Comprehensive Spinal Tuberculosis Score: A Clinical Guide for the Management of Thoracolumbar Spinal Tuberculosis.

STUDY DESIGN: A newly proposed scoring tool was designed to assist in the clinical management of adult thoracolumbar spinal tuberculosis (TB). PURPOSE: To formulate a comprehensive yet simple scoring tool to guide decision-making in the management of adult thoracolumbar spinal TB. OVERVIEW OF LITERATURE: Spine surgeons have differing consensus in defining the threshold grade for clinico-radiological parameters when deciding between operative or conservative treatment for adult thoracolumbar spinal TB. Currently, the void in decision-making from the lack of well-defined guidelines is compensated by the surgeon's experience in treating these patients. To the best of our knowledge, no scoring system holistically integrates multiple facets of spinal TB to guide clinical decision-making. METHODS: The RAND/University of California, Los Angeles appropriateness method was employed among an expert panel of 10 spine surgeons from four apex tertiary care centers. Vital characteristics that independently influenced treatment decisions in spinal TB were identified, and a scoring tool was formulated. Points were assigned for each component based on their severity. The cutoff scores to guide clinical management were determined from the receiver operating characteristic curve based on the retrospective records of 151 patients treated operatively or non-operatively with improved functional outcomes at the 1-year follow-up. RESULTS: The components of the comprehensive spinal TB score (CSTS) are pain, kyphosis angle, vertebral destruction, and neurological status. A score classification of <5.5, 5.5-6.5, and >6.5 was established to guide the patient toward conservative, conservative/ operative, and operative management, respectively. CONCLUSIONS: The CSTS was designed to reflect the essential indicators of mechanical stability, neurological stability, and disease process stabilization in spinal TB. The scoring tool is devised to be practical and serve as a common language in the spine community to facilitate discussions and decision-making in thoracolumbar spinal TB. The validity, reliability, and reproducibility of this tool must be assessed through multicenter long-term studies.

Impairments in pulmonary functions in paediatric spinal tuberculosis: a cross-sectional study.

PURPOSE: This study aimed to investigate the impact of vertebral column destruction and kyphotic deformity due to spinal tuberculosis on pulmonary functions in paediatric patients. METHODS: A cross-sectional study was conducted, involving 30 patients diagnosed with healed spinal tuberculosis, aged 7-18 years. Detailed radiographic measurements, including the level of involvement, kyphosis angle, Spinal Deformity Index (SDI), and drug-resistance status, were compared with various pulmonary function parameters. RESULTS: The mean age of the study group was 12.8 ± 2.7 years (range 7-17 years), consisting of 11 males and 19 females. Fourteen patients were managed conservatively and 16 were managed operatively. The mean SDI was 5.2 ± 4.7. The mean kyphotic angle was 31.3° ± 25.3. The average number of involved vertebrae was 2.6 ± 1.5. Pulmonary functions were classified as restrictive in 24 patients, normal in 4 patients, obstructive in 1 patient, and mixed in 1 patient. Multidrug-resistant tuberculosis (MDR-TB) was detected in 5 (16.7%) patients, while the remaining 25 (83.3%) patients were sensitive to conventional antitubercular drugs. The correlation coefficients between the percentage reduction in forced vital capacity (FVC) and kyphosis angle, SDI, and number of vertebrae were 0.4 (p = 0.026), 0.4 (p = 0.028), and 0.19 (p = 0.295), respectively. The mean percentage reduction in FVC and total lung capacity (TLC) were 35.8 ± 15.7 and 6.2 ± 2.3, respectively. No significant association was observed between pulmonary functions and drug sensitivity status (p = 0.074). CONCLUSIONS: Paediatric spinal tuberculosis can lead to thoracic insufficiency due to progressive destruction and shortening of the spinal column, spinal growth inhibition, and kyphotic deformity. Management of these cases should focus on promoting normal lung development while ensuring disease resolution and deformity correction. Further research should explore growth conserving or growth guiding systems to address or prevent growth retardation and simultaneously provide spinal stabilization.

Tibial lengthening for massive distal femoral bone loss.

A man in his 30s was involved in a road traffic accident (RTA) and sustained a grade-IIIA distal femur fracture with acute loss of distal two-third of the femur. Initially, damage control surgery was done by an external fixator application. Later, staged limb reconstruction surgery was undertaken as a definitive procedure that involved bifocal distraction osteogenesis involving the proximal tibia and femur along with docking of the corticotomised femoral fragment onto the tibial plateau to achieve knee arthrodesis. The tibial and femoral regenerate together measured 25.8 cm at the end of distraction phase leaving behind a limb length discrepancy of 5 cm. Acute traumatic large bone loss is a rare presentation and is beset with unique management challenges. Limb reconstruction surgery (LRS) with LRS system provides flexibility to tackle individual case-based scenarios and helps achieve limb length, maintain alignment and restore function.

Perineal injuries in patients with complex femoral fractures operated on a fracture table using traction and counter traction: A case series and review of the literature.

Introduction: PA fracture table with a perineal post for counter traction is frequently used in the surgical treatment of lower limb fractures. Nevertheless, persistent use of the perineal post has been linked to serious side effects. We discuss our experience treating genitoperineal wounds due to traction table. Methods: During a month, our facility treated 3 patients who had genitoperineal injuries related to the usage of a traction table. We assessed the clinical appearance of these perineal injuries, the length of the operation, the treatment strategy, the clinical results, and the length of the hospital stay. Result: After surgery, partial thickness necrosis in the region including the scrotum and perineum developed in all patients. Two patients who had necrotic tissue infections received surgical debridement. In all cases, the wound healed fully with secondary intention by continued cleaning, dressing, and appropriate antibiotics. Conclusion: Genitoperineal skin necrosis caused by a perineal traction post necessitates surgical debridement and prolongs hospitalization. Orthopaedic surgeons should utilize several techniques such as proper perineal post diameter, length of surgery, positioning of the limb during surgery, etc. to lower the likelihood of this problem.

Correction: Short-Term Outcomes of Uncemented Bipolar Hemiarthroplasty Using Stainless Steel Fully Hydroxyapatite-Coated Stem in Transcervical Fracture of the Femur.

[This corrects the article DOI: 10.1007/s43465-023-00942-2.].

Short-Term Outcomes of Uncemented Bipolar Hemiarthroplasty Using Stainless Steel Fully Hydroxyapatite-Coated Stem in Transcervical Fracture of the Femur.

Background: Bipolar hemiarthroplasty is the standard of care for transcervical fracture in the elderly. Stainless steel being cheaper is preferred over titanium in developing nations for implants and prostheses. This study was conducted for assessing the short-term outcomes of uncemented bipolar hemiarthroplasty done using hydroxyapatite-coated stainless steel prosthesis. Methods: Sixty-five patients, >60 year of age operated between 2018 and 2020 at tertiary care centre with stainless steel (316L) completely coated with hydroxyapatite bipolar hemiarthroplasty implants were retrospectively followed up. Radiological outcomes were assessed based on pedestal formation, stem position, radiological limb length discrepancy, sinkage of stem, spot welds and stress shielding. Clinical and functional outcomes were assessed based on mean Harris Hip score. Results: Mean Harris Hip score at baseline, 3-week follow-up, 6-week follow-up, 3-month follow-up and 1-year follow-up was 45.9 (SD 2.5), 63.2 (SD 6.5), 75.1 (SD 9.9), 83.9 (SD 9.8) and 87.1 (SD 9.9), respectively. Excellent, good, fair, poor results were seen in 32.31, 40, 18.46, 9.23 of the patients, respectively. Valgus, central and varus stem position was seen in 49.23, 40, 10.77 percent of the patients, respectively. Pedestal formation, radiological limb length discrepancy, sinkage, spot welds, stress shielding was seen in 6.15, 32.31, 3.07, 53.85, 40 percent of the patients, respectively. Conclusion: Short-term outcomes of this study provides evidence that using a more affordable fully hydroxyapatite-coated stainless steel prosthesis for uncemented bipolar hemiarthroplasty is an appropriate treatment option for the transcervical femur fracture.

Subacute Bacterial Infection Mimicking a Slipped Capital Femoral Epiphysis in an Obese Adolescent Male - A Case Report and Review of Literature.

Introduction: Atypical and subacute presentations of pediatric bacterial septic arthritis are difficult to diagnose due to lack of systemic manifestations and inadequate laboratory data. Furthermore, they may mimic certain well-documented pediatric disorders to confound the diagnosis and management. Case Report: The authors present a case of an adolescent obese male with features suggestive of a slipped capital femoral epiphysis (SCFE). Further investigations revealed bacterial septic arthritis which may have contributed to the slip. He was treated with an initial debridement followed by a definitive pelvic support osteotomy (PSO) with a compensatory distal femoral varus osteotomy. At 12 months, he had a satisfactory clinical and radiological outcome. Conclusion: Clinicians should have a high degree of suspicion for infection in patients presenting with atypical clinical or radiological signs of SCFE. A thorough investigation in such cases is a must, to aid in correct management. PSO is an effective salvage procedure in adolescents with septic hip sequelae.

Proximal Thoracic Kyphoscoliosis with Dorsal Myelopathy in a Case of Congenital Absence of Thoracic Pedicles: A Case Report.

CASE: A 14-year-old boy with proximal thoracic kyphoscoliosis associated with the bilateral absence of thoracic pedicles presented with progressive deformity, paraparesis, and difficulty in ambulation. The case was managed by preoperative halo traction, single-stage 2-level vertebral column resection, decompression, and arthrodesis of thoracic vertebrae. Two years postoperatively, the patient showed neurological improvement, leading to unassisted ambulation and fusion at the corpectomy site. CONCLUSION: Preoperative halo-gravity traction restores the sagittal and coronal balance, improves the functional status of the patient, and corrects the deformity to some extent. 3D printed models help in better understanding of osseous anatomy and minimizing intraoperative time.

Functional outcomes in the management of cervicothoracic junction tuberculosis.

Background: We analyzed the clinical and radiological parameters influencing functional outcomes and neurological recovery in patients with cervicothoracic junctional tuberculosis (TB). Methods: This was a retrospective analysis of 16 cases of cervicothoracic junction (CTJ) spinal TB; 11 patients were managed operatively, while five were managed conservatively. Patients' outcomes were assessed at 1 month, 1 year, and yearly thereafter and included an analysis of multiple outcome scores, various radiographic parameters, and sensitivity or resistance to anti-tubercular therapy. Results: Patients averaged 25.94 years of age, and typically had three-level vertebral involvement. They were followed for a mean duration of 24 months, and the duration of anti-tubercular therapy averaged 17 months. Patients demonstrated clinical improvement on Japanese Orthopedic Association score and Neck disability index (P < 0.005) starting from 1 month following initiation of treatment which continued in subsequent follow-up, along with change in radiological parameters consisting of mean segmental kyphotic angle from 18.98° to 15.13°, C2-C7 SVA from 16.13 mm to 22.61 mm, T1 slope from 22.80° to 14.66°, thoracic inlet angle from 75.35° to 63.25°, neck tilt from 51.81° to 48.33°, and cervical lordosis from 4.66° to -0.44° (P > 0.05) at the end of 1 year. Conclusion: Tuberculous affection of the dynamic CTJ is a challenging scenario in clinical practice and its management involves consideration of disease extent, neurological status, and effort toward restoration of normal alignment of spine in sagittal and coronal plane to get favorable clinical outcomes.

Isolated L5 nerve root injury without osseous disruption in a case of gunshot injury to the paediatric spine-A case report.

INTRODUCTION: There exists sparse literature on Gunshot injuries (GSI) to the pediatric spine, its natural course, management protocols and outcomes following surgical intervention. Here, we present a projectile injury to the paediatric lumbar spine without any osseous disruption in a 5-year-old child requiring surgical management. CASE PRESENTATION: A 5-year-old child presented with a gunshot injury to the pediatric lumbar spine. On radiological imaging, there was no osseous disruption and an intraspinal canal projectile was embedded in an organised infected complex, compressing onto the left-sided L5 traversing nerve root with resultant grade 4 motor power of the left Extensor Hallucis Longus (EHL). Under fluoroscopic guidance using two separate mini-open incisions, the pellets were extracted. One from the spinal canal through left-sided L4 laminotomy and the other from the right paraspinal region. Post-surgical decompression and pellet retrieval there was gradual recovery to grade 5 motor power of Left EHL and improvement in the general condition of the child. CONCLUSION: The absence of osseous disruption can be attributed to the size of the projectile, widely spaced interlaminar spaces in the lumbar spine due to the absence of lumbar lordosis in the pediatric group and flexibility of the pediatric spine owing to its ligamentous laxity.

Evaluation of functional outcome and neurological recovery pattern in patients with retro-thecal tubercular epidural abscess managed at a tertiary center.

We performed a retrospective observational study to analyze the neurological recovery pattern in patients with a sub-laminar retro-thecal epidural abscess managed at our tertiary apex center from 2014 to 2020. We evaluated the Maximal Spinal Cord Compression (MSCC) ratio on Magnetic Resonance Imaging (MRI), the time interval between the appearance of neurological deficit and the initiation of management, spasticity as per Modified Ashworth Scale, presence of drug resistance, and the Lower Extremity Motor Score (LEMS). All patients were given anti-tubercular chemotherapy. We surgically managed 8 patients of which 6 required decompression alone, while 2 patients required additional instrumentation. 2 patients were managed conservatively of which 1 responded favorably to conservative treatment while the other patient showed a worsening of neurology following the detection of drug resistance and abrupt discontinuation of chemotherapy. The mean LEMS on admission was 20.2, which improved to 38.5 at the end of 1 year (p-value <0.05). The patients in whom the time interval between the onset of neurological deficit and the initiation of management was fewer than 6 weeks showed better LEMS and milder or absent spasticity at follow-up (p-value <0.05). The MSCC ratio did not have a significant correlation with the LEMS (p-value >0.05).

A rare case of an expansile spinopelvic aneurysmal bone cyst managed with embolization, excision, and fusion.

BACKGROUND: Aneurysmal bone cysts (ABC) are benign osteolytic lesions of the metaphyseal regions of long bones that typically contribute to rapid bony expansion. Here, we present an ABC involving the spinopelvic region in a 15-year-old male that required embolization, surgical excision, and fusion. CASE DESCRIPTION: A 15-year-old male, presented with gradually progressive painful lower back swelling of 4 months' duration. Once the diagnosis of an ABC was established based on a combination of X-ray, MR, and CT studies, he underwent selective arterial embolization, extended surgical excision (i.e. curettage), with a posterior fusion. Two years postoperatively, the patient remained neurologically intact without radiographic evidence of lesion recurrence. CONCLUSION: Large expansile ABC involving the vertebral bodies should be managed with preoperative selective arterial embolization, surgical decompression/curettage, and spinopelvic fixation.

Learning from Mistakes: Pancreatic Laceration: Devastating Complication During Spine Surgery.

BACKGROUND: Posterior decompression and fusion surgery is one of the most commonly performed surgeries for thoracolumbar tuberculosis with destruction of vertebral bodies. Tuberculosis causes gross destruction of the vertebral bodies and surrounding tissue, making them friable. CASE DESCRIPTION: We present an unusual but dreaded complication which we encountered during posterior decompression and instrumentation surgery in a 65-year-old woman with T10-11 tuberculosis of the spine. During surgical exposure, while reflecting posterior paraspinal muscles on the left side, there was an accidental slip of the Cobb elevator around the transverse process to the extent of two-thirds of its length on the left side anteriorly. The instrument was immediately withdrawn. There was no active bleeding in the field. The rest of the surgery was uneventful. In the postoperative period, however, the patient developed severe abdominal pain with abdominal distention. General surgery opinion was immediately taken and the patient was immediately investigated in the form of a computed tomography scan. It was found that there was a traumatic laceration of the pancreas. The patient underwent emergency exploratory laparotomy and repair of the pancreatic laceration. The patient required intensive monitoring and critical care unit stay and ultimately went on to recover fully over the next few weeks. CONCLUSIONS: This case illustrates the possibility of pancreatic injury should always be kept in mind if the patient develops acute abdominal discomfort in the postoperative period. Also, a multidisciplinary approach along with intensive care backup and vigilant postoperative monitoring is of utmost importance, especially when an unusual event has occurred during the surgery.

Multidrug-resistant tuberculosis of lumbosacral spine producing extensive destruction with lumbosacral kyphosis.

It is uncommon to get lumbosacral junction deformity due to tuberculosis. Lumbosacral junction alignment is of paramount importance in maintaining global sagittal balance. In this case report, we present a case of a 42-year-old woman with multidrug-resistant tuberculosis of lumbosacral spine with complete destruction of L3, L4 and L5 vertebra with partial destruction of L2 and S1 vertebra leading to significant shortening and lumbosacral kyphosis. The patient had severe axial low back pain, inability to sleep in supine position due to deformity and difficulty in walking due to loss of spinal alignment. The patient was treated with 6 weeks of antituberculous drugs followed by all posterior decompression with instrumentation from D10 to S2 with a reconstruction of anterior vertebral bodies with the help of an expandable cage. Antituberculous treatment was continued for 18 months. At present, the patient is asymptomatic with no neurological deficit and has completed 3.5 years of regular follow-up.