Effect on functional outcome of robotic assisted rehabilitation versus conventional rehabilitation in patients with complete spinal cord injury: a prospective comparative study.

STUDY DESIGN: Prospective Comparative Study. OBJECTIVE: This study aims to compare the functional outcomes of Robotic-assisted rehabilitation by Lokomat system Vs. Conventional rehabilitation in participants with Dorsolumbar complete spinal cord injury (SCI). SETTING: University level teaching hospital in a hilly state of northern India. METHODS: 15 participants with Dorsolumbar SCI with ASIA A neurology were allocated to robotic rehabilitation and 15 participants to conventional rehabilitation after an operative procedure. Pre-and Post-rehabilitation parameters were noted in terms of ASIA Neurology, Motor and sensory function scores, WISCI II score (Walking Index in SCI score), LEMS (Lower Extremity Motor Score), SCI M III score (Spinal Cord Independence Measure III score), AO Spine PROST (AO Patient Reported Outcome Spine Trauma), McGill QOL score (Mc Gill Quality of Life score), VAS score (Visual Analogue Scale) for pain and Modified Ashworth scale for spasticity in lower limbs. RESULTS: On comparing robotic group with conventional group there was a statistically significant improvement in Robotic-assisted rehabilitation group in terms of Motor score (p = 0.034), WISCI II score (p = 0.0001), SCIM III score (p = 0.0001), AO PROST score (p = 0.0001), Mc GILL QOL score (p = 0.0001), Max velocity (p = 0.0001) and Step length (p = 0.0001). Whereas LEMS score (p = 0.052), ASIA neurology (p = 0.264 (ASIA A); 1.000 (ASIA B); 0.053 (ASIA C)), VAS score (p = 0.099), Sensory score (p = 0.422) and Modified Ashworth scale for spasticity (p = 0.136) were not statically significant when comparing between two groups. CONCLUSION: Robot-assisted rehabilitation is superior than conventional rehabilitation in people living with SCI with AIS A neurology. Differences in the patient group, type of a lesion its and severity, duration from onset to initiation of rehabilitation, devices employed, administration of the therapies and regulation of interventions are likely the cause of variations in the findings seen in the literature for robotic assisted training. LEVEL OF EVIDENCE: III.

Risk factors for ninety-day readmissions following full-endoscopic transforaminal lumbar discectomy for 1542 patients in the biggest spine institutes in Korea.

INTRODUCTION: Endoscopic techniques are becoming popular among spine surgeons because of their advantages. Though the advantages of endoscopic spine surgery are evident and patients can be discharged home within hours of surgery, readmissions can be sought for incomplete relief of leg pain, recurrent disc herniation, and recurrent leg pain. We aim to find out the factors related to the readmission of patients treated for lumbar pathologies. MATERIALS AND METHODS: This is a retrospective analysis of the data between the time duration of 2012 and 2022. Patients in the age group of 18-85 years, with lumbar disc herniation treated by transforaminal endoscopic lumbar procedures, were included. The patients who were readmitted within 90 days were included in the R Group and those who were not were included in the NR group. Univariable and multivariable logistic regression analyses were used to find the risk factors for 90-day readmission. RESULTS: There were a total of 1542 patients enrolled in this study. Sex, number of episodes before admission, hypertension, smoking, BMI, migration, disc height, disc height index, spondylolisthesis, instability, pelvic tilt (PT), and disc cross-sectional area (CSA) were found significant on univariable analysis. Age, spondylolisthesis, instability and muscle CSA were the only variables that were found to be statistically significant on multivariable analysis. CONCLUSIONS: This study shows that the elderly age group, presence of spondylolisthesis, segmental instability and decreased muscle cross-sectional area are independent risk factors for 90-day hospital readmissions. Patients having the above risk factors should be carefully counseled regarding the possibility of readmission in the future.

Simultaneous decompression of all stenotic regions versus decompression of only the most symptomatic region in patients with tandem spinal stenosis: a systematic review and meta-analysis.

PURPOSE: Selection of anatomic region of spine for decompression in patients with symptomatic tandem spinal stenosis (TSS) remains a challenge due to the confusing clinical presentation as well as uncertain evidence. A systematic review and meta-analysis of observational studies were conducted to compare the outcomes between simultaneous decompression of all stenotic regions (cervical and lumbar, Group 1) and decompression of only the most symptomatic stenotic region (cervical/lumbar, Group 2) in patients with TSS. METHODS: A systematic review was conducted, and a comprehensive literature search with well-established inclusion and exclusion criteria with JOA score as an outcome measure was done on PubMed, Google Scholar, and EMBASE database (till January 2021). Observational studies reporting outcomes after simultaneous decompression or only the most symptomatic region were included. NIH quality assessment tool was used to check the quality of each study, and treatment effects were calculated using Dersimonian and Laird random effects model. RESULTS: Ten studies were included in the analysis out of which all were retrospective observational studies (Level 4 evidence) except one (Level 3 evidence). Overall proportional meta-analysis showed no significant difference in change in JOA scores, operative time, blood loss, total and major complications between Group 1 and Group 2. However, minor complications were significantly increased on performing decompression of both regions simultaneously (p = 0.04). On performing subgroup analysis comparing cervical surgery cohort with lumbar surgery cohort, no difference was found in change in JOA score and requirement of second-stage surgery. CONCLUSION: Decompression of the most symptomatic region alone irrespective of its location has equal clinical outcomes with less complication rate than simultaneous decompression in patients with TSS.

Conundrum in surgical management of three-column injuries in sub-axial cervical spine: a systematic review and meta-analysis.

STUDY DESIGN: Systematic Review and Meta-analysis. PURPOSE: Three-column injuries making the spine unstable require adequate fixation which can be achieved by anterior alone, posterior alone or combined anterior-posterior approach. There is no general consensus till date on a single best approach in sub-axial cervical spine trauma. This study comparing the three approaches is an attempt to establish a firmer guideline in this disputed topic. MATERIAL AND METHODS: The protocol was registered with PROSPERO. PubMed, Embase and Google Scholar were searched for relevant literature. For each study, pre-defined data were extracted which included correction of kyphosis, loss of correction, hospital stay, operative time, blood loss during surgery as the outcome variables. Studies were also screened for the complications. RESULTS: Eleven studies were evaluated for qualitative analysis and quantitative synthesis of the data in our review. The result demonstrated significant difference with most correction achieved in combined approach subgroup. Though no significant difference was found, the anterior group was having maximum loss of correction. Combined approach showed significantly more operative time and blood loss followed by posterior approach and then anterior approach alone. The improvement in VAS was significantly more in anterior subgroup when compared to combined approach. CONCLUSION: Cervical alignment is best restored by combined approach compared to the other two. Anterior only approach showed more correction than posterior approach. However, there is no significant difference between all three approaches in loss of correction at long-term follow-up. Anterior only approach is superior to posterior and combined approach on basis of intraoperative and perioperative parameters. LEVEL OF EVIDENCE I: Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

Is detethering necessary before deformity correction in congenital scoliosis associated with tethered cord syndrome: a meta-analysis of current evidence.

PURPOSE: To compare the clinical and radiological outcomes in patients with congenital scoliosis (CS) and tethered cord syndrome (TCS) undergoing deformity correction with (NI group) versus without (NNI group) prior neurosurgical intervention aimed at detethering the cord. METHODS: A systematic review and meta-analysis were performed. The databases PubMed, Embase and Google Scholar were searched until March 2020. Inclusion criteria was studied describing performance of deformity correction and fusion surgery for congenital scoliosis with tethered cord syndrome with or without prior detethering procedure. Studies describing growth sparing procedures or congenital scoliosis associated with non-tethering pathologies such as syrinx were excluded. Case reports and series with less than 10 subjects were also excluded. NIH quality assessment tool was used for assessing quality of individual study. RESULTS: Sixteen studies were included for analysis of which eight were found to be retrospective case series (level IV evidence) and retrospective case-control studies (level III evidence) each. Overall proportional meta-analysis found no significant difference in correction rate, operative duration, blood loss or complication rate between the NI and NNI groups. However, subgroup analysis performed after inclusion of only level III evidence studies revealed significantly lesser operative duration and blood loss with comparable correction and complication rate in NNI group. CONCLUSION: Deformity correction and fusion surgery may be performed safely and effectively in CS with TCS patients without the need of a prior detethering procedure.

Sociodemographic patterns of spinal tuberculosis patients from a tertiary care teaching hospital: A 5-year cross-sectional study.

Background: The distribution of spinal tuberculosis (STB) differs due to variations in lifestyles, socio-economic conditions, geographical locations, available medical services, and other factors. In the literature, very few studies have been done on demographic profile and morphological distribution of tuberculosis (TB) spine. We conducted this study to identify the disease distribution and various parameters affecting the disease in our area which caters to populations from both plains and hills. Materials and Methods: This was a cross-sectional study using 5-year retrospective data retrieved from medical records, Department of Orthopaedics of a tertiary care teaching hospital, from April 2015 to October 2020. The patient distribution was studied according to the different variables. Results: A total of 286 patients were enrolled in the study. Females amounted to 54.96% (n = 159) of the total and 46.1% (n = 127) were males. The mean age of the demographic group was 36.9 years (2.5-80 years) (±SD = 17.63). The majority (46.5%) of the patients were young adults in the age group (21-40 years). The majority of deficits were seen in the dorsal spine (n = 27) followed by multifocal contiguous lesions (n = 22). Among the patients having single-segment disease, 33.9% (n = 61) involved the lumbar spine and 28.7% (n = 52) involved the dorsolumbar spine. Multifocal Potts disease amounted to 36.25% (n = 105) of the total patients. Conclusions: Female preponderance was observed in our study. Involvement of the lumbar spine was the most common form involving single-segment disease followed by dorsolumbar, dorsal, and cervical spine. The multifocal contiguous type of affection of STB was found to be the most common type of STB.

Neglected Dorsal Proximal Interphalangeal Joint Dislocation Treated by Volar Plate Arthroplasty: A Case Series.

Chronic unreduced dislocations of the proximal interphalangeal joint are uncommon, and management principles for these injuries have not been defined. The dislocation can be volar or dorsal and closed reduction is rarely successful owing to soft tissue contractures. Treatment options in literature reviews for such rare injuries included open reduction of pip joint with volar plate arthroplasty, extension block pinning, hemi hamate arthroplasty, pip joint arthrodesis, Suzuki dynamic frame fixation, open reduction and repair of capsule and collateral ligaments with suture anchors. Few cases of amputation following treatment were even reported in literature emphasizing the role of meticulous soft tissue handling in such neglected cases of hand. We report six cases of neglected (more than three months old) dorsal dislocation of the PIP joint of the hand, treated with volar plate arthroplasty and extension block pinning. A functional range of motion with a stable joint can be achieved in such injuries with volar plate arthroplasty, as long as the articular cartilage is relatively preserved and bone loss is <30%.

Outcomes of Dorsolumbar and Lumbar Spinal Tuberculosis Treated by Minimally Invasive and Open Techniques: A Prospective Comparative Study.

Purpose of Study: To compare the outcomes of minimally invasive and open techniques in the surgical management of dorsolumbar and lumbar spinal tuberculosis (STB). Methods: Skeletally mature patients with active STB involving thoracolumbar and lumbar region confirmed by radiology (X-ray, MRI) and histopathological examination were included. Healed and mechanically stable STB, patients having severe hepatic and renal impairment, coexisting spinal conditions such as ankylosing spondylitis and rheumatoid arthritis, and patients unwilling to participate were excluded from the study. The patients were divided in to two groups, group A consisted of patients treated by MIS techniques and group B consisted of patients treated by open techniques. All the patients had a minimum follow-up of 24 months. Results: A total of 42 patients were included in the study. MIS techniques were used in 18 patients and open techniques were used in 24 patients. On comparison between the two groups, blood loss (234 ml vs 742 ml), and immediate post-operative VAS score (5.26 vs 7.08) were significantly better in group A, whereas kyphotic correction (16° vs 33.25°) was significantly better in group B. Rest of the parameters such as duration of surgery, VAS score, ODI score and number of instrumented levels did not show significant difference between the two groups. Conclusion: MIS stabilization when compared to open techniques is associated with significant improvement in immediate post-operative VAS scores. The MIS approaches at 2-year follow-up have functional results similar to open techniques. MIS is inferior to open techniques in kyphosis correction and may be associated with complications.

The Transaxillary Approach as a Direct Route in the Management of Upper Thoracic Spine Pathology: A Technical Note with Case Series.

This retrospective case series of prospective data aims to describe the transaxillary approach for the treatment of upper thoracic spine pathology. Various surgical techniques and approaches have been reported across the literature to address upper thoracic spine pathology, including the cervicothoracic approach, anterior transsternal approach, posterolateral approach, supraclavicular approach, and lateral parascapular approaches. These techniques are invasive. A minimally invasive, less morbid, and direct access approach to the pathology of the upper thoracic spine has not been reported in the literature. Patients with pathology affecting the first thoracic vertebra up to the sixth thoracic vertebra were classified into the upper thoracic spine group. Patients with pathology below the sixth thoracic vertebra were excluded. Patients not having a minimum follow-up of 12 months were also excluded. The study analyzed 18 patients. The mean preoperative modified Japanese Orthopedic Association score was 7.2±1.44, which improved to 10.16±1.2 (p<0.05). The majority (14/18) of the patients had an excellent outcome. Three patients had good outcomes, and one patient had a fair outcome. Five cases of intraoperative dural leak were recorded, and one patient had postoperative neurological deficit. The transaxillary approach is a safe, viable, muscle-sparing, and minimally invasive approach for ventral pathologies of the upper thoracic spine.

Full Endoscopic Transpedicular Technique in the Treatment of High Grade Down Migrated Herniated Disc: An Evaluation of Clinical Outcomes at 12 Months Follow-Up.

OBJECTIVE: High-grade migrated lumbar disc herniation (LDH) such as up-migrated and down-migrated discs are challenging pathologies to treat. High-grade migrated discs are usually sequestered and situated adjacent to the medial pedicle wall. This can be easily addressed if the pedicle is used as an access route. The authors present a retrospective case series of high-grade migrated LDH treated using a full endoscopic transforaminal approach. MATERIALS AND METHODS: This is a retrospective case series. The clinical outcomes in the patients were evaluated according to improvement in the symptoms as suggested by improvement in Visual Analog Score (VAS) and Oswestry Disability Index (ODI) scores in the immediate postoperative period and at the final follow-up. The radiological outcomes were evaluated using postoperative magnetic resonance imaging and computed tomography scans. After the data were collected and tabulated, descriptive statistics were used for continuous variables. The t test was used to determine the significance of changes in the VAS and ODI scores. Statistical significance was set at P < 0.05. RESULTS: Five patients underwent discectomy using the transpedicular technique, and the mean preoperative VAS scores for the back and leg were 7.2 ± 0.83 and 8.4 ± 0.54, respectively. The mean VAS scores at the final follow-up for the back was 0.2 ± 0.4 and 0 for the leg (P < 0.05). The mean preoperative ODI score was 72 ± 8.3, which improved to 6 ± 4.69 at the final follow-up (P < 0.05). All patients had a hospital stay of 1 day. CONCLUSIONS: The full endoscopic transpedicular approach is a good option for treating highly migrated LDH. Surgical planning, including pedicle morphometry and the angle of the approach, should be undertaken preoperatively for the best results.

Idiopathic spinal cord herniation with postoperative paraplegia-A case report.

Key clinical message: Spinal cord herniation is an uncommon diagnosis. There should be a high index of suspicion to diagnose spinal cord herniation when a patient presents with incomplete neurological deficits. Surgical repair of the hernia can have postoperative complications with new neurological deficits and they should be considered during the treatment. Abstract: A 37-year-old male presented with insidious onset upper back pain and altered sensations of pain and temperature over the right half of the body below the nipple for 2 months. MRI of the thoracic spine showed an anterolateral defect (left) at the level of T2-T3 vertebra. The defect was covered by a dural graft and the wound was closed with a drain On the 3rd postoperative day, neurological weakness progressed to paraplegia. Patient was treated by exploration and decompression of the hematoma. The deficits were completely recovered at one-month follow-up. Patients with spinal cord herniation and neurologic deficits when treated timely have good outcomes.

Deformity Correction with Interbody Fusion Using Lateral versus Posterior Approach in Adult Degenerative Scoliosis: A Systematic Review and Observational Meta-analysis.

This study was designed to systematically review and meta-analyze the functional and radiological outcomes between lateral and posterior approaches in adult degenerative scoliosis (ADS). Both lateral (lumbar, extreme, and oblique) and posterior interbody fusion (posterior lumbar and transforaminal) are used for deformity correction in patients with ADS with unclear comparison in this cohort of patients in the existing literature. A literature search using three electronic databases was performed to identify studies that reported outcomes of lateral (group L) and posterior interbody fusion (group P) in patients with ADS with curves of 10°-40°. Group P was further subdivided into minimally invasive surgery (MIS-P) and open posterior (Op-P) subgroups. Data on functional, radiological, and operative outcomes, length of hospital stay (LOHS), fusion rates, and complications were extracted and meta-analyzed using the random-effects model. A total of 18 studies (732 patients) met the inclusion criteria. No significant difference was found in functional and radiological outcomes between the two groups on data pooling. Total operative time in the MIS-P subgroup was less than that of group L (233.86 minutes vs. 401 minutes, p <0.05). The total blood loss in group L was less than that in the Op-P subgroup(477 mL vs. 1,325.6 mL, p <0.05). Group L had significantly less LOHS than the Op-P subgroup (4.15 days vs. 13.5 days, p <0.05). No significant difference was seen in fusion rates, but complications were seen except for transient sensorimotor weakness (group L: 24.3%, group P: 5.6%; p <0.05). Complications, such as postoperative thigh pain (7.7%), visceral injuries (2%), and retrograde ejaculation (3.7%), were seen only in group L while adjacent segment degeneration was seen only in group P (8.6%). Lateral approach has an advantage in blood loss and LOHS over the Op-P subgroup. The MIS-P subgroup has less operative time than group L, but with comparable blood loss and LOHS. No significant difference was found in functional, radiological, fusion rates, pseudoarthrosis, and complications, except for transient sensorimotor deficits. Few complications were approach-specific in each group.

Is it Safe to Save Levels and Choose the Lowest Instrumented Vertebra as Touched Vertebra While Selectively Fusing Lenke 1/2 Curves? A Proportional Meta-Analysis of Existing Evidence.

STUDY DESIGN: Meta-analysis. OBJECTIVE: To compare the clinical and radiological outcomes in patients with Adolescent Idiopathic scoliosis (AIS) treated by selective thoracic fusion (STF) with lowest instrumented vertebra (LIV) at touched vertebra (TV) vs stable vertebra (SV). METHODS: The databases PubMed, Embase and Google Scholar were searched until November 2020.Studies which had Lenke type 1 curves and Lenke type 2 curves in adolescent population treated by STF and which reported pre- and post-operative curve characteristics including correction percentage and complications were included. Studies which did not report the LIV selection, curve correction percentages and whose full text could not be acquired were excluded. RESULTS: Eight studies were included for analysis of which seven were found to be retrospective studies (level III evidence) and one was prospective study (level II evidence) each. Overall proportional meta-analysis found no significant difference in correction rate, total srs-22 scores, and complication rates. CONCLUSION: The evaluation of SV group and TV group as LIV for selective thoracic fusions in AIS reveals a comparable outcome in terms of curve correction, patient satisfaction scores and complication rates. The TV can be chosen safely as the LIV especially in type A and B Lenke 1&2 curves, as it saves more motion segments when compared to SV.

Is Final Fusion Necessary for Growing-Rod Graduates: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVES: The need for definitive fusion for growing rod graduates is a controversial topic in the management of Early-onset scoliosis (EOS) patients. The authors performed a systematic review and meta-analysis on the available literature to evaluate the outcomes of growing rod graduates undergoing final fusion or observation with implants in-situ. METHODS: An extensive literature search was carried out aimed at identifying articles reporting outcomes in growing rod graduates. Apart from the study characteristics and demographic details, the extracted data included Cobb's correction, trunk height parameters, and revision rate. The extracted data was analyzed and forest plots were generated to draw comparisons between the observation and fusion groups. RESULTS: Of the 11 included studies, 6 were case-control and 5 were case series. The authors did not find any significant difference between the 2 groups with respect to the pre-index and final Cobb's correction, T1-T12 or T1-S1 height gain in either over-all, or sub-analysis with case-control studies. The meta-analysis showed a significantly higher revision rate in patients undergoing a definitive fusion procedure. CONCLUSION: The current analysis revealed comparable outcomes in terms of correction rate and gain in the trunk height but a lesser need of revisions in observation sub-group. The lack of good quality evidence and the need for prospective and randomized trials was also propounded by this review.

Biomechanical analysis of Instrumented decompression and Interbody fusion procedures in Lumbar spine: a finite element analysis study.

Interbody fusions have become increasingly popular to achieve good fusion rates. Also, unilateral instrumentation is favored to minimize soft tissue injury with limited hardware. Limited finite element studies are available in the literature to validate these clinical implications. A three-dimensional, non-linear ligamentous attachment finite element model of L3-L4 was created and validated. The intact L3-L4 model was modified to simulate procedures like laminectomy with bilateral pedicle screw Instrumentation, transforaminal, and posterior lumbar interbody fusion (TLIF and PLIF, respectively) with unilateral and bilateral pedicle screw instrumentation. Compared to instrumented laminectomy, interbody procedures showed a considerable reduction in range of motion (RoM) in extension and torsion (6% and 12% difference, respectively). Both TLIF and PLIF showed comparable RoM in all movements with < 5% difference in reduction of RoM between them. Bilateral instrumentation showed a more significant decrease in RoM (> 5% difference) in the entire range of motion except in torsion when compared to unilateral instrumentation. The maximum difference in reduction in RoM was noted in lateral bending (24% and 26% for PLIF and TLIF, respectively), while the least difference in Left torsion (0.6% and 3.6% for PLIF and TLIF, respectively) in comparing bilateral with unilateral instrumentation. Interbody fusion procedures were found to be biomechanically more stable in extension and torsion than the instrumented laminectomy. Single-level TLIF and PLIF achieved a similar reduction in RoM with a < 5% difference. Bilateral screw fixation proved biomechanically superior to unilateral fixation in the entire range of motion except in torsion.

Neglected floating cervical spine fracture with myelopathy and Anderson lesion of D2 D3: report of an unusual case.

INTRODUCTION: The cervical spine is the most commonly affected region in traumatic spine injuries of patients with Ankylosing Spondylitis (AS), accounting for 75% of cases, followed by the thoracic and lumbar spine. The fracture may not be detectable in plain radiographs alone due to pre-existing kyphotic deformity with distorted anatomy and high-riding shoulders. CASE PRESENTATION: We present a case with a floating cervical spine following a trivial trauma injury and with cervical myelopathy symptoms. After posterior fixation of the cervico-thoracic spine, the patient improved with Nurick score and mJOA score improvement. After 6 months follow up the patient was walking without support, and myelopathy symptoms were negligible. DISCUSSION: In this patient, a posterior approach was performed. We obtained a rigid construct so that we were able to mobilize a patient on the very next day and his myelopathy symptoms improved with minimal postoperative complications.

Variability in Management Practices and Surgical Decision Making in Spinal Tuberculosis: An Expert Survey-Based Study.

STUDY DESIGN: Electronic survey-based study. PURPOSE: The aim of the study was to objectively review the variability in the prevailing treatment protocols and surgical decision making in the management of patients with spinal tuberculosis (TB) among spine surgeons with expertise in spinal TB across the country. OVERVIEW OF LITERATURE: A lack of good-quality evidence, ambiguities in the national spinal TB guidelines, and the demand for early rehabilitation and a better quality of life in patients with spinal TB has led to the emergence of various gray zones in the management of spinal TB. METHODS: Seventeen fellowship-trained spinal TB experts representing different geographical regions of India completed an online survey consisting of questions pertaining to the conservative management of spinal TB (antitubercular therapy) and 30 clinical case vignettes including a wide spectrum of presentations of spinal TB with no or minimal neurological deficit. The variability in the responses for questions and case wise variability with respect to surgical decision making was assessed using the index of qualitative variation (IQV). The average tendency to operate (TTO) was calculated for various groups of respondents. RESULTS: High variability was observed in all questions regarding conservative spinal TB management (IQV > 0.8). Among the 30 case vignettes, 14 were found to have high variability with respect to surgical decision making (IQV > 0.8). With respect to levels of fixation, all but two cases had poor or slight agreement. Younger age and practice in a government or tertiary care teaching hospital were factors associated with a higher TTO. CONCLUSIONS: Significant variability was detected in treatment practices for the management of spinal TB among experts. Most of the case vignettes were found to have significant heterogeneity with respect to surgical decision making, which reflects a significant lack of consensus and lacunae in literature.

Factors affecting urinary outcome after delayed decompression in complete cauda equina syndrome: "A regression model study".

PURPOSE: To evaluate the recovery of urinary functions and the factors predicting urinary recovery, following delayed decompression in complete cauda equina syndrome (CESR) secondary to Lumbar disc herniation (LDH). METHODS: Retrospective study evaluated 19 cases of CESR due to single-level LDH, all presenting beyond 72 h. Mean delay in decompression was 11.16 ± 7.59 days and follow-up of 31.71 ± 13.90 months. Urinary outcomes were analysed on two scales, a 4-tier ordinal and a dichotomous scale. Logistic regression analysis was used for various predictors including delay in decompression, age, sex, radiation, level of LDH, motor deficits, type and severity of presentation. Time taken to full recovery was correlated with a delay in decompression. using Spearman-correlation. RESULTS: Optimal recovery was seen in 73.7% patients and time to full recovery was moderately correlated with a delay in decompression (r = 0.580, p = 0.030). For those with optimal bladder recovery, mean recovery time was 7.43 ± 5.33 months. Time to decompression and other evaluated factors were not found contributory to urinary outcomes on either scales. Three (15.8%) patients had excellent, 11 (57.9%) had good, while 3 (15.8%) and 2 (10.5%) had fair and poor outcomes respectively. CONCLUSIONS: Occurrence of CESR is not a point of no-return and complete recovery of urinary functions occur even after delayed decompression. Longer delay leads to slower recovery but it is not associated with the extent of recovery. Since time to decompression is positively correlated with time to full recovery, early surgery is still advised in the next available optimal operative setting. LEVEL OF EVIDENCE: IV.

Correlation of spinopelvic parameters with functional outcomes in surgically managed cases of lumbar spinal tuberculosis- A retrospective study.

BACKGROUND: The advanced stage of vertebral involvement in spinal tuberculosis (STB) can cause vertebral body collapse, which leads to kyphotic deformity and paraplegia in severe cases. Surgery is indicated in patients having disabling back pain, progressive neurological deficit, and instability in spine despite conservative management. The derangement of lumbar parameters, especially the loss of lumbar lordosis has been found to cause functional deterioration in patients. With the current evidences in place, this study was done to evaluate the correlation between the restoration of lumbar lordosis, pelvic parameters, and functional outcome when posterior only approach was used to manage the lumbar STB. METHODS: Active Tuberculosis of lumbar vertebra (L1-S1) confirmed by radiology (X-ray, MRI) and histopathological examination were included. All the cases scheduled for surgery underwent radiographs, CT scan, and MRI scans. Lumbar lordosis and other pelvic parameters were calculated on X-rays. VAS scores and ODI scores were documented during the follow-up to assess functional well-being. RESULTS: A total of 33 (22 M:11 F) patients were included in the study. The mean lumbar lordosis pre-operatively was -22.84 ± 11.19° which was corrected to -37.03 ± 9.02° (p < 0.05) post-operatively. The pelvic tilt pre-operatively was 25.33 ± 6.75° which was corrected to 19.63 ± 5.84° (p < 0.05) post-operatively. The mean ODI improved from 84.33 ± 11.84 to 26.93 ± 8.74 (p < 0.05) at the final follow-up. The mean VAS score pre-operatively was 8.06 ± 1.27 which improved to 2.45 ± 0.93 (p < 0.05) in the post-operative period. CONCLUSION: The study found a strong negative correlation between ODI scores and lumbar lordosis and a strong positive correlation between pelvic tilt and ODI scores. But the correlation needs to be further studied and evaluated by a well-constructed study especially with a control group treated conservatively.

Management of Andersson lesions of spine: A systematic review of the existing literature.

Introduction: Andersson lesions also termed as aseptic spondylodiscitis, spinal pseudoarthrosis are known to occur in patients with ankylosing spondylitis. Trauma as well as inflammation has been cited as factors responsible for the causation of these lesions. A variety of surgical approaches have been described in the literature such as anterior, posterior, combined anterior and posterior, with or without reconstruction of the anterior column defect. Controversy still exists regarding the optimal management these lesions. Objective: To address the optimal method of management, levels of instrumentation, requirement of fusion and anterior instrumentation and general epidemiological profile of the patients with Andersson lesions. Materials and methods: An electronic search for studies on the surgical management of Andersson lesions of spine was performed. Quality assessment of the included articles was done by two independent authors according to the criteria used by researchers previously in systematic reviews. Results: Males were found to have an increased incidence with the thoracolumbar junction being the most common level. Posterior approach was the most favoured with reconstruction of the gap in the anterior column. Posterior osteotomy with correction of deformity was done commonly for an optimal healing environment. Instrumenting 2-3 levels above and below the lesion is favoured by most. Conclusion: Conservative management for Andersson lesions can be employed in the setting of acute trauma and stable fractures involving a single column. Surgical management of these lesions with a posterior long segment fixation and anterior column reconstruction is the favoured treatment in majority of the cases.