Thoracic Compressive Myelopathy in a Patient With Takayasu Arteritis.

Takayasu arteritis (TA), also known as occlusive thromboaortopathy, is a type of chronic inflammatory arteritis that primarily affects large vessels. Compressive thoracic myelopathy is a rare and distinct manifestation of TA. We present the case of a 60-year-old woman who developed gradually progressive spastic paraplegia over one year. Magnetic resonance imaging revealed a well-defined extra-dual, intensely enhancing ventrodorsal lesion with severe spinal cord impingement. The aortogram revealed dilatation of the aortic arch (with narrowing of arch vessels) and descending aorta, as well as a right paravertebral soft tissue mass at the D4 level. Given the likelihood of TA, the patient underwent decompressive laminectomy and spinal fusion due to severe spinal cord compression. The biopsy of the dural-based lesion revealed an inflammatory granuloma, and the patient was treated postoperatively with oral prednisolone and mycophenolate mofetil. After six months of immunotherapy, there was excellent neurological recovery and near-total resolution of the lesion.

Multidisciplinary Management of Primary Sacral Tumors: A Tertiary Care Center's Experience and Literature Review.

Sacral tumors are rare and can be benign or malignant. Their management is multifactorial and is based on the pathology, extent, and local and distant spread. Managing sacral tumors is challenging due to their proximity to visceral and neural structures. Surgical wide excision has been the standard of care for aggressive benign and malignant tumors. Our purpose was to evaluate the outcomes of a multimodal approach to managing primary sacral tumors in Sakra World Hospital, a tertiary spine care center in Bengaluru, India and perform a literature review to determine a workflow pathway. Our study was a retrospective review of patient records and included 15 patients with primary sacral tumors. Eleven surgically treated patients were evaluated clinically and radiologically and underwent biopsy before surgical excision by an all-posterior approach. A multidisciplinary approach that included intraoperative neural monitoring, plastic reconstruction, adjuvant chemotherapy, and radiotherapy was implemented whenever necessary. Sacral root preservation was attempted whenever feasible. Functional outcomes (based on the Visual Analog Scale [VAS] and Biagini scoring system) were analyzed along with disease control, with a minimum of 2 years of follow-up. The mean follow-up was 29±9.8 months. The mean VAS score significantly improved from 7.8±2.6 to 3.7±3.8 (p =0.026). Bowel function showed statistically significant improvement, from a mean score of 0.81±0.47 to 0.63±0.52 (p =0.026) at 2 years of follow-up. The mean pretreatment motor and bladder function scores were 0.53±0.31 and 0.74±0.44, respectively, improving to 0.48±0.33 and 0.68±0.56 at follow-up but without statistical significance. There was no significant loss of function, which is expected in radical sacral resections. In conclusion, primary sacral tumors require a multidisciplinary approach and management for optimal outcomes. A stand-alone posterior approach can be employed to treat most sacral lesions. En-bloc wide resection is the optimal treatment for primary malignant and aggressive benign tumors. Preservation of at least one functional S2 nerve root is imperative to preserve bowel and bladder function.

Distal Junctional Failure Secondary to Nontraumatic Fracture of Lower Instrumented Vertebra: Our Experience and Review of Literature.

BACKGROUND: Junctional kyphosis (JK) is usually observed in long-level instrumented fusion surgeries. Various contributing factors are proposed, the pre-existing and postoperative spinal imbalance is considered as the single most important factor for the development of JK in adult spinal deformity surgeries. Distal JK (DJK) is seldom reported compared to proximal JK (PJK), and scarce literature exists. METHODS: We report 2 unique cases of distal junctional failure (DJF) with worsening of neurology, secondary to nontraumatic fracture of a lower instrumented vertebra operated for thoracic canal stenosis without deformity. The first case had acute worsening of the Neurology during follow up and on evaluation, the supine CT and MRI scan revealed well decompressed spinal canal, no implant migration to the canal, no screw loosening, or rod failure. Supine sitting radiographs demonstrated DJK with Fracture and the patient underwent extension of fusion till the pelvis with 3-rod construct and interbody fusion, because of the instability at the L1 level.The second case remained neurologically stable for a month and then had an acute onset of back pain, sensory deficit, and urine incontinence. The supine-sitting dynamic radiograph done demonstrated L1 fracture with DJK at D12-L1 levels. The patient was counseled for extension of fusion, which was deferred by the patient. RESULTS: Patients in our series, had an acute worsening of neurological deficit within a month of posterior spinal fixation. Their supine imaging was almost normal, and the diagnosis of DJK with L1 fracture instability was possible only on a supine-sitting dynamic radiograph. Various factors like obesity, TL kyphosis, osteoporosis, etc. can be the attributing factors for the development of DJK CONCLUSION: A high index of suspicion is required for diagnosing nontraumatic fracture in long-level fusion patients with acute neurological worsening. The supine-sitting dynamic radiograph is an important diagnostic tool for DJF in patients having difficulty standing erect. LEVEL OF EVIDENCE: 4. CLINICAL RELEVANCE: Application of sitting and supine dynamic radiographs to diagnose instability in patients unable to stand for flexion and extension radiographs.

Unstable Hangman Fracture Complicated by Vertebral-Venous Fistula: Surgical Considerations and Review of Literature.

BACKGROUND: Hangman fracture or traumatic spondylolisthesis of the axis associated with a traumatic vertebral venous fistula (VVF) is a rare entity and sparsely reported in literature. Standard recommendations for management of such rare and complex scenarios are not available and hence the strategy has to be individualized on a case-by-case basis. METHODS: We report a 70-year-old man having an unstable hangman fracture with VVF. Both pathologies were simultaneously managed uniquely. The VVF was managed by endovascular occlusion. The fracture was managed by anterior fusion alone as posterior fusion was deemed riskier in the aftermath of a recently occluded VVF. The patient had good neck function and bony fusion at 1-year follow-up. CONCLUSION: This case report emphasizes the need for timely recognition and management of a VVF, which can rarely coexist with hangman fracture, and discusses the interesting surgical paradigms in the management. We also present a review of literature.

Multimodal Intraoperative Neurophysiological Monitoring in Spine Surgeries: The Experience at a Spine Centre through Years.

STUDY DESIGN: Retrospective observational study. PURPOSE: To share our experience of multimodal intraoperative neurophysiological monitoring (IONM) used in Sakra World Hospital, Bengaluru in various spine surgeries. OVERVIEW OF LITERATURE: The development of new onset postoperative neurological deficits can be completely avoided. In order to avoid these, IONM has become a standard of care in recent times for early detection and manipulation of the surgical procedure to prevent postoperative neurological deficits. METHODS: This retrospective study was performed on 408 patients who had undergone spine surgeries with IONM during April 2014 to March 2020 at a single center. The operative report, anesthesia record, and IONM were reviewed. All the patients were reassessed for postoperative neurological deficits in the postoperative period and followed up based on the intraoperative findings and neurological deficits for 4 weeks. Signal changes in IONM were reviewed, and the obtained results were further categorized into true positive, true negative, false positive, or false negative. If changes were observed during the IONM, the patients were managed as per the algorithm. RESULTS: Of the 408 patients being monitored continuously during the intraoperative period, 38 showed changes in recordings, 28 developed postoperative neurological deficits, and one developed neurological deficit without any change in the IONM. Nine patients had transient neurological deficits, and the other 20 had permanent neurological deficits. Overall, the multimodal IONM used in our study had a sensitivity of 96.6%, specificity of 97.4%, a positive predictive value of 73.7%, and a negative predictive value of 99.7%. CONCLUSIONS: Use of decision algorithm and multimodal neuromonitoring consisting of motor evoked potentials, somatosensory evoked potentials, and electromyography complement each other in the detection of neurological injury during the course the surgery, improve intraoperative care, and prevent further damage and morbidity in patients.

Is Transoral Surgery Still a Relevant Procedure in Atlantoaxial Instability?

BACKGROUND: The treatment of atlantoaxial instability (AAI) involves stable fixation and fusion with adequate decompression of spinal cord. After the advent of the Goel posterior joint manipulation technique, most of the once irreducible atlantoaxial dislocations (AAD) could be reduced and the need for transoral odontoidectomy became almost nil. Here we tried to iterate the indications of anterior transoral odontoid surgery for AAI in the current scenario. METHODS: A retrospective study compiling the clinical, radiological, and surgical characteristics of 6 cases (5 scenarios). These patients underwent anterior transoral surgery alone or in combination with a posterior approach. RESULTS: Two patients had a well-formed occipito-cervical fusion mass, with a displaced odontoid and unreduced C1-C2 joint causing cervical myelopathy. A middle-aged woman presented with unreduced AAD following failed C1-C2 joint distraction technique. A displaced dystopic os odontoideum ossicle was found in an adolescent boy, prohibiting the reduction of AAD. A young man had displacement of the fractured odontoid segment with intact transverse alar ligament and C1-C2 joint complex. One patient had a rare scenario of abnormal orientation of the C1-C2 joint. All 6 patients were successfully treated with adequate spinal cord decompression achieved by the anterior transoral route and stabilization by either the anterior approach itself or in combination with posterior surgery. All had significantly better postoperative outcomes except for 1 patient who expired due to poor respiratory reserve. CONCLUSION: We tried to emphasize the indications for using transoral anterior odontoid surgery over the posterior approach in the management of AAI. This will prevent the surgical technique of anterior odontoidectomy from becoming an obsolete procedure in the current practice.

Hydrocephalic Attack-An Uncommon Complication of Spine Surgery: A Case Series and Review of Literature.

BACKGROUND: Spinal pseudomeningocele refers to an abnormal accumulation of cerebrospinal fluid (CSF) in a fibrous sac without arachnoid lining that occurs mostly as a result of an accidental dural opening. When accidental dural openings are found intraoperatively, they should be repaired to prevent further complications. Sometimes inadequately dealt dural openings, unnoticed, or postoperative dural openings may produce complications. CASE DESCRIPTION: Three patients had complications as a result of spine surgery and presented several days after the surgery with episodic symptoms of raised intracranial pressure, including headache, opisthotonos, altered breathing patterns, and altered sensorium. These symptoms increased whenever pressure was applied on the operated area suggesting hydrocephalic attacks. All 3 patients had a giant pseudomeningocele at the operated area, a complication that resulted from the spine surgery. Magnetic resonance imaging CSF flow study revealed hyperdynamic flow and increase in absolute stroke volume across the cerebral aqueduct when constant pressure was applied on the pseudomeningocele sac. CONCLUSIONS: Usually pseudomeningoceles are asymptomatic, and if symptomatic, the common presentations are local swelling, back pain, radiculopathy, and orthostatic headache. To our knowledge, this is the first article in the literature reporting the uncommon presentation of hydrocephalic attacks in 3 cases subsequent to CSF backflow from the sac, confirmed with MRI CSF flow study. This case series emphasizes rare presentations can result from transiently increased intracranial pressure related to postoperative pseudomeningocele in spine surgeries.

Evolution of surgical techniques in the management of vertebral body tumours and the current status.

Primary vertebral body tumours constitute only about 5% of skeletal tumours. Their morbidity is high due to instability and neurological deficits related to the spine. The complex anatomy further highlights the expertise needed in their management. A multidisciplinary management has heralded tremendous improvements in the treatment of primary vertebral body tumours. From incomplete resection with a high recurrence of these tumours in the early 20th century, to the present day complete en-bloc excision of the tumours, guided by the well-established staging and classification systems, have been the significant changes brought about in the long course of treatment of these complex tumours. The overall results are better with radical excision in combination with adjuvant therapies. Complex and previously unimaginable surgical techniques are accomplished easily with a multi-disciplinary approach and with newer spinal instrumentation. Understanding of the evolution of surgical techniques and the prevalent classifications are essential in the surgical management of vertebral body tumours.

Lumbar pseudomeningocele presenting as decerebrate rigidity-A rare case entity.

INTRODUCTION: Spinal pseudomeningoceles are extradural collections of cerebrospinal fluid that result following a breach in the dural-arachnoid layer and is reported as one of the complications of lumbar disc surgery. Although they are often self subsiding and asymptomatic, they may occasionally cause low-back pain, headaches, and even nerve root entrapment. The purpose of this case report is to present an unreported presentation of pseudomeningocele PRESENTATION OF CASE: A 34 year obese male presented one month post lumbar discectomy with symptoms suggestive of raised intra cranial pressure presenting as repetitive decerebrate rigidity and altered sensorium lasting for few minutes when there is pressure on the pseudomeningocele sac and subsiding with change in position of the patient. He underwent surgical repair of the dural tear and was improved symptomatically with no recurrence of symptoms at five years follow up. DISCUSSION: Radiological investigation helped in ruling out the other causes of decerebrate rigidity and the possible mechanism of development of such symptom in pseudomeningocele is discussed. CONCLUSION: To the best of our knowledge, this is the first reported case of pseudomeningooele presenting as decerebrate rigidity. Spinal pseudomeningocele can present in varied ways and earliest detection is the key to avoid such complications.

Kyphoplasty for osteoporotic vertebral fractures with posterior wall injury.

BACKGROUND CONTEXT: Cement augmentation techniques are standard treatments for osteoporotic vertebral fractures. Compared with vertebroplasty, kyphoplasty is associated with lower rates of cement leak and better deformity correction; however, posterior wall fractures are relative, but not absolute; contraindications for both techniques and hence treatment practices vary among spine centers. PURPOSE: The primary aim of this study was to assess our center's incidence of posterior cement leakage in osteoporotic vertebral fractures with posterior wall injury treated by balloon kyphoplasty (BKP). Secondarily, physiological results, pain relief, complication rates, and non-posterior cement leakage were also evaluated. STUDY DESIGN: This is a prospective cohort study done in a high-volume spine center in Germany. PATIENT SAMPLE: Eighty-two patients with 98 osteoporotic vertebral fractures with posterior wall cortical injury were studied from 2012 to 2016. OUTCOME MEASURES: The following were the outcome measures: (1) physiological measures: standing plain x-rays (anteroposterior and lateral views), with the following parameters evaluated: cement leak behind the posterior vertebral body border, Cobb angle for local sagittal deformity, vertebral wedge angle, and anterior vertebral height; (2) cement volume injected in each vertebra; and (3) self-report measures: visual analog scale (VAS). METHODS: All patients underwent BKP using a bipedicular approach. Preoperative clinical and neurologic evaluations were done. Radiological evaluations included plain X-ray images, computed tomography scans and magnetic resonance imaging. The average follow-up period was 18 months. RESULTS: No cement leakage into the spinal canal occurred in any of the patients. Asymptomatic leakage into other sites was seen in 22 vertebrae (22.45%). There was significant improvement in the Cobb angle, the vertebral wedge angle, and the anterior vertebral height in all cases. The mean preoperative VAS was 8.1, and this improved to 2.3 on the third postoperative day. CONCLUSION: Balloon kyphoplasty is a viable option for the treatment of osteoporotic vertebral fractures even with posterior wall involvement.

Is the Cage an Additional Hardware in Lumbar Interbody Fusion for Low Grade Spondylolisthesis? A Prospective Study.

INTRODUCTION: Lumbar interbody fusion has become the standard of care for the management of lumbar instability, where fusion is achieved using bone grafts, cages, etc. AIM: The aim of the study was to compare the outcomes of the interbody fusion using interbody cage technique and stand alone local bone graft technique. MATERIALS AND METHODS: A total of 30 patients, operated for single level instability with low grade lytic and degenerative spondylolisthesis of L4-5/L5-S1, were selected and grouped into two groups: Group I (stand alone grafts) and Group II (interbody cage and graft) based on computer generated random numbers. All patients who underwent interbody fusion through conventional open posterior approach were included in the study. Data regarding the time taken for interbody fusion, formaninal height maintenance, disc height restoration, translation, functional scores (VAS,ODI) and operative complications were analysed using in both the groups was collected and a student's-t test was performed to evaluate the difference. RESULTS: The mean age of patients in Group I was 46.7 years whereas, the mean age of patients in Group II was 43.5 years with mean age of 46.7 years and 43.5 years respectively. Interbody fusion, was achieved in seven and eight months in Group I and II respectively (p>0.05). The clinical results of both groups were comparable and there was no significant difference between the two groups in VAS score (p-0.147) and ODI score (p-0.983). Radiological parameters were also comparable and there was no significant difference between the postoperative measurements of the two groups (p=0.348 for translation, p=0.310 for intervertebral disc height and p=0.135 for foraminal height). One patient in Group I had transient foot drop which recovered, while one in Group II had infection, wound was managed with wound wash and antibiotics and another patient in Group II had pseudoarthrosis. CONCLUSION: Lumbar interbody fusion with standalone local bone grafts is sufficient in single level low grade spondylolisthesis treated by conventional open surgery.

Clinico-radiological Outcome Analysis of Parallel Plating with Perpendicular Plating in Distal Humeral Intra-articular Fractures: Prospective Randomised Study.

INTRODUCTION: The distal humeral fractures are common fractures of upper limb and are difficult to treat. These fractures, if left untreated or inadequately treated, leads to poor outcomes. Management of distal humeral fractures are pertained to many controversies and one among them is position of plates. AIM: To compare the clinical and radiological outcomes in patients with intra-articular distal humerus fractures, treated using parallel and perpendicular double plating methods. MATERIALS AND METHODS: A total of 38 patients with distal humerus fractures, 20 in perpendicular plating group (group A) and 18 in parallel plating group (group B), were included in this prospective randomised study. At each follow up patients were evaluated clinically and radiologically for union and the outcomes were measured in terms of Mayo Elbow Performance Score (MEPS) consisting of pain intensity, range of motion, stability and function. MEP score greater than 90 is considered as excellent; Score 75 to 89 is good; Score 60 to 74 is fair and Score less than 60 is poor. RESULTS: In our study, 15 patients (75%) in group A, and 13 patients (72.22%) in group B achieved excellent results. Two patients (10%) in group A and 4 patients (22.22%) in group B attained good results. Complications developed in 2 patients in each groups. No significant differences were found between the clinical outcomes of the two plating methods. CONCLUSION: Neither of the plating techniques are superior to the other, as inferred from the insignificant differences in bony union, elbow function and complications between the two plating techniques.

Ilizarov hip reconstruction in skeletally mature young patients with chronic unstable hip joints.

PURPOSE: Hip reconstruction with subtrochanteric valgus extension pelvic support osteotomy and distal femoral osteotomy for lengthening and varus correction is one of the options available for salvage of chronic unstable hips and is also known as Ilizarov hip reconstruction (IHR). This study evaluated the outcomes and complications associated with IHR in skeletally mature young patients. METHODS: Twelve patients (7 males, 5 females) with a mean age of 23 years underwent IHR for chronically dislocated hips due to various causes. Preoperative clinical and radiological evaluations were used to determine the site of osteotomies and the required angulations. Postoperatively the patients were followed up clinically and radiologically for a minimum of 36 months. Ilizarov fixator was removed when adequate lengthening was achieved and there was radiological evidence of union. Harris Hip Score was used to document hip function preoperatively and at final evaluation. RESULTS: Significant improvements occurred in limb length discrepancy (LLD) 5.11 cm preoperatively to 0.9 cm at final evaluation, Harris Hip Score 44.33 points preoperatively to 70.83 points (p < 0.0001) at final evaluation. Trendelenberg sign disappeared completely in nine patients and was delayed in three at final evaluation. The abduction at the hip increased from the preoperative mean of 12.08° (range 0°-25°) to 22.5° (range 15°-35°) postoperatively. The fixed flexion deformity at the hip decreased from 22° (range 10°-35°) preoperatively to 3° postoperatively (range 0°-10°). The amount of free flexion at the operated hips decreased from the preoperative mean of 88.33° (range 70°-120°) to 70.42° (range 45°-105°) at final follow up. The mean fixator interval was 7.33 months (5-12 months) and the mean follow up duration was 59.4 months (38-86 months). CONCLUSIONS: IHR is effective in improving the hip biomechanics, correcting the LLD and eliminating the Trendelenberg sign. Lengthy period of fixator wear, knee stiffness and pin tract infections, though minor are known limitations of this procedure.