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).

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.

Association between single nucleotide polymorphism in collagen IX and intervertebral disc disease in the Indian population.

BACKGROUND: Symptomatic intervertebral disc degeneration is being recently reported in younger population, questions the basis of its degenerative etiology. Latest evidences show that genetics play a significant role. Collagen IX, an important constituent of disc, is found to be altered in genetically predisposed individuals. Mutations have been reported in COL9A2 and COL9A3 genes, which encode Collagen IX, in Finnish and various other populations. The purpose of the present study is to test the significance of these genes in the Indian population. MATERIALS AND METHODS: One hundred proven cases of intervertebral disc disease (IDD) of various regions of spine were selected for the study, along with matched controls. They were tested for the above mentioned alleles by allelic discrimination method with real-time polymerase chain reaction (PCR) study after isolation of DNA from blood sample. Each blood sample was classified into one of the three types - homozygous, heterozygous, and wild (normal) type allele - separately for COL9A2 and COL9A3 genes. RESULTS: Homozygosity for COL9A2 allelic variation was associated with 100% occurrence of the disease. Heterozygous allele of COL9A2 was significantly higher in the study group (42%) as compared to the control group (17%). In contrast, allelic variation in COL9A3 gene was found to have no significant correlation with disc disease. There was no single patient with homozygous allelic variation for COL9A3, suggesting predominance of COL9A2 variation in the Indian population. CONCLUSION: This candidate gene strategy approach adds considerably to our knowledge of genetic makeup of Indian populations in relation with disc disease. This study highlights importance of COL9A2 gene variation especially of homozygous variety in contrast to COL9A3 variation in causing disc disease in Indian population.

Polyarthritic, symmetric arthropathy in reactive arthritis.

Reactive arthritis (ReA) is an immune mediated disease, clinically associated with oligoarthritis of the lower limbs and sometimes with urethritis and conjunctivitis. In our case, a 24-year-old male presented with severe mutilating arthritis involving both upper and lower extremities in contrast to conventional Reiter's syndrome which presents with asymmetric oligoarthritis. He had multiple well-defined, irregular, erythematous, hyperkeratotic, scaly and itchy plaques, not easily distinguishable from pustular psoriasis. The patient also gave history of circinate balanitis and urethritis. He was started on methotrexate (7.5 mg/week, later escalated to 15 mg/week with 15 mg/day folinic acid supplementation) to which he responded. But when he stopped it on his own, the symptoms recurred. Hence, methotrexate was restarted, but still the patient suffers from fixed flexion deformities in affected joints. Histopathological examination of skin lesions is also suggestive of ReA. Thus, this case report suggests that diagnosis of Reiter's should be considered in symmetrical, mutilating polyarthritis patients with typical skin lesions.