1) solvent system and acquired through HPLC-MS/MS platform using C18 reversed-phase column. From the total IVD metabolome, microbial metabolites were filtered by mapping against HMDB, ChEBI, SigMol, Siderophore database, ecdmb database, and PaMet databases. The biological functions of the metabolites were then studied by MSEA pipeline from Metaboanalyst, and the enrichment ratio, p-value, and Variably Importance Projection scores of the metabolites were calculated. Degeneration responsive changes in the abundance of the microbial metabolites were calculated based on the peak intensities between the control and cases. RESULTS: Mass spectrometry identified a total of 17601 and 15003 metabolites, respectively, in the control and degenerated discs. Preliminary mapping of the above metabolites against HMDB indicated the multiple sources, and of these, 64 metabolites were of microbial origin, accounting for 1.6% of the total IVD metabolome. Principle Component Analysis and Orthogonal Partial Least Square-Discriminant Analysis (OPLS-DA) showed distinct clustered patterns between control and disc degene`ration, indicating a strong variation in concentration, peak, and spectral values of the 64 metabolites between controls and cases. After the exclusion of metabolites that were also associated with humans, drugs, and food, 39 metabolites specific to bacteria were isolated. Nine were primary metabolites related to bacterial growth and survival, and the remaining 30 were secondary metabolites related to different environmental stress response activities. The three significant pathways (p<.001) which were predominant in the bacterial metabolites were autoinducer-2 biosynthesis, peptidoglycan biosynthesis, and chorismate pathway. In addition, a significant fold change of >1.0 was found for nine metabolites which included (S)-14-Methyilhexadecanoic acid related to P. acnes, 9-OxoODE, and 13-OxoODE related to gut flora, vibriobactin - a siderophore, tuberculosinol and iso-tuberculosinol, virulence factors of M. tuberculosis. There was also upregulation of Autoinducer- 2, an important "Quorum sensing molecule" involved in bacterial cross-talk. CONCLUSION: We identified several bacterial-specific metabolites participating in bacterial growth, survival, and cross-talk pathways. These were found in both groups but up-regulated in degenerated discs. The presence of Quorum sensing molecules and cell-cell interactions provides firm proof of colonization and growth. These findings indicate that the bacterial presence may not be mere contamination but could be colonization with a possible role in infection-mediated inflammation in DD. CLINICAL SIGNIFICANCE: Proof of subclinical infection as an initiator of DD and documentation of exact germ and drug sensitivity will change the way millions of patients with non-specific low back pain (NSLBP) are treated across the world.

Risk factors for thirty-day morbidity and mortality after spinal trauma.

BACKGROUND: Traumatic Spinal Injuries (TSI) often follow high velocity injuries and frequently accompanied by polytrauma. While most studies have focussed on outcomes of spinal cord injuries, the incidence and risk factors that predict morbidity and mortality after TSI has not been well-defined. METHODS: Data of consecutive patients of TSI (n = 2065) treated over a 5-year-period were evaluated for demographics, injury mechanisms, neurological status, associated injuries, timing of surgery and co-morbidities. The thirty-day incidence and risk factors for complications, length of stay and mortality were analysed. RESULTS: The incidence of spinal trauma was 6.2%. Associated injuries were seen in 49.7% (n = 1028), and 33.5% (n = 692) patients had comorbidities. The 30-day mortality was 0.73% (n = 15). Associated chest injuries (p = 0.0001), cervical spine injury (p = 0.0001), ASIA-A neurology (p < 0.01) and ankylosing spondylitis (p = 0.01) correlated with higher mortality. Peri-operative morbidity was noted in 571 patients (27.7%) and were significantly associated with age > 60 (p = 0.043), ASIA-A neurology (p < 0.05), chest injuries (p = 0.042), cervical and thoracic spine injury (p < 0.0001). The mean length of stay in hospital was 8.87 days. Cervical spine injury (p < 0.0001), delay in surgery > 48 h (p = 0.011), Diabetes mellitus (p = 0.01), Ankylosing spondylitis (p = 0.009), associated injuries of chest, head, pelvis and face (p < 0.05) were independent risk factors for longer hospital stay. CONCLUSION: Key predictors of mortality after spinal trauma were cervical spine injury, complete neurological deficit, chest injuries and ankylosing spondylitis, while additionally higher age and thoracic injuries contributed to higher morbidity and prolonged hospitalisation. Notably multi-level injuries, higher age, co-morbidities and timing of surgery did not influence the mortality.

In Vertebral Hemangiomas with Neurological Deficit, Is a Less Extensive Approach Adequate.

STUDY DESIGN: This was a retrospective study. PURPOSE: To analyze the surgical and neurological outcomes following surgical decompression in patients with aggressive vertebral hemangioma (AVH) presenting with neurological deficit and to determine whether a less extensive approach is appropriate. OVERVIEW OF LITERATURE: AVHs are a rare subset of benign vascular tumors frequently presenting with neurological deficit because of spinal cord compression. Though the results of surgical management have improved over time, there is a lack of consensus on the ideal management in this group of patients. METHODS: Twenty-one patients who underwent surgery for AVH between 2009 and 2018 were analyzed. Demographic and clinical details of patients were retrieved from hospital information system. Imaging information (i.e., radiography, computed tomography, magnetic resonance imaging) of all patients was accessed and analyzed in picture archiving and communication system. Tumor staging was performed using Enneking and Weinstein-Boriani-Biagini classifications and Spinal Instability Neoplastic Score. At followup, neurological and radiological evaluations were performed. RESULTS: Twenty-one patients (13 [61.9%] females and 8 [38.1%] males) were included with a mean age of 44.29 years (range, 14-72 years). All patients in the study had neurological deficit. Back pain was present in 80.9% of patients. Mean duration of symptoms was 4.6 months (range, 1 day to 10 months). Most common lesion location was thoracic spine (n=12), followed by thoracolumbar (D11- L2; n=7) and lumbar (n=2) regions. Ten patients had multiple level lesions. All patients underwent preoperative embolization. Nine patients underwent intralesional spondylectomy with reconstruction; another nine patients underwent stabilization, decompression, and vertebroplasty; three patients underwent decompression and stabilization. Neurology improved in all patients, and only one case of recurrence was noted in a mean follow-up of 55.78±25 months (range, 24-96 months). CONCLUSIONS: In AVH, good clinical and neurological outcomes with low recurrence rates can be achieved using less extensive procedures, such as posterior instrumented decompression with vertebroplasty and intralesional tumor resection.