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

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

Tibial lengthening for massive distal femoral bone loss.

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

Outcome of Joint Aspiration in Acute Knee Haemarthrosis in a Haemophilic Joint: A Prospective Randomised Controlled Trial in 120 Patients in a Tertiary Haemophilia Care Centre.

Background: Bleeding into the joints cause major morbidity in haemophilia patients. The clinical hallmark of haemophilia is haemarthrosis especially in knee, ankle and elbow joint. Current literature suggests that aspiration of an acute haemarthrosis in haemophilia may lead to further bleeding and prevent tamponade effect. But the rehabilitation gets delayed, leading to joint stiffness and the function gets deteriorated. This study was done to evaluate the efficacy of joint aspiration in the management of acute knee haemarthrosis, with regard to pain relief and functional outcome. Materials and Methods: This is a prospective, randomised controlled trial in a tertiary care haemophilia treatment centre comprising 120 haemophilic patients with unilateral acute knee haemarthrosis. Factor level was checked and appropriate factor replacement [40%] was done. The patients were randomly allocated in two groups: Group A and Group B, each consisting of 60 patients. All patients received ice application, limb immobilisation, analgesics, physiotherapy and compression bandage as the routine primary management. In addition, study Group A also received therapeutic aspiration of the knee joint at initial presentation, after the first factor infusion. All patients were clinically evaluated for pain in terms of Visual Analogue Scale (VAS score) and function in terms of Haemophilic Joint Health Score [HJHS], before and at 4 h, 48 h and 7 days after initial factor administration. Results: All patients showed therapeutic improvement in terms of a declining trend in VAS and HJHS scores. Pain relief (VAS Score) in Group A, was found to be significantly better compared to Group B at the end of 4 h [4.80 ± 0.49 vs 6.54 ± 1.05; p < 0.001], 48 h [2.48 ± 0.50 vs 3.30 ± 0.46; p < 0.001] and 7 days [1.16 ± 0.37 vs 1.70 ± 0.46; p < 0.001]. Functional improvement (HJHS Score) in Group A, was found to be significantly better compared to Group B as well at the end of 4 h [11.24 ± 0.77 vs 14.52 ± 0.61; p < 0.001], 48 h [7.24 ± 0.65 vs 11.28 ± 0.64; p < 0.001] and 7 days [2.36 ± 0.48 vs 5.52 ± 0.67; p < 0.001]. Conclusion: Our study recommends the use of joint aspiration as a therapeutic tool in the holistic management of acute knee haemarthrosis in addition to usual treatment of ice application, immobilization and oral tranexamic acid. Early factor replacement along with therapeutic joint aspiration is a key for better pain relief and a better functional outcome.

The influence of joint line restoration on functional outcome after primary total knee arthroplasty: A prospective study.

Objective: Restoration of proper joint line position after primary total knee arthroplasty (TKA) is important for improved knee function and kinematics. We reviewed the magnitude of joint line alteration and the resulting effect on post-operative knee outcomes scores at one year follow-up. Materials and methods: 120 patients who underwent TKA for primary osteoarthritis knee were included. Assessment of joint line position before and after surgery was performed with the help of bony landmarks (excluding osteophytes): Medial Epicondyle Joint Line distance (MEJL), Lateral Epicondyle Joint Line distance (LEJL) and Fibula Head Joint Line distance (FHJL) were calculated. Post-operative knee function was assessed using 'The Western Ontario and McMaster Universities Arthritis Index' (WOMAC) and 'Knee Society Score' (KSS) at one year follow-up. Results: Joint line elevation was observed in 104/120 (86.7%) patients and 16/120 (13.3%) patients had no joint line elevation. The mean joint line elevation was 3.00 (±2.13) mm. The patients were sub-classified into two study groups: Group A- Joint line elevation <5 mm and Group B- Joint line elevation ≥ 5 mm. The mean post-op one-year KSS score was significantly higher in patients in Group A compared to Group B (52.82 ± 7.564 vs. 40.73 ± 7.146; p < 0.001). The mean post-op one-year WOMAC score was lower in patients in Group A compared to Group B (65.51 ± 14.762 vs.75.64 ± 8.203) and the difference was statistically significant (p = 0.002). Conclusion: Elevation of joint line ≥5 mm from the pre-operative value has a negative impact on post-operative functional outcome in primary TKA.

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

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

Functional outcomes in the management of cervicothoracic junction tuberculosis.

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

Clinicoradiological outcome of percutaneous intralesional polidocanol in Aneurysmal Bone Cysts: A prospective study of 43 patients in a single tertiary care centre.

Objective: The study reports the efficacy of sequential instillations of intralesional percutaneous polidocanol in the treatment of skeletal ABC. The study also analyses the pain relief, recurrence, radiological outcome and complications after percutaneous sclerotherapy. Materials and methods: A total of 43 patients with ABC were managed by fluoroscopy assisted percutaneous intralesional sclerotherapy with 3% Injection Polidocanol under suitable anaesthesia. The pain relief was assessed by Visual Analog Scale (VAS) and the progressive healing of the lesion by Rastogi Classification. Patients were evaluated clinico-radiologically, pre-operatively and at monthly interval for the first three months and then at 6 months, one year and two years follow up. Result: The VAS score decreased significantly at six months follow up and was zero (No pain) at one year follow up. Out of 43 patients, 37 patients had Degree I (excellent) residual lesion and 6 patients had degree II (good) lesion at one year follow-up as per Rastogi classification. The lesions resolved completely by two-year follow-up with all 43 patients having Degree (excellent) I resolution. Conclusion: Our study highlights the efficacy of percutaneous intralesional polidocanol in the treatment of ABC's. The procedure is safe, simple and effective with excellent outcome. Sclerotherapy is highly beneficial for deep lesions which are difficult to assess and for comorbid patients who are medically unfit for surgery. Our study strongly advocates the use of sclerotherapy as the first line treatment for ABC, considering its clinical and radiological efficacy.

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

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

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

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

Management Dilemma of a Neuropathic Knee in a Known Case of Larsen Syndrome: A Case Report.

Introduction: Larsen syndrome (LS) is a rare genetic disorder affecting mainly the connective tissues. It is characterized by characteristic facial anomalies, cervical kyphosis, cardiorespiratory disorders, and multiple joint dislocations. We present a case of a 15-year-old male with unstable neuropathic knee joint instability in a known case of LS. The paucity of literature on the management of this rare condition puts an orthopedician in dilemma regarding the optimal treatment. Case Report: A 15-year-old male, known case of LS, presented to our outpatient department with pain and instability in the right knee for 2 years. Clinically, the patient was having syndromic facies. The diagnosis of LS was confirmed on gene mapping. The right knee was swollen with medial joint line tenderness and restricted flexion. The patient had coronal plane valgus instability. The hypertrophied synovium eroded the articular surface. The radiograph of knee was suggestive of neuropathic arthropathy in fragmentation stage. Conclusion: Orthopedician should be aware of such rare entity with its bony and soft-tissue manifestations. Neuropathic knee is not an absolute contraindication to total knee replacement, especially with advanced prosthesis. Primary arthrodesis to be considered in young adults with instability.

Better late than never: Clinical outcomes of delayed fixation in thoracolumbar spinal trauma.

PURPOSE: To analyse factors influencing functional outcome and neurological recovery in patients undergoing delayed surgery for traumatic spinal cord injury (SCI) involving thoracolumbar spine. METHODS: Retrospective analysis of 33 patients with thoracolumbar SCI who underwent delayed surgery (≥ 72hrs post-trauma) with a minimum follow-up of 1 year (average:32.55 months) was done. The parameters studied included age, sex, co-morbidities, mode of trauma, associated trauma, level and number of vertebrae involved, fracture morphology, thoracolumbar injury classification and severity score (TLICS), maximal spinal cord compression (MSCC), signal changes in the cord, neurological deficit as per the American Spinal Injury Association (ASIA) scale, lower extremity motor score (LEMS), bowel bladder involvement, time interval between trauma and surgery. RESULTS: Mean time interval from injury to spine surgery was 24.45 days. At the end of 1-year follow-up, 17(51.5%), 12(36.36%), and 3(9.1%) patients had ≥ 1, ≥ 2, and ≥ 3-grade ASIA improvement, respectively. The mean LEMS rose to 33.86 from 17.09 (P < 0.001). 8 out of 20 patients with bladder involvement showed improvement. 4 patients succumbed, 22 were ambulatory, and 7 remained non-ambulatory. On comparing various parameters, pre-operative LEMS score (P-value: < 0.001), cord signal changes (P-value:0.002), and presence of cord transection (P-value:0.007) differed significantly in the above-mentioned three groups, while age (P-value:0.442), average TLICS (P-value:0.872), time from injury to surgery (P-value:0.386) did not differ significantly. CONCLUSION: This study highlights that there is still a significant scope for neurological improvement even after delayed surgery in patients with thoracolumbar SCI. The lower the LEMS score at the time of presentation, signal changes in the cord and presence of cord transection have a significant influence on unfavourable clinical outcomes at the end of 1-year post-surgery.

It's Never Too Late: Neurological Outcome of Delayed Decompression in Tuberculosis of Spine.

STUDY DESIGN: Retrospective observational study. OBJECTIVE: To study the neurological recovery in patients with progressive neurological deficit undergoing delayed decompression and fixation in tuberculosis of spine. METHODS: Retrospective analysis of 50 cases with thoracolumbar tuberculosis of spine, undergoing posterior decompression and instrumentation was done. Parameters like time interval between appearance of neurological deficit to decompression surgery, maximal spinal cord compression, neurology on admission, presence of drug resistance, and number of vertebrae involved were evaluated. The subjects were divided into 2 groups depending on neurological improvement measured with LEMS (Lower Extremity Motor Score) at the end of 1-year follow-up. RESULTS: The mean LEMS score on admission was 27.72 (SD 12.88), which improved to 40.80 (SD 10.46) at the end of 1 year (P < .001). A total of 26 (52%) subjects were categorized into "Satisfactory" outcome (LEMS >10) group and remaining 24 subjects formed the "nonsatisfactory" outcome group. The median time interval between the appearance of neurological deficit and decompression surgery was 23.50 days in the satisfactory group and 29.50 days (P = .110) in the nonsatisfactory group. Maximal spinal cord compression was 0.370 in satisfactory group and 0.357 in nonsatisfactory group (P = .754). The mean preoperative LEMS score was 34.62 in the satisfactory outcome group while that in the nonsatisfactory outcome group was 20.25 (P < .001). CONCLUSION: There is significant scope for neurological improvement even after delayed decompression and fixation in cases of tuberculosis of spine with progressive neurological deficits. Preoperative neurological status was found to be the most significant determinant of postoperative neurological outcome.

Vertebral column resection for post tuberculosis severe kyphotic deformity: Results of 5 year follow-up.

BACKGROUND: Spinal TB is endemic in our study region and many patients present with severe kyphotic deformities and neurological deficit. We corrected such deformities with all posterior single stage surgeries. This study was undertaken to evaluate the results, efficacy and safety of this technique. METHODS: Deformity correction of 16 patients was done during January 2012 to December 2014. All patients underwent posterior only approach for vertebral column resection at peri-apical region, posterior instrumentation with pedicular screws and anterior reconstruction using mesh cage. Postoperative X-ray films were evaluated. All patients were followed up at six weeks, 12 weeks, 18 weeks, six months and yearly thereafter. At follow-up patients were evaluated neurologically and radio-graphically. RESULTS: Mean age of the patients was 19.43 years. (Range 3-37) An average 1.62 vertebrae were excised and 5.93 vertebral levels were instrumented. Mean blood loss was 1013 ml and the mean duration of surgery was 6.78 h. The decrease in mean kyphotic deformity from preoperative 90.08° to postoperative 38.06° was statistically significant. (P < 0.000) Mean percentage correction was 57.59%. No pseudoarthrosis was found on X-rays. The decrease in Oswestry's Disability Index was from 55.43 to 10.06 was statistically significant. (P < 0.000) Two patients had neurological complications and one patient had wound complication. CONCLUSION: The safety and efficacy of Posterior VCR technique for post tuberculosis severe kyphotic deformity is favorable with no severe late stage complications. Excision of ribs, careful handling of cord and gradual correction of deformity with good hemostasis is important.

Dysplasia and anomalies of atlas result in pediatric torticollis: A case report and literature review.

BACKGROUND: Often, the cause of bony torticollis is difficult to determine, especially in cases of multiple craniovertebral junction anomalies. CASE DESCRIPTION: We report a rare case of a dysplastic C1 vertebra (assimilation to the right occiput and C2, a nonseparated left odontoid, and discontinuity in both anterior and posterior arches of the atlas) in a 6-year-old child with progressive torticollis. Notably, the mechanism of torticollis was not a rotatory subluxation of C1-C2, but differential growth between C1-C2. The child underwent a successful C1-C2 Goel and Harms fusion with reduction/correction of the torticollis. CONCLUSION: Torticollis caused by differential growth between the C1 and C2 vertebrae resulting in a nonrotatory subluxation/torticollis in a 6-year-old child, was successfully managed with a C1-C2 Goel and Harm's fusion.

Does Mesh Cage Subsidence Have any Effect on Functional Outcome in Spinal Tuberculosis?

INTRODUCTION: Occurrence of mesh cage subsidence in patients undergoing anterior column reconstruction following Tuberculosis spine is frequent radiological finding as bone quality of affected vertebrae is poor. This study aims at determining effect of mesh cage subsidence on functional outcome. METHODS: Retrospective demographics of 30 patients of consecutive series in age range 4-60 year were collected with Clinical outcome evaluation using VAS, ODI and ASIA scale. 30 patient having Dorsolumbar tuberculosis with vertebral involvement ranging from 1-6 with mean vertebral level involvement of 2.71, underwent anterior column reconstruction through posterior only approach between 2011-15 were reviewed. Patients were followed at regular intervals of 6 weeks, 12 weeks, 6 months & thereafter on yearly basis. They were evaluated for interbody height loss with subsidence, fusion & segmental angle. RESULTS: Clinical parameters i.e. VAS & ODI showed improvement in postoperative period which continued to remain same even after subsidence (P < 0.05). Subsidence was categorized as combined anterior + posterior < 5mm; 5 -10mm; >10mm. ODI at follow up was 8.5 ±4.62, 9 ± 2 and 9 ± 4.2 (P = 0.961) respectively & VAS score in above group was 1.3 ± 0.51, 1.5 ± 1.2 & 1.5 ± 0.7 (P = 0.975) respectively. Subsidence was age, spinal level nonspecific. CONCLUSION: Study indicates that though Cage subsidence occurs to varying severity due to weakened vertebral bodies, it did not have significant impact on functional outcome in terms of VAS, ODI or radiological evidence of fusion following reconstruction in Spinal tuberculosis.

High sensitive C-reactive protein-Effective tool in determining postoperative recovery in lumbar disc disease.

BACKGROUND: It is common in medical practice to see patients having persistent pain and radiculopathy even after undergoing discectomy surgery. Inflammatory cytokines, such as interleukins are produced at the site of disc herniation and are now considered responsible for the pain perceived by the patient. This study has used high sensitive C-reactive protein (HSCRP) assay for predicting inflammation around the nerve roots on very same principle, which has used HSCRP for predicting coronary artery diseases in current clinical practice. Thus, purpose of this study is to test whether HSCRP can stand as an objective tool to predict postoperative recovery in patients undergoing lumbar discectomy. That is, to study association between preoperative HSCRP blood level and postoperative recovery with the help of modified Oswestry Back Disability Score. MATERIALS AND METHODS: A study group consisting of 50 cases of established lumbar disc disease and control group of 50 normal subjects, matched with the study group. Both the study and control groups were subjected to detailed evaluation with the help of modified Oswestry Low Back Pain Scale both pre and postoperatively at 3 months, 6 months and 1-year. The preoperative blood samples were analyzed to assess the HSCRP concentration. All the cases underwent surgery over a period of 1-year by the same surgeon. RESULTS: The level of HSCRP in the study group was between 0.050- and 0.710 mg/dL and in the control group, 0.005-0.020 mg/dL. There was highly significant positive correlation between preoperative HSCRP level and postoperative score at P < 0.005. Cases with HSCRP level in the range of 0.1820 ± 0.079 mg/dL, showed better recovery (score improved > 10 points), while those with HSCRP level in the range of 0.470 ± 0.163 mg/dL, showed poor recovery (score improved < 10 points). CONCLUSION: HSCRP will serve as a good supplementary prognostic marker for operative decision making in borderline and troublesome cases of lumbar disc disease.