Role of Biochemical Nutritional Parameters as Predictors of Postoperative Morbidity in Major Spine Surgeries

Methods@#The values of serum albumin, prealbumin, total lymphocyte counts, and transferrin were documented preoperatively and postoperatively on day 5 for all patients undergoing major spine surgery (surgery involving instrumentation of at least three motion segments). In addition, patients’ surgical wound healing status, duration of hospital stay, and duration of ICU stay in the postoperative period were documented. Finally, the statistical correlation between the nutritional markers and these complications was determined. @*Results@#Low postoperative prealbumin levels was significantly associated with increased complication rates. ICU stay demonstrated a statistically significant association with low postoperative albumin, prealbumin, and transferrin levels. Similarly, we observed that low postoperative albumin and prealbumin levels could significantly predict the need for prolonged hospital stay in patients undergoing major spine surgery. @*Conclusions@#The magnitude of the decrease in nutritional status due to surgery with respect to albumin and prealbumin levels is a significant (p<0.05) predictor of wound-related complications, rather than a single nutritional parameter evaluated at a point of time.

Role of Biochemical Nutritional Parameters as Predictors of Postoperative Morbidity in Major Spine Surgeries

Methods@#The values of serum albumin, prealbumin, total lymphocyte counts, and transferrin were documented preoperatively and postoperatively on day 5 for all patients undergoing major spine surgery (surgery involving instrumentation of at least three motion segments). In addition, patients’ surgical wound healing status, duration of hospital stay, and duration of ICU stay in the postoperative period were documented. Finally, the statistical correlation between the nutritional markers and these complications was determined. @*Results@#Low postoperative prealbumin levels was significantly associated with increased complication rates. ICU stay demonstrated a statistically significant association with low postoperative albumin, prealbumin, and transferrin levels. Similarly, we observed that low postoperative albumin and prealbumin levels could significantly predict the need for prolonged hospital stay in patients undergoing major spine surgery. @*Conclusions@#The magnitude of the decrease in nutritional status due to surgery with respect to albumin and prealbumin levels is a significant (p<0.05) predictor of wound-related complications, rather than a single nutritional parameter evaluated at a point of time.

Does the Surgical Reduction of High Grade Spondylolisthesis Restore Spino-Pelvic Alignment? An Analysis of 35 Patients

Methods@#This is a retrospective case series of 35 patients with Meyerding grades III, IV, or V spondylolisthesis who underwent surgical treatment in our institution. Before and after surgery, we took standing lateral radiographs from L1 vertebra to pelvis, including the femoral heads, and measured the slip grade, pelvic incidence, sacral slope, pelvic tilt, lumbosacral angle, and lumbar lordosis. Patients were subdivided into “balanced” and “unbalanced” pelvis groups. To determine the effect and correlation of reduction on these spinopelvic parameters, we statistically compared the pre- and postoperative measurements. @*Results@#The average follow-up was 9 months (range, 3–169 months). Slip grade improved from an average 74.0%±13.2% to 30.0%±14.0% (p<0.001), and lumbosacral angle reduced from an average 32.0°±11.6° to 6.0°±0.6° (p<0.001). Although the pelvic tilt was reduced, this was not significant. There was a modest negative correlation between the reduction in slip grade and the increase in sacral slope (r=−0.3, p=0.06). At follow-up, five patients improved, from an unbalanced pelvis to a balanced pelvis. Fusion occurred in 33 patients (95%). @*Conclusions@#Surgical reduction of HGS restores the lumbosacral alignment. However, a similar trend is not noted with the pelvic parameters.

'Need of the Hour': Early Diagnosis and Management of Multidrug Resistant Tuberculosis of the Spine: An Analysis of 30 Patients from a “High Multidrug Resistant Tuberculosis Burden” Country

STUDY DESIGN: Retrospective study. PURPOSE: To report the prevalence of patients with multidrug-resistant (MDR) tubercular spondylodiscitis and their outcomes. Additionally, to assess the role of Xpert MTB/RIF assay in early detection of MDR tuberculosis. OVERVIEW OF LITERATURE: MDR tuberculosis is increasing globally. The World Health Organization (WHO) has strongly recommended Xpert MTB/RIF assay for early detection of tuberculosis. METHODS: From 2006 to 2015, a retrospective study was conducted on patients treated for MDR tuberculosis of the spine. Only patients whose diagnosis was confirmed using either culture and/or the Xpert MTB/RIF assay were included. Diagnostic method, treatment regimen, time taken to initiate second-line antituberculosis treatment (ATT), drug-related complications, and cost of medications were analyzed. All patients with MDR were treated according to the WHO recommendations for 2 years. The outcome parameters analyzed included clinical, biochemical, and radiological criteria to assess healing status. RESULTS: From 2006 to 2015, a total of 730 patients were treated for tubercular spondylodiscitis. Of those, 36 had MDR tubercular spondylitis (prevalence, 4.9%), and three had extremely drug resistant tubercular spondylitis (prevalence, 0.4%). In this study, 30 patients, with a mean age of 29 years and a mean post-treatment follow-up of 24 months, were enrolled. The majority (77%) had secondary MDR, 17 (56%) underwent surgery, and 26 (87%) completed treatment for 2 years and were healed. Drug-related complications (33%) included ototoxicity, hypothyroidism, and hyperpigmentation of the skin. The average time taken for initiation of second line ATT for MDR patients with Xpert MTB/RIF assay as the diagnostic tool was 18 days, when compared to patients for whom the assay was not available which was 243 days. CONCLUSIONS: The prevalence of MDR tubercular spondylodiscitis was 4.9%. In total, 87% of patients were healed with adequate treatment. The sensitivity and specificity of the Xpert MTB/RIF assay to detect MDR was 100% and 92.3%, respectively.

Non-Caseating Granulomatous Infective Spondylitis: Melioidotic Spondylitis

STUDY DESIGN: Retrospective clinical analysis. PURPOSE: To delineate the clinical presentation of melioidosis in the spine and to create awareness among healthcare professionals, particularly spine surgeons, regarding the diagnosis and treatment of melioidotic spondylitis. OVERVIEW OF LITERATURE: Melioidosis is an emerging disease, particularly in developing countries, associated with a high mortality rate. Its causative pathogen, Burkholderia pseudomallei, has been labeled as a bio-terrorism agent. METHODS: We performed a retrospective analysis of patients who were culture positive for B. pseudomallei. Assessment of patients was performed using clinical, radiological, and blood parameters. Clinical measures included pain, neurological deficit, and return to work. Radiological measures included plain radiography of the spine and magnetic resonance imaging. Blood tests included erythrocyte sedimentation rate and C-reactive protein levels. RESULTS: Four patients having melioidosis with spondylitis were evaluated. All of them had diabetes mellitus; three had multiple abscesses which required incision and drainage. Their clinical spectrum was similar to that of tuberculous spondylitis; all had back pain and radiology revealed infective spondylodiscitis with prevertebral and paravertebral collections with psoas abscess. Three patients underwent ultrasound-guided drainage of the psoas abscess and one had aspiration of the subcutaneous abscess. Bacteriological cultures showed presence of B. pseudomallei, and histopathology showed non-caseating granulomatous inflammation. All patients were treated with intravenous Ceftazidime for 2 weeks, followed by oral bactrim double strength and Doxycycline for 20 weeks. All patients improved with treatment and were healed at follow up. CONCLUSIONS: Melioidosis presents with a clinical spectrum similar to that of tuberculosis. A diagnosis of melioidotic spondylitis should be considered, particularly in patients with diabetes with neutrophilic leukocytosis and clinical-radiological features suggestive of infective spondylodiscitis. Bacteriological culture and histopathology helps in differentiating the two conditions. Health education for healthcare professionals is important for correctly diagnosing this disease.

Recurrent Lumbar Disc Herniation: Results of Revision Surgery and Assessment of Factors that May Affect the Outcome. A Non-Concurrent Prospective Study

STUDY DESIGN: Non-concurrent prospective study. PURPOSE: To determine the functional outcome after open 'fragment' discectomy for recurrent lumbar disc herniation, and to analyze the factors that may affect the outcome. OVERVIEW OF LITERATURE: Literature search revealed only four studies where the factors affecting the outcome of a revision surgery for recurrent disc herniation have been evaluated. None of these studies analyzed for diabetes, disc degeneration and facet arthropathy. We have analyzed these features, in addition to the demographic and clinical factors. METHODS: Thirty-four patients who underwent the procedure were followed up for an average period of 27.1 months. The Japanese Orthopaedic Association (JOA) score and Oswestry disability index (ODI) were used to assess the functional outcome. Age, gender, smoking, diabetic status, duration of recurrent symptoms, the side of leg pain, level and type of disc herniation, degree of disc degeneration on magnetic resonance imaging, and facet joint arthritis before first and second surgeries, were analyzed as factors affecting the outcome. RESULTS: The average Hirabayashi improvement in JOA was 56.4%. The mean preoperative ODI was 74.5% and the mean ODI at final follow-up was 32.2%, the difference being statistically significant (p<0.01). Patients with diabetes, all of whom had poor long term glycemic control, were found to have a poor outcome in terms of ODI improvement (p=0.03). CONCLUSIONS: Open fragment discectomy is a safe and effective surgical technique for the treatment of recurrent disc herniation. However, patients with uncontrolled diabetes may have a less favorable outcome.

The Extended Posterior Circumferential Decompression Technique in the Management of Tubercular Spondylitis with and without Paraplegia

STUDY DESIGN: Retrospective clinical series. PURPOSE: To study the clinical, functional and radiological results of patients with tuberculous spondylitis with and without paraplegia, treated surgically using the "Extended Posterior Circumferential Decompression (EPCD)" technique. OVERVIEW OF LITERATURE: With the increasing possibility of addressing all three columns by a single approach, posterior and posterolateral approaches are gaining acceptance. A single exposure for cases with neurological deficit and kyphotic deformity requiring circumferential decompression, anterior column reconstruction and posterior instrumentation is helpful. METHODS: Forty-one patients with dorsal/dorsolumbar/lumbar tubercular spondylitis who were operated using the EPCD approach between 2006 to 2009 were included. Postoperatively, patients were started on nine-month anti-tuberculous treatment. They were serially followed up to thirty-six months and both clinical measures (including pain, neurological status and ambulatory status) and radiological measures (including kyphotic angle correction, loss of correction and healing status) were used for assessment. RESULTS: Disease-healing with bony fusion (interbody fusion) was seen in 97.5% of cases. Average deformity (kyphosis) correction was 54.6% in dorsal spine and 207.3% in lumbar spine. Corresponding loss of correction was 3.6 degrees in dorsal spine and 1.9 degrees in the lumbar spine. Neurological recovery in Frankel B and C paraplegia was 85.7% and 62.5%, respectively. CONCLUSIONS: The EPCD approach permits all the advantages of a single or dual session anterior and posterior surgery, with significant benefits in terms of decreased operative time, reduced hospital stay and better kyphotic angle correction.

Gorham's Disease of Spine

Gorham's disease is a rare disorder characterized by clinical and radiological disappearance of bone by proliferation of non-neoplastic vascular tissue. The disease was first reported by Jackson in 1838 in a boneless arm. The disease was then described in detail in 1955 by Gorham and Stout. Since then, about 200 cases have been reported in the literature, with only about 28 cases involving the spine. We report 2 cases of Gorham's disease involving the spine and review related literature to gain more understanding about this rare disease.

Chondrosarcoma of the Spinous Process: A Rare Presentation

Chondrosarcomas are malignant cartilage forming tumours. They form the second most common primary malignant tumour involving the vertebral axis. We present a rare presentation of a secondary chondrosarcoma from the spinous process of lumbar vertebra and discussed its management. The main emphasis is on the rare presentation and the need for awareness and suspicion of the pathology.

The Use of Titanium Mesh Cages in the Reconstruction of Anterior Column Defects in Active Spinal Infections: Can We Rest the Crest?

STUDY DESIGN: Retrospective clinical series. PURPOSE: To assess whether titanium cages are an effective alternative to tricortical iliac crest bone graft for anterior column reconstruction in patients with active pyogenic and tuberculous spondylodiscitis. OVERVIEW OF LITERATURE: The use of metal cages for anterior column reconstruction in patients with active spinal infections, though described, is not without controversy. METHODS: Seventy patients with either tuberculous or pyogenic vertebral osteomyelitis underwent a single staged anterior debridement, reconstruction of the anterior column with titanium mesh cage and adjuvant posterior instrumentation. The lumbar spine was the predominant level of involvement. Medical co-morbidities were seen in 18 (25.7%) patients. A significant neurological deficit was seen in 32 (45.7%) patients. At follow up patients were assessed for healing of disease, bony fuson, and clinical outcome was assessed using Macnab's criteria. RESULTS: Final follow up was done on 64 (91.4%) patients at a mean average of 25 months (range, 12 to 110 months). Pathologic organisms could be identified in 42 (60%) patients. Forty two (60%) patients had histopathological findings consistent with tuberculosis. Thirty of 32 (93.7%) patients showed neurological recovery. The surgical wound healed uneventfully in 67 (95.7%) patients. Bony fusion was seen in 60 (93.7%) patients. At final follow up healing of infection was seen in all patients. As per Macnab's criteria 61 (95.3%) patients reported a good to excellent outcome. CONCLUSIONS: Inspite of the theoretical risks, titanium cages are a suitable alternative to autologous tricortical iliac crest bone graft in patients with active spinal infections.