Reliability of Allen Ferguson classification versus subaxial injury classification and severity scale for subaxial cervical spine injuries: a psychometrics study.

STUDY DESIGN: A psychometrics study. OBJECTIVES: To determine intra and inter-observer reliability of Allen Ferguson system (AF) and sub-axial injury classification and severity scale (SLIC), two sub axial cervical spine injury (SACI) classification systems. SETTING: Online multi-national study METHODS: Clinico-radiological data of 34 random patients with traumatic SACI were distributed as power point presentations to 13 spine surgeons of the Spine Trauma Study Group of ISCoS from seven different institutions. They were advised to classify patients using AF and SLIC systems. A reference guide of the two systems had been mailed to them earlier. After 6 weeks, the same cases were re-presented to them in a different order for classification using both systems. Intra and inter-observer reliability scores were calculated and analysed with Fleiss Kappa coefficient (k value) for both the systems and Intraclass correlation coefficient(ICC) for the SLIC. RESULTS: Allen Ferguson system displayed a uniformly moderate inter and intra-observer reliability. SLIC showed slight to fair inter-observer reliability and fair to substantial intra-observer reliability. AF mechanistic types showed better inter-observer reliability than the SLIC morphological types. Within SLIC, the total SLIC had the least inter-observer agreement and the SLIC neurology had the highest intra-observer agreement. CONCLUSION: This first external reliability study shows a better reliability for AF as compared to SLIC system. Among the SLIC variables, the DLC status and the total SLIC had least agreement. Low-reliability highlights the need for improving the existing classification systems or coming out with newer ones that consider limitations of the existing ones.

Reliability assessment of AOSpine thoracolumbar spine injury classification system and Thoracolumbar Injury Classification and Severity Score (TLICS) for thoracolumbar spine injuries: results of a multicentre study.

PURPOSE: The aim of this multicentre study was to determine whether the recently introduced AOSpine Classification and Injury Severity System has better interrater and intrarater reliability than the already existing Thoracolumbar Injury Classification and Severity Score (TLICS) for thoracolumbar spine injuries. METHODS: Clinical and radiological data of 50 consecutive patients admitted at a single centre with a diagnosis of an acute traumatic thoracolumbar spine injury were distributed to eleven attending spine surgeons from six different institutions in the form of PowerPoint presentation, who classified them according to both classifications. After time span of 6 weeks, cases were randomly rearranged and sent again to same surgeons for re-classification. Interobserver and intraobserver reliability for each component of TLICS and new AOSpine classification were evaluated using Fleiss Kappa coefficient (k value) and Spearman rank order correlation. RESULTS: Moderate interrater and intrarater reliability was seen for grading fracture type and integrity of posterior ligamentous complex (Fracture type: k = 0.43 ± 0.01 and 0.59 ± 0.16, respectively, PLC: k = 0.47 ± 0.01 and 0.55 ± 0.15, respectively), and fair to moderate reliability (k = 0.29 ± 0.01 interobserver and 0.44+/0.10 intraobserver, respectively) for total score according to TLICS. Moderate interrater (k = 0.59 ± 0.01) and substantial intrarater reliability (k = 0.68 ± 0.13) was seen for grading fracture type regardless of subtype according to AOSpine classification. Near perfect interrater and intrarater agreement was seen concerning neurological status for both the classification systems. CONCLUSIONS: Recently proposed AOSpine classification has better reliability for identifying fracture morphology than the existing TLICS. Additional studies are clearly necessary concerning the application of these classification systems across multiple physicians at different level of training and trauma centers to evaluate not only their reliability and reproducibility, but also the other attributes, especially the clinical significance of a good classification system.

Antepartum surgical management of Pott's paraplegia along with maintenance of pregnancy during second trimester.

INTRODUCTION: The existing literature is limited and inconclusive regarding management of spinal tuberculosis with neurological deficit during advanced pregnancy. None of the previously published case series concerning this problem during the second trimester of pregnancy have explored the option of simultaneous surgical intervention for it along with maintenance of pregnancy. CASE REPORT: A 22-year-old woman with 26 weeks of pregnancy (2nd trimester) presented with upper back pain for the past 2 months, inability to move both lower limbs for the last 1 week, bladder and bowel dysfunction for the past 5 days (Frankel Grade B). Patient subsequently underwent MRI scan dorsal spine and the image findings were suggestive of spinal tuberculosis T2 level. After obstetric evaluation and opinion of the expectant mother, in view of extensive neurological deficit which progressed rapidly, decision was taken for surgical intervention along with maintenance of pregnancy. Patient was positioned in right lateral position after giving general anesthesia using double lumen endotracheal tube with lung isolation technique. Exposure was done using transthoracic third rib excision approach. Decompression was achieved by radical debridement at T2 vertebrae level followed by multiple rib strut grafts and stabilization with screw and rod construct between T1 and T3 vertebrae. Intra-operative measures including type of anesthesia, prevention of maternal hypotension, hypoxemia and hypothermia, and fetal monitoring by attending obstetrician were undertaken to maintain feto-maternal safety. Postoperative ultrasonography evaluation of the fetus revealed a normal study. Post-surgery histopathological evaluation of the surgical specimen confirmed tuberculosis infection and the patient continued anti-tubercular drug therapy for 9 months. She delivered a healthy girl child at 36 weeks of gestation by cesarean section. After about 14 months of postoperative follow-up, patient has completely recovered motor power with mild persistent sensory symptoms. She is self-voiding with mild constipation requiring occasional intermittent laxative use. Radiological improvements in comparison to the previous reports were also seen at the last follow-up. CONCLUSION: Although this is only a single case but being the first to our knowledge, the good results highlight the point that both surgical management and maintenance of pregnancy during second trimester complicated by Pott's paraplegia are possible, involving a multi-disciplinary team approach for optimal maternal and fetal outcome.

A case of severe and rigid congenital thoracolumbar lordoscoliosis with diastematomyelia presenting with type 2 respiratory failure: managed by staged correction with controlled axial traction.

INTRODUCTION: Congenital lordoscoliosis is an uncommon pathology and its management poses formidable challenge especially in the presence of type 2 respiratory failure and intraspinal anomalies. In such patients standard management protocols are not applicable and may require multistage procedure to minimize risk and optimize results. CASE DESCRIPTION: A 15-year-old girl presented in our hospital emergency services with severe breathing difficulty. She had a severe and rapidly progressing deformity in her back, noted since 6 years of age, associated with severe respiratory distress requiring oxygen and BiPAP support. She was diagnosed to have a severe and rigid congenital right thoracolumbar lordoscoliosis (coronal Cobb's angle: 105° and thoracic lordosis -10°) with type 1 split cord malformation with bony septum extending from T11 to L3. This leads to presentation of restrictive lung disease with type 2 respiratory failure. As her lung condition did not allow for any major procedure, we did a staged procedure rather than executing in a single stage. Controlled axial traction by halogravity was applied initially followed by halo-femoral traction. Four weeks later, this was replaced by halo-pelvic distraction device after a posterior release procedure with asymmetric pedicle substraction osteotomies at T7 and T10. Halo-pelvic distraction continued for 4 more weeks to optimize and correct the deformity. Subsequently definitive posterior stabilization and fusion was done. The detrimental effect of diastematomyelia resection in such cases is clearly evident from literature, so it was left unresected. A good scoliotic correction with improved respiratory function was achieved. Three years follow-up showed no loss of deformity correction, no evidence of pseudarthrosis and a good clinical outcome with reasonably balanced spine. CONCLUSION: The management of severe and rigid congenital lordoscoliotic deformities with intraspinal anomalies is challenging. Progressive reduction in respiratory volume in untreated cases can lead to acute respiratory failure. Such patients have a high rate of intraoperative and postoperative morbidity and mortality. Hence a staged procedure is recommended. Initially a less invasive procedure like halo traction helps to improve their respiratory function with simultaneous correction of the deformity, while allowing for monitoring of neurological deficit. Subsequently spinal osteotomies and combined halo traction helps further improve the correction, following which definitive instrumented fusion can be done.

Vertebral Artery Injury in Cervical Spine Fracture Dislocation: An Observational Study in a Tertiary Care Center.

BACKGROUND: The incidence of traumatic vertebral artery injury (VAI) associated with cervical spine trauma varies widely in published trauma series. The primary aim of this study was to determine the incidence of traumatic VAI in patients who suffered cervical spine injuries by means of routine magnetic resonance imaging, and the secondary objective was to identify any associations with injury mechanism, level of injury, and neurologic injury severity.  Materials and methods: A retrospective review was conducted on 96 patients who suffered cervical spine fracture dislocation with or without an associated spinal cord injury (SCI) in Indian Spinal Injuries Center (ISIC), New Delhi, India from January 2013 to April 2023. Cervical magnetic resonance imaging (MRI) was used to diagnose VAI. Patient's age, sex, cervical injury level, mechanism of injury, neurologic level of injury, association with foraminal fracture, facet dislocation, and clinical sequelae of vertebral artery injury were analyzed. RESULTS: In this study, of 96 patients who met the inclusion criteria, 18 patients (18.75%) had VAI on the MRI study. Thirteen (72.22%) of the eighteen patients had right-sided injuries, four (22.22%) had left-sided injuries, and one (5.55%) had bilateral injuries. There was an associated SCI in every VAI patient. VAI was significantly more common in patients who had ASIA A (61%, n = 11) and ASIA B (22%, n = 4) injuries, and no VAI was noted in neurologically intact patients (p<0.001). The incidence of VAI was higher in the flexion distraction type of injury (n = 12, 66%). The most commonly involved cervical spine injury level was C5-C6 (27%, n = 5), followed by 22% (n = 4) at C4-C5 and C6-C7 levels. About 27.8% (n = 5) of VAI was associated with foraminal fractures, and 72% (n = 13) of VAI was associated with facet dislocations, of which 44% (n = 8) were bifacetal and 28% (n = 5) were unifacetal dislocations. On clinical symptoms, only one (5.56%) patient had a headache, and 17 (94.4%) had no clinical features due to VAI. CONCLUSION: The incidence of traumatic vertebral artery disease is not very uncommon and requires careful and meticulous screening and management. Otherwise, complications like pseudoaneurysm, neurologic deficit, late-onset hemorrhage, infarction, and death can happen. Mostly, it is associated with high-velocity injuries and neurological injuries. MRI can be used as a good screening tool, which can be aided by a CT angiogram or digital subtraction angiography for confirmation. Proper pre-operative evaluation of vascular injury in cervical spine fracture dislocation is very important for patient counseling, patient management, and surgical planning.

DEXA and Imaging in Osteoporosis.

Background: Reduced bone density and increased fragility are hallmarks of osteoporosis, making the disease a major public health concern. The disease necessitates early diagnosis and appropriate therapy depend on an accurate evaluation of bone health. Essential tools for assessing osteoporosis include dual-energy X-ray absorptiometry (DEXA) and other imaging modalities. Methods: This chapter focuses on dual-energy X-ray absorptiometry (DEXA) and other imaging methods as essential tools for assessment of osteoporosis. The chapter also explores complementary imaging modalities that help overcome limitation of DEXA by providing insights into the microarchitecture and bone quality. Results: T-scores, used to categorise bone health, are determined by DEXA by comparing bone mineral density to age-matched standards. Bone mineral density (BMD) is the most common indicator of bone health; nevertheless, DEXA may misclassify bone health owing to reasons other than BMD. These constraints may be overcome with the use of complementary imaging methods, which provide information on the microarchitecture and quality of bone. The evaluation of bone structure is aided by high-resolution peripheral quantitative computed tomography (HR-pQCT), which produces precise 3D images of the trabecular and cortical bone compartments. Independent of traditional methods of gauging fracture risk, quantitative ultrasonography (QUS) uses an analysis of the characteristics of sound waves to determine bone health. Diagnostic precision is improved by magnetic resonance imaging (MRI) due to its ability to view bone marrow and trabecular structure without the use of ionising radiation. Discussion: New methods, such as the trabecular bone score (TBS), examine bone texture and provide more data on the likelihood of fracture than conventional DEXA. By modelling bone strength using imaging data, finite element analysis (FEA) provides a biomechanical viewpoint on breakage probability. These combined methods boost diagnostic accuracy and pave the way for individualised treatment plans. Imaging helps with therapy monitoring as well as diagnosis. By monitoring bone density and structure over time, therapy effectiveness or course corrections may be quickly identified. The availability of sophisticated imaging techniques and the standardisation of procedures provide obstacles not withstanding their advantages. Ongoing work is being done to solve these issues and standardise and disseminate these methods in a variety of contexts. Conclusion: The evaluation of osteoporosis is significantly aided by DEXA and other imaging methods. While DEXA is still the gold standard for diagnosing osteoporosis, other imaging techniques may shed light on bone health in greater detail. These methods improve fracture risk prediction and treatment assessment by providing information on bone architecture, quality, and strength. Integration of several imaging modalities shows potential for bettering osteoporosis therapy and patient outcomes as the field develops.

Unilateral Neurological Deficit Due to Spinal Epidural Hematoma Following Midline-Sparing Spine Surgery: A Case Report.

Symptomatic spinal epidural hematoma (SEH) is a rare but well-documented complication in spine surgery, often associated with risk factors such as abnormal coagulation parameters, low platelets, excessive epidural bleeding, and inadequate hemostasis. While bilateral SEH is frequently described in the literature, unilateral SEH following spine surgery is seldom reported. We present a unique case of a unilateral neurological deficit resulting from an SEH following midline-sparing spine surgery due to unilateral drain placement in an 80-year-old male patient without comorbidities and normal coagulation parameters. Subsequent evacuation of the hematoma was done leading to gradual recovery of neurology. This emphasizes the importance of bilateral drain placement in such midline-sparing spine surgeries. This report underscores the significance of early SEH diagnosis and intervention, providing valuable insights into preventive measures and the need for a high index of suspicion in managing this potentially debilitating complication.

A Computed Tomography-Based Assessment of the Anatomical Parameters Concerning S2-Alar Iliac Screw Insertion Using "Safe Trajectory Method" in Indian Population.

STUDY DESIGN: A retrospective computed tomography (CT)-based radiological analysis. PURPOSE: To obtain CT-based morphometric data for the S2 alar iliac (S2AI) screw in the Indian population presenting to School of Medical Sciences and Research, Greater Noida, we used the concept of "safe trajectory" by Pontes and his colleagues in a recent study. OVERVIEW OF LITERATURE: Although previous CT-based morphometric studies on the S2AI screw have been published for a variety of ethnic groups, morphometric data specifically for the Indian population are scarce. METHODS: We used the three-dimensional multiplanar reformatting software to conduct a retrospective CT analysis of 112 consecutive patients who met our exclusion criteria for various abdominal and pelvic pathologies. CT imaging planes were rotated between the S1 and S2 foramen until they matched the ideal S2AI screw trajectory, which was represented by the longest and widest iliac osseous channel observed in the axial CT section. Following the concept of a safe trajectory, S2AI screw morphometric parameters were measured on both sides of the pelvis using corresponding axial and sagittal CT images. RESULTS: In the sagittal and transverse planes on both sides of the pelvis, females had significantly higher screw trajectory angulation than males (p<0.001). On both sides of the pelvis, males had significantly greater iliac width, maximum screw trajectory length, and intrascrotal length than females (p<0.001). On both sides of the pelvis, the S2AI screw entry point in females was significantly deeper than in males from the skin margin (p<0.001). CONCLUSIONS: Based on our methodology, we discovered that the S2AI screw trajectory is significantly more caudal and lateral in females, the maximum screw length is sufficient for use in clinical practice regardless of gender, and that 8.5 mm or even larger screw diameters are feasible in the majority of the Indian population.

Introduction of a Novel "Segmentation Line" to Analyze the Variations in Segmental Lordosis, Location of the Lumbar Apex, and Their Correlation with Spinopelvic Parameters in Asymptomatic Adults.

STUDY DESIGN: Cross-sectional study. PURPOSE: This study aimed to understand the sagittal spinopelvic parameters, segmental lumbar parameters, and lumbar apex location in asymptomatic adults and analyze their correlations with each other. OVERVIEW OF LITERATURE: Roussouly and his colleagues reported that pelvic incidence (PI) influences the lower arc of lumbar lordosis, whereas Pesenti and his colleagues reported that PI influences only the proximal part of lordosis and not the distal part. Both studies have their shortcomings. METHODS: One hundred asymptomatic adult volunteers (mean age, 29.1±7.9 years; 69 males, 31 females) who satisfied the selection criteria were enrolled in this study. Standing antero-posterior and lateral whole spine and pelvis X-rays were performed, and the radiographic parameters were analyzed. We introduced a "segmentation line" bisecting the apical vertebra/disk to divide the upper arc of lumbar lordosis (ULL) and lower arc of lumbar lordosis (LLL). RESULTS: The mean PI was 48.02°, ULL 29.12°, LLL 16.02°, total lumbar lordosis (TLL) 45.14°, lumbar tilt angle 4.73°, and location of the apex of lumbar lordosis (LLA) 4.11°. The location of the lumbar apex moved higher as the PI increased. The PI was strongly positively correlated with the LLL (r =0.582, p <0.001) and TLL (r =0.579, p <0.001) but not with the ULL (r =0.196, p =0.05). The LLA was strongly positively correlated with the ULL (r =0.349, p <0.001), negatively with the LLL (r =-0.63, p <0.001), and not correlated with the TLL (r =-0.177, p =0.078). CONCLUSIONS: The PI influences the location of the lumbar apex, the LLL, and the TLL but not the ULL. The location of the lumbar apex significantly influences the segmental lordosis but not the TLL.

Radiographic Analysis of the Sagittal Alignment of Spine and Pelvis in Asymptomatic Indian Population.

STUDY DESIGN: This is a descriptive observational study. PURPOSE: The objective of this study is to analyze and document the sagittal alignment of the spine and pelvis in normal Indian adult volunteers and compare these parameters with the study population of other races and ethnicities. OVERVIEW OF LITERATURE: Given the importance of the spinopelvic parameters, there is a need to describe the parameters differentially in relation to the ethnicity of the studied individual. Very few reports have defined the normal physiological value. Ethnic differences are a significant factor not only when describing the anthropometric data but also when applying the findings to a different ethnic group. We have compared these values with other races and ethnicities so that we can know whether the principles of spinal fixation can be applied globally. METHODS: In total, 100 participants were studied by using their anteroposterior and lateral radiographic images of whole of pelvic and spinal area. Additionally, various spinal and pelvic parameters were also measured. Subsequently, the outcomes were analyzed with respect to age, sex, and body mass index (BMI). The correlation between different parameters and differences in these parameters between Indians and other races/ethnicities along with population groups were also analyzed. RESULTS: There was a significant increase in thoracic kyphosis (TK) from T1-T12 and T4-T12 with increasing age. Lumbar lordosis (LL), sacral translation (sagittal vertical axis), and pelvic tilt were significantly higher among females. Additionally, sacral slope (SS), pelvic incidence, C7 sagittal offset, and T9 sagittal offset were also higher in females. TK (T4-T12 and T1-T12), LL, SS, and pelvic incidence showed a significant correlation with BMI. As compared to European population, TK, segmental LL, and sacral translation were found to be significantly lesser in Indian population. CONCLUSIONS: There is a statistically significant difference between Indians and other races/ethnicities and population groups with respect to TK, LL, and sacral translation. The values obtained can be considered as the physiological normal values for Indian population. Importantly, these values can serve as the reference values for future studies.

Posterior Stabilization Without Neural Decompression in Osteoporotic Thoracolumbar Fractures With Dynamic Cord Compression Causing Incomplete Neurological Deficits.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: Management of osteoporotic vertebral compression fracture (OVCF) remains an unsolved problem for a spine surgeon. We hypothesize that instability at the fracture site rather than neural compression is the main factor leading to a neurological deficit in patients with OVCF. METHODS: In this study, the prospective data of patients with osteoporotic fractures with incomplete neurological deficits from January 2015 to December 2017 was analyzed in those who underwent posterior instrumented fusion without neural decompression. RESULTS: A total of 61 patients received posterior indirect decompression via ligamentotaxis and stabilization only. Of these 17 patients had polymethylmethacrylate (PMMA) augmented screws and in 44 patients no PMMA augmentation was done. The mean preoperative kyphosis was 27.12° ± 9.63°, there was an improvement of 13.5° ± 6.87° in the immediate postoperative period and at the final follow-up, kyphosis was 13.7° ± 7.29° with a loss of correction by 2.85° ± 3.7°. The height restoration at the final follow-up was 45.4% ± 18.29%. In all patients, back pain was relieved, and neurological improvement was obtained by at least 1 American Spinal Injury Association Impairment Scale in all except 3 patients. CONCLUSION: We propose that neural decompression of the spinal cord is not always necessary for the treatment of neurological impairment in patients with osteoporotic vertebral collapse with dynamic mobility. Dynamic magnetic resonance imaging is a valuable tool to make an accurate diagnosis and determine precise surgical plan and improving the surgical strategy of OVCF.

Thoracic myelopathy due to ossification of ligamentum flavum: a retrospective analysis of predictors of surgical outcome and factors affecting preoperative neurological status.

Despite good posterior decompression of thoracic myelopathy due to ossification of ligamentum flavum (OLF), recovery varies widely from 25 to 100%. Neurological status on presentation also varies widely in different patients. We, therefore retrospectively studied relation of various clinical and magnetic resonance imaging (MRI) parameters with preoperative neurological status and postoperative recovery in 25 patients who underwent decompressive laminectomy for thoracic myelopathy due to OLF. Patients were assessed using leg-trunk-bladder scores of JOA scale and recovery rate (RR) was calculated as RR = postoperative score - preoperative score/11 - preoperative score × 100. With Pearson's correlation, postoperative recovery rate (RR) significantly correlated with preoperative duration of symptoms, JOA score, sensory JOA score, canal grade, dural canal-body ratio (DCBR), intramedullary signal size (ISS), and intramedullary signal type (IST) on MRI. On MRI, two types of signal changes were identified: normal in T1/hyperintense in T2 representing cord edema and hypointense in T1/hyperintense in T2 representing cystic changes indicating lesser and higher grades, respectively. Presence or absence of signal changes did not correlate with postoperative recovery; but whenever present, ISS greater than 15 mm significantly compromised recovery. Multiple regression analysis (MRA) identified preoperative duration of symptoms and preoperative ISS as significant predictors of postoperative outcome. Based on MRA, we formulated a multiple regression equation to predict RR as Predicted RR = 83.4 + (0.1 × age in years) - (0.7 × preoperative duration of symptoms in months) + (1.5 × preoperative JOA score) + (0.2 × preoperative canal grade in percentage) - (2.5 × ISS in mm) - (1.5 × IST in grade). Though age, preoperative anal sensations, spasticity, canal grade, DCBR, ISS, and IST significantly correlated with preoperative neurological status, MRA identified ISS as most important factor determining preoperative neurological status. Preoperative duration of symptoms and developmentally narrow canal had no influence on preoperative neurological status. Patients with developmentally narrow canal showed significant correlation with younger age at onset of myelopathy. To conclude, only independent factor determining preoperative neurological status is ISS. Predictors of postoperative recovery are preoperative duration of symptoms and ISS. Postoperative recovery can be predicted by formulated equation.

An unusual complication of quadriparesis after trigger point injection: a case report.

ABSTRACT: Quadriparesis after intramuscular trigger point injections for myofascial pain syndrome has been rarely reported in the literature. A 37-year-old male patient presented with myofascial pain syndrome and was given trigger point injections in trapezius muscles under ultrasound guidance. The patient noticed weakness in all the 4 limbs at approximately 12 hours after the procedure, which gradually progressed to functional quadriplegia at the time of presentation to the emergency department. On examination, he had quadriparesis with no sensory involvement and superficial reflexes were normal. MRI screening of the whole spine was unremarkable, and MRI brain suggested an incidental granuloma, which could not explain his symptoms. Blood tests revealed severe hypokalemia (2.2 mEq/L) and deranged thyroid function tests. Immediate potassium correction with intravenous and oral potassium chloride was initiated, and the patient showed improvement within 6 hours of initiating correction. Stress of the procedure, use of steroids with mineralocorticoid effects such as methylprednisolone, or deranged thyroid function tests may have acted as triggers to precipitate hypokalemic paralysis in the patient. Knowledge of this complication is essential as prompt diagnosis and timely management of hypokalemia can result in complete resolution of the symptoms.

Computed Tomography-Based Feasibility Study of C1 Posterior Arch Crisscrossing Screw Fixation.

STUDY DESIGN: Retrospective radiographic analysis. PURPOSE: Posterior fixation of C1 using screws is the most popular technique among the various methods for C1 stabilization, but it places the surrounding neurovascular structures at risk. Approximately 20% of the population has an anomalous groove for the vertebral artery; therefore, salvage methods are necessary. Therefore, we analyzed the feasibility of a newer C1 posterior arch crisscrossing screw fixation technique and studied its feasibility in the Indian population on the basis of the anatomy of the C1 posterior arch. OVERVIEW OF LITERATURE: Multiple techniques have been described for C1-C2 fixation, such as wiring techniques, interlaminar clamps, transarticular screws, screw-plate/screw-rod system fixation, and hook-screw system fixation techniques, to provide rigid C1-C2 stability. However, although C1 fixation has evolved with time, it is not complication-free. METHODS: A 100 computed tomography (CT) scans of cervical spines with 1 mm slice thickness in the axial and sagittal sections obtained were randomly selected for the evaluation. Atlantoaxial anomalies due to trauma, deformities, infections, and tumors were excluded. All the images were measured for height of the posterior tubercle, width of the posterior arch, and length of the screw, and the screw projection angle was calculated. Demographic data were collected for all the subjects. RESULTS: Out of the 88 CT scans analyzed, the mean height of the posterior tubercle was 7.4 mm, wherein 84.09% exceeded 7 mm, and the width of the posterior tubercle was 5.4 mm, wherein 88.6% (n=78) had posterior arch width >3.5 mm. A total of 13.6% (n=12) vertebrae were not suitable for screw placement, whereas 75% (n=66) vertebrae could accommodate 3.5×15 mm or longer screws. The screw projection angles ranged from 11.2° to 35° on the right and from 15.6° to 38.2° on the left. CONCLUSIONS: C1 posterior arch screw fixation is a feasible and safe method because it poses little risk of injury to the surrounding neurovascular structures.

Degenerative cervical myelopathy: Recent updates and future directions.

Advances in patient selection, surgical techniques, and postoperative care have facilitated spine surgeons to manage complex spine cases with shorter operative times, reduced hospital stay and improved outcomes. We focus this article on a few areas which have shown maximum developments in management of degenerative cervical myelopathy and also throw a glimpse into the future ahead. Imaging modalities, surgical decision making, robotics and neuro-navigation, minimally invasive spinal surgery, motion preservation, use of biologics are few of them. Through this review article, we hope to provide the readers with an insight into the present state of art in cervical myelopathy and what the future has in store for us.

Sexual and Bladder Dysfunction in Cauda Equina Syndrome: Correlation with Clinical and Urodynamic Studies.

STUDY DESIGN: Retrospective cohort study. PURPOSE: To analyze the clinical and sphincteric outcomes and the extent of sexual dysfunction (SD) in subjects with cauda equina syndrome (CES) and to assess their correlation with patient-reported and clinical/urodynamic parameters. OVERVIEW OF LITERATURE: Despite vast literature present for CES, extent of the problem of SD in CES patients has not received enough attention as reflected by the limited information in literature. Little is known about exact prevalence at presentation or about the recovery. A better understanding of SD and bladder dysfunction in CES secondary to lumbar disc herniation is essential as it commonly occurs in the sexually active age group. METHODS: All cases of cauda equine syndrome secondary to lumbar disc herniation were recruited. Biographical and clinical data, history, examination findings, operative variables, recovery, and SD were noted. Water cystometry and uroflowmetry were done pre- and postoperatively. The International Index of Erectile Function questionnaire and Female Sexual Function Index were used to assess SD among the men and women, respectively. RESULTS: A total of 43 patients with up to 2.94-year follow-up were included. Urodynamic studies were found to correlate significantly with age, days of bladder involvement, perianal numbness, and motor weakness (p<0.01). In step-wise regression analysis, perianal sensation and overall motor weakness were bladder function determinants. Bladder function recovery was directly related to the number of delay days (t=2.30, p<0.05) and with unilateral leg pain (t=2.15, p<0.05). Significant correlation between SD with age and days of bladder involvement before surgery was found (p<0.01). CONCLUSIONS: Surgery timing is related to patient's functional and sexual outcomes. Patients with unilateral leg pain and hypocontractile bladder have better outcomes. SD is a remarkable problem in CES.

Clinicoradiological outcomes of Goel and Harms fixation for atlantoaxial instability: An institutional experience.

BACKGROUND: Few studies have reported on the long-term outcomes of Goel and Harms C1-C2 fusions in the Asian population. METHODS: This was a retrospective analysis of 53 patients undergoing Goel and Harms fixation (2010 -2018). Clinical outcomes were assessed utilizing the neck disability index (NDI), Japanese Orthopedic Association (JOA) score, and visual analog scale (VAS). Outcomes were then correlated with fusion rates (using dynamic X-rays), atlanto-dens interval (ADI), and space available for cord (SAC) data. RESULTS: The study's 53 patients averaged 49.98 years of age and included 42 males and 11 females. The mean preoperative versus postoperative scores on multiple outcome measures showed NDI 31.62 ± 11.05 versus decreased to 8.68 ± 3.76 post, mean JOA score (e.g., in 41 patients with myelopathy) improved from 13.20 ± 3.96 to 15.2 ± 2.17, and the mean VAS decreased from 4.85 ± 1.03 to 1.02 ± 0.87 and showed restoration of the ADI (1.96 ± 0.35 mm) and SAC (20.42 ± 0.35 mm). A 98.13% rate of C1-C2 fusion was achieved at 12 postoperative months. CONCLUSION: Goel and Harms technique for C1-C2 fusion resulted in both good clinical and radiological outcomes.

Severe Pott's Kyphosis in a 19-Month-Old Child: Case Report and Review of Literature.

BACKGROUND: Spinal osseous tuberculosis, or Pott's spine, although very common in endemic countries, has a lower incidence in very young children. However, the infection has the propensity to cause greater vertebral destruction in this age group, leading to severe structural kyphotic deformity and associated neurologic deficits. We report the case of a 19-month-old child with severe tubercular kyphotic deformity of the upper thoracic spine managed with posterior vertebral column resection (VCR) and nonfusion posterior pedicle screw instrumentation. CASE DESCRIPTION: This 19-month-old boy presented with 1-month history of spontaneous-onset, progressive, painful rigid kyphotic deformity of the upper back associated with spastic paraparesis with bowel and bladder incontinence. Magnetic resonance imaging showed severe destruction of bodies of D4-D7 vertebrae with cord edema and draping of the spinal cord over the internal gibbus at D4-D7. Surgery was performed with a restricted anterior fusion via single-stage posterior VCR at D4-D7 with nonfusion pedicle screw instrumentation from D1 to D9, with subsequent extension of instrumentation to D10 after 4 months. CONCLUSIONS: Multilevel posterior VCR with a restricted fusion and nonfusion pedicle screw instrumentation beyond the resection site can be safely done in young children (age <3 years) requiring rigid tubercular kyphotic deformity correction. However, these patients require regular follow-up and may need multiple surgeries.

Intradural Disc a Diagnostic Dilemma: Case Series and Review of Literature.

INTRODUCTION: We present a case series of six cases of intradural disc herniation at L4-L5 level diagnosed on the basis of intraoperative findings. RESULT: All our cases, on preoperative magnetic resonance imaging (MRI) were reported as having diffuse annular bulge with large posterocentral extrusion. Our study comprised patients in age group of 30-60 years. Four cases out of six presented with cauda equina syndrome. In three cases, cauda equina was associated with sudden deterioration in the power of lower limb muscle groups. DISCUSSION: We suspect that intradural herniation of disc was synchronous with cauda equina syndrome in these cases, which was very well documented in one of the cases. On retrospective analysis, MRI findings of mass effect in the form of displacement of the traversing nerve roots due to large central disc with crumble disc sign were suggestive of early evidence of intradural disc herniation. Y sign in ventral dura due to splitting of ventral dura and arachnoid mater by disc material was a good diagnostic sign to suspect intradural extra-arachnoid disc. The presence of hypointense structure inside the dura with no continuity with the adjacent intervertebral disc on MRI was highly suggestive of an intradural disc. CONCLUSION: Intradural disc prolapse remains a diagnostic dilemma as it is very difficult to diagnose all the cases preoperatively. The presence of above-mentioned radiological signs on MRI in patients having the large central disc on MRI, especially at L4-L5 levels, should raise suspicion of intradural herniation of disc.

Aortic Rupture During Surgical Management of Tubercular Spondylodiscitis.

Aortic rupture is a rare but possible complication during spine surgery. It may manifest as severe intraoperative hemorrhage or present in a delayed manner after the formation of an aneurysm or an arteriovenous fistula. Though it is commonly encountered during anterior surgeries involving the surgical field close to the thoracic or abdominal aorta, it can also occur during a posterior surgery. Aortic injury could be associated with surgeries ranging from the commonly performed pedicle screw instrumentation to a complex three-column osteotomy. It can also occur, as in the reported case, while performing complex procedures in the presence of a pre-existing aneurysm or aortic adhesions due to coexisting infectious or inflammatory pathologies. The treatment options for such aortic ruptures range from open repair to endovascular stenting techniques. We discuss a case of an aortic rupture that occurred during a posterior vertebral column resection (PVCR) procedure performed on a 58-year-old female with spastic paraparesis secondary to tuberculous spondylodiscitis and the lessons learnt.