Isolated costotransverse joint tuberculosis - A rare location for tubercular arthritis.

Background: Posterior element involvement of the spine with tuberculosis (TB) is very uncommon. Case Description: A 25-year-old immunocompetent female presented with dull mid-back ache and tenderness over the inferior angle of the left scapula and left 7th costovertebral junction. The MRI showed erosion and enhancing soft tissue in the periarticular region of the left 7th costotransverse joint. After the CT-guided biopsy confirmed the diagnosis of TB, she was successfully managed with antitubercular chemotherapy. Conclusion: In a 25-year-old female, the early diagnosis of atypical TB involving the left T7 costotransverse joint allowed for allowed for its successful treatment/resolution with antitubercular chemotherapy.

Sagittal Balance, Pulmonary Function, and Spinopelvic Parameters in Severe Post-Tubercular Thoracic Kyphosis.

STUDY DESIGN: Cross-sectional study. PURPOSE: To evaluate sagittal balance, pulmonary function, and spinopelvic parameters in patients with healed spinal tuberculosis with severe thoracic kyphosis. OVERVIEW OF LITERATURE: Deterioration of neurological function is an absolute indication of surgical intervention in severe post-tubercular kyphosis, but the relationship of compromise in lung function and spinal alignment with severity of kyphosis is still unclear. METHODS: Twenty patients (age, 14-60 years) with healed spinal tuberculosis with thoracic kyphosis >50° were included. Lateral-view radiography of the whole spine, including both hips, was performed for assessment of kyphotic angle (K angle), sagittal balance, lumbar lordosis, and spinopelvic parameters. Pulmonary function was assessed by measuring the forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and their ratio (FEV1/FVC) by spirometry. RESULTS: A positive correlation between severity of kyphosis and sagittal imbalance was noted, with compensatory mechanisms maintaining the sagittal balance in only up to 80° of dorsal kyphosis. In >80° of kyphosis, FVC was found to be markedly decreased (mean FVC=50.6%). The mean K angle was lower in subjects with lower thoracic kyphosis. In lower thoracic kyphosis, due to short lordotic and long kyphotic curves, both lumbar lordosis and pelvic retroversion worked at compensation, whereas, in middle thoracic kyphosis, due to long lordotic curve, only lumbar lordosis was required. Normal pulmonary function (mean FVC, 83.0%) and lesser kyphotic deformity (mean K angle in adolescents, 69.8°; in adults, 94.4°) were found in adolescents. CONCLUSIONS: In >80° of thoracic kyphosis, there is sagittal imbalance and a markedly affected pulmonary function. Such patients should be offered corrective surgery if they are symptomatic and medically fit to undergo the procedure. However, whether the surgical procedure would result in improved pulmonary function and sagittal balance needs to be evaluated by a follow-up study.

A systematic review of MIS and open decompression surgery for spinal metastases in the last two decades.

OBJECTIVE: The primary intention of this review being to produce an updated systematic review of the literature on published outcomes of decompressive surgery for metastatic spinal disease including metastatic spinal cord compression, using techniques of MIS and open decompressive surgery. METHODS: The authors conducted database searches of OVID MEDLINE and EMBASE identifying those studies that reported clinical outcomes, surgical techniques used along with associated complications when decompressive surgery was employed for metastatic spinal tumors. Both retrospective and prospective studies were analysed. Articles were assessed to ensure the required inclusion criteria was met. Articles were then categorised and tabulated based on the following reported outcomes: predictors of survival, predictors of ambulation or motor function, surgical technique, neurological function, and miscellaneous outcomes. RESULTS: 2654 citations were retrieved from databases, of these 31 met the inclusion criteria. 5 studies were prospective, the remaining 26 were retrospective. Publication years ranged from 2000 to 2020. Study size ranged from 30 to 914 patients. The most common primary tumors identified were lungs, breast, prostate and renal cancers. One study ( Lo and Yang, 2017)13 reported that in those patients with motor deficit, survival was significantly improved when surgery was performed within 7 days of the development of motor deficit compared to situations when surgery was carried out 7 days after onset. This was the only study that showed that the timing of surgery plays a significant role w.r.t. survival following the onset of spinal cord compression symptoms. Four articles identified that a pre-operative intact motor function and or ambulatory status conferred a higher likelihood of a better post-operative outcome, not just in relation to survival but also in relation to post-operative ambulation as well as a greater tendency towards suitability for adjuvant treatment. Even for the same scoring system e.g. tokuhashi and its effectiveness in predicting survival, results from different studies varied in their outcome. The Karnofsky Performance Status (KPS) being the most commonly used tool to assess functional impairment, the Eastern Cooperative Oncology Group (ECOG) performance status being used in two studies. 23 studies identified an improvement in neurological function following surgery. The most common functional scale used to assess neurological outcome was the Frankel scale, 3 studies used the American Spinal Injury Association (ASIA) impairment scale for this purpose. Wound problems including infection and dehiscence appeared to be the most commonly reported surgical complication. (25 studies). The most commonly used surgical technique involved a posterior approach with decompression, with or without stabilisation. Less commonly employed techniques included percutaneous pedicle screw fixation associated with or without mini-decompression as well as anterior approaches involving corpectomy and instrumentation. 9 studies included in their data, the effect of radiation therapy in combination with surgery or as a comparison used as an alternative to surgery in spinal metastases. CONCLUSIONS: We provide a systematic literature review on the outcomes of decompressive surgery for spinal metastases. We analyse survival data, motor function, neurological function, as well as the techniques of surgery used. Where appropriate complications of surgery are also highlighted. It is the authors' intention to provide the reader with a reference text where this information is ready to hand, allowing for the consideration of means and methods to improve and optimise the standard of care in patients undergoing surgical intervention for metastatic spinal disease.

Pediatric Anterior Transolecranon Fracture-Dislocation of the Elbow: A Case Report and Review of Literature.

A five-year-old female child came to us with complaints of pain, swelling and deformity of the left elbow following fall on flexed elbow. Radiographs showed an anterior transolecranon-fracture dislocation of the elbow. After an unsuccessful attempt at closed reduction, open reduction and internal fixation with a tension band construct using two 1.5 mm Kirschner wires and a 20-gauze stainless steel (SS) wire was done. Active assisted mobilisation was started 2 weeks postoperatively. At 2 months after the surgery, the child had regained unrestricted and painless elbow movements. All the wires were removed at 6 months. Anterior transolecranon-fracture dislocation of the elbow is an extremely rare entity with only 11 cases reported till date, none being from India. We, hereby, report new observation, discuss the mechanism of injury and management protocol for such cases, and highlight the causes of under-reporting and importance of early intervention and mobilisation.

Contiguous Three-Level Vertebral Collapse in Thoracic Spine: A Novel Presentation of Chronic Recurrent Multifocal Osteomyelitis in 12 years old and Review of Literature.

Introduction: Chronic recurrent multifocal osteomyelitis (CRMO) is a rare autoimmune disorder of childhood and adolescence which often manifests as recurring episodes of inflammatory bone pains. Spinal involvement is rare; however, recent studies advocate full body magnetic resonance imaging in all suspected cases to pick up asymptomatic lesions early to prevent complications. Spinal involvement may manifest as fractures, scoliosis, or kyphotic deformity. Case Report: We present a case of a 12-year-old boy who had three-level involvement of thoracic spine, T6-T8, and was worked up and managed for pathological fracture of spine. He underwent biopsy for the same and was later diagnosed as CRMO. Here, we discuss the diagnostic challenges involved in CRMO, need for biopsy, and the management options available. Conclusions: Identifying CRMO is challenging and remains a diagnosis of exclusion. Nonsteroidal anti-inflammatory drugs often constitute the first line of treatment and other drugs such as bisphosphonates and biologics such as TNF-alpha antagonists are reserved for more severe cases. Although CRMO is considered a benign disease, recent data suggest up to 50% rate of residual impairments despite optimal management.

Lateral lumbar interbody fusion in adult spine deformity - A review of literature.

INTRODUCTION: Surgery for adult spine deformity presents a challenging issue for spinal surgeons with high morbidity rates reported in the literature. The minimally invasive lateral approach aims at reducing these complications while maintaining similar outcomes as associated with open spinal surgeries. The aim of this paper is to review the literature on the use of lateral lumbar interbody fusion in the cases of adult spinal deformity. METHODS: A literature review was done using the healthcare database Advanced Research on NICE and NHS website using Medline. Search terms were "XLIF" or "LLIF" or "DLIF" or "lateral lumbar interbody fusion" or "minimal invasive lateral fusion" and "adult spinal deformity" or "spinal deformity". RESULTS: A total of 417 studies were considered for the review and 44 studies were shortlisted after going through the selection criteria. The data of 1722 patients and 4057 fusion levels were analysed for this review. The mean age of the patients was 65.18 years with L4/5 being the most common level fused in this review. We found significant improvement in the radiological parameters (lordosis, scoliosis, and disk height) in the pooled data. Transient neurological symptoms and cage subsidence were the two most common complications reported. CONCLUSION: LLIF is a safe and effective approach in managing adult spinal deformity with low morbidity and acceptable complication rates. It can be used alone for lower grades of deformity and as an adjuvant procedure to decrease the magnitude of open surgeries in high-grade deformities.

Giant Cell Tumor of the Calcaneus.

A 17-year-old female presented to us with pain and swelling in the right heel. Examination revealed the swelling to be tender, hard and fixed to the calcaneus. Radiographs showed an expansile, lytic lesion of the calcaneus with well-defined margins and no extraosseus spread. A core biopsy was done which showed multinucleated giant cells in a sea of mononuclear stromal cells, suggestive of a giant cell tumour (GCT). Curettage and filling up of the defect with bone cement was done under anaesthesia. The patient was fully ambulatory three months after the surgery. At two-year follow-up, the patient continued to be asymptomatic and radiographs revealed no signs of recurrence. It is important to note that GCT can occur in these rare sites and unusual age groups, and hence requires a good level of awareness of the surgeon and adequate preoperative workup, including biopsy, before proceeding to the definitive treatment of the lesion. Considering its potential local aggressiveness, early intervention is necessary. The patient should be kept under regular follow-up to detect any recurrence or metastasis in early stage.