Infective Spondylodiscitis of Unknown Origin in a Patient with Chronic Kidney Disease - Case report.

Introduction: Infective spondylodiscitis, resulting from bacterial or fungal infections in intervertebral discs and adjacent vertebral bodies, poses diagnostic dilemmas due to its rare occurrence and subtle symptomatology. This report underscores the importance of a multidisciplinary approach in navigating the complexities of infective spondylodiscitis, particularly in patients with concomitant chronic kidney disease (CKD). Case Report: A 53-year-old male, 5 years into renal dialysis for CKD, presented with a 3-month history of severe neck pain radiating to both arms, accompanied by tingling sensations. Neurological evaluation revealed weakness and gait imbalance. Laboratory findings indicated elevated serum creatinine, erythrocyte sedimentation rate, and C-reactive protein. Imaging confirmed vertebral destruction, necessitating a staged treatment plan involving surgical intervention, corpectomy, mesh placement, and fusion. Intraoperative cultures yielded negative results, prompting continued broad-spectrum antibiotic therapy intravenously for 2 weeks, followed by an additional 4 weeks orally. Discussion: The case discussion explores common risk factors for infective spondylodiscitis, emphasizing the need for a comprehensive diagnostic approach in patients with immunocompromised conditions, such as CKD. Despite negative cultures, the patient's favorable clinical response and neurological recovery underscore the intricate nature of infectious processes, especially in individuals with underlying health concerns. Conclusion: This case report serves as a poignant reminder of the challenges associated with infective spondylodiscitis in CKD patients on hemodialysis. The classic triad of pain, fever, and neurological deficits should trigger a thorough diagnostic investigation, leveraging advanced imaging techniques for accurate diagnosis. A multidisciplinary approach and regular follow-ups are essential in managing such complex cases, contributing to improved patient outcomes and overall healthcare quality.

Does Early Treatment With Teriparatide Prevent the Need for Surgical Intervention in Osteoporotic Vertebral Compression Fractures.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: The primary objective of this study is to evaluate the efficacy of early administration of Teriparatide in preventing the necessity of surgical intervention in individuals with osteoporotic vertebral compression fractures. METHODS: In a 24-month follow-up retrospective analysis, 191 OVCF patients from January 2016 to October 2020 were randomly assigned to Non teriparatide Group A (n = 104) or Group B teriparatide (n = 87). At baseline, 6 months, 1 year, and 2 years following treatment, demographic data and need of surgical intervention, VAS, ODI, union rates, and kyphosis development, were examined. RESULTS: Our study found that non-teriparatide group individuals had an 11.53% higher risk of non-union formation that required surgery. Only 8.63% of teriparatide group patients needed surgery. Both groups had significant VAS score reductions. Non-teriparatide group scores declined from 8.38 ± 0.74 to 3.15 ± 1.40, while teriparatide group scores decreased from 8.49 ± 0.73 to 1.11 ± 0.31. The 2-year follow-up ODI scores significantly decreased, with values of 25.02 ± 13.94 for non-teriparatide patients and 15.11 ± 2.17 for teriparatide patients. The kyphosis progression angles in the teriparatide group were considerably lower (4.97 ± 0.78°) compared to the other group (8.09 ± 1.25°). CONCLUSION: With increasing elderly populations, it is necessary to take measures to prevent surgical intervention in osteoporotic spinal compression fractures. Teriparatide can be employed as an early medication in the management of these fractures to avert non-union and the minimise the progression of kyphosis.

Is Teriparatide Superior in Treating Osteoporotic Vertebral Compression Fractures in Comparison to Bisphosphonates Treatment Alone: A 2-Year Retrospective Analysis.

STUDY DESIGN: Retrospective cohort study. PURPOSE: This study aimed to compare the efficacy of bisphosphonates and teriparatide in the management of osteoporotic vertebral compression fractures with regard to pain management, prevention of nonunion, and radiological as well as clinical outcomes. OVERVIEW OF LITERATURE: Osteoporosis refers to a skeletal disorder characterized by decreased bone strength caused by poor bone density and quality causing fragility, resulting in long periods of pain-related immobilization. METHODS: In a 24-month follow-up retrospective study, 191 patients with osteoporotic vertebral compression fractures were randomly assigned to the bisphosphonate group (n=104) or the teriparatide group (n=87), with patients opting for their treatment between January 2016 and October 2020. Demographic data and patient-reported outcomes scores, including the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), union rates, and kyphosis progression, were assessed at baseline, 6 months, 1 year, and 2 years after treatment. RESULTS: Both groups had a significant decrease in VAS, from 8.38±0.74 to 3.15±1.40 in the bisphosphonate group and from 8.49±0.73 to 1.11±0.31 in the teriparatide group. The ODI scores reduced significantly at 2-year follow-ups, recording 25.02±13.94 and 15.11±2.17 in the bisphosphonate and teriparatide groups, respectively. Risks of nonunion development were slightly higher at 11.53% in the bisphosphonate group and 8.63% in the teriparatide group required operative intervention. The kyphosis progression angles were also significantly lower in the teriparatide group (4.97°±0.78°) than in the bisphosphonate group (8.09°±1.25°). CONCLUSIONS: Over time, numerous studies have demonstrated the efficacy of bisphosphonates and teriparatide in ameliorating pain. In this study, the efficacy of teriparatide surpassed that of bisphosphonates in certain aspects, such as the initial 6-month union rates and reduction in the progression of segmental kyphosis. However, bisphosphonates and teriparatide yield similar and favorable union rates at 1 year and final follow-up.

Chloroma - A Rare Case of Metastatic Tumor to Dorsal Spine in Patient of Chronic Myeloid Leukemia Causing Acute Paraparesis.

Introduction: Chloromas are defined as metastatic granulocytic solid tumors of myeloid origin occurring at an extramedullary site. In this case report, we present an uncommon case of chronic myeloid leukemia (CML) presenting with metastatic sarcoma to the dorsal spine causing acute paraparesis. Case Report: A 36-year-old male presented in the OPD with complaints of progressive upper back pain and acute paraparesis since a 1 week. The patient is a previously diagnosed case of CML on treatment for the same. MRI of the dorsal spine indicated extradural soft-tissue lesions in D5-D9 extending to the right side of the spinal canal displacing the cord to the left. Considering the acute paraparesis that the patient developed, he was taken for an emergency decompression of the tumor. Microscopy showed infiltration of fibrocartilaginous tissue of polymorphous origin mixed with atypical myeloid precursor cells. Immunohistochemistry reports show atypical cells diffusely expressing myeloperoxidase, focally expressing CD34 and Cd117. Conclusion: Rare case reports like this are the only literature available on remission in CML cases with sarcomas. The acute paraparesis in our patient was prevented from increasing to a paraplegia by surgical means. Immediate decompression of the spinal cord in patients with paraparesis and associated radiotherapy and chemotherapy should be considered in all patients with myeloid sarcomas of CML origin. While examining patients of CML, the possibility of a granulocytic sarcoma should always be kept in mind.

Spinal cord compression from malignant relapsed Hodgkin's lymphoma presenting with neurological symptoms - Case report.

Introduction: Hodgkin's lymphoma has been observed to rarely manifest with extra nodal involvement, typically occurring in the latter stages of the disease. However, spinal cord compression may also be regarded as a rare predominant symptom to occur in this context. In this case report, we discuss the clinical details of a 37-year-old patient who exhibited upper motor neuron symptoms and gait imbalance. The patient's medical history includes a confirmed diagnosis of Hodgkin's lymphoma. Case Report: A 37-year-old male patient reported to the outpatient department with bilateral upper limb weakness and gait impairment. The individual presented as a documented case of previous Hodgkin's lymphoma, with magnetic resonance imaging (MRI) revealing the presence of anterior epidural soft tissue mass at the C6-D1 vertebral levels. This pathological condition resulted in the compression and posterior displacement of the spinal cord. The patient was scheduled to have an emergency decompression surgery involving a C7 corpectomy and C6-D1 fusion procedure utilizing a mesh cage and plate. Conclusion: The conventional approach of utilizing only Chemotherapy and Radiotherapy for patients with Hodgkin's lymphoma should be reevaluated, as it is imperative to address neurological symptoms resulting from spinal cord compression which also can indicate the stage of the disease. Incorporating surgical interventions into the treatment plan can contribute to the restoration of function in affected patients.

Acute Paraparesis in a Patient after High Velocity Manipulation of Cervical Spine and its Management.

Introduction: In this case report, we question the safety associated with high velocity manipulations of the cervical spine. These procedures do not frequently cause catastrophic adverse effects but few and rare case reports like this make us aware about the possible complications of the maneuvers. Case Report: This case report presents an uncommon presentation of acute neurodeficit to a 57-year-old male following a neck manipulation by a barber in the saloon which recovered partially with Intravenous steroid therapy but required active intervention surgically to treat his complete symptomatology. The magnetic resonance imaging (T2-weighted) showed a high signal intensity within the spinal cord at the C4C5 level (cord edema). Here, we discuss the possible mechanism of injury and the need to educate the lesser common risks of performing such sudden and forceful maneuvers. Conclusion: This case report is a reminder that people should be careful while trying alterative types of therapy which use forceful neck manipulations to relieve pain as this maneuver could cause injuries to the disc complex especially when the patient already has a disc prolapse which is asymptomatic, causing the disc to fail again making it symptomatic.

Anthropometric evaluation for surgical feasibility of C1-C2 transarticular screw stabilization in Indian population.

STUDY DESIGN: This study was a radiographic observational study for C1-C2 anthropometry. PURPOSE: The purpose of the study was to understand the anatomic relationship of C1-C2 in view of transarticular screw (TAS) fixation, to overcome the difficulties related with TAS placement, and to minimize the technique-related complications. MATERIALS AND METHODS: It was an anthropometric observational study with retrospectively obtained anatomical data of randomly selected 116 patients from a single center. The anatomical measurements such as pars width, pars height, screw trajectory, and length were evaluated on the axial, sagittal, and three-dimensional reconstructed cervical CT scan using the radiant DICOM viewer software by the two fellowship trained spine surgeons which were blind to the study group details. The intra- and interobserver reliability with regard to the measured parameters was statistically analyzed. RESULTS: The mean age of male and female was 28 and 29 years. The average BMI was calculated to be 23.5 and 25 for males and females, respectively. The mean right pars width in males was 5.78 ± 0.93 (range: 3.1-6.5 mm), while in female, it was 5.84 ± 0.95 (range: 3.1-6.5). The mean left pars width in males was 5.95 ± 1.13 (range: 3.8-8.1 mm), while in females, it was 5.70 ± 1.18 (range: 3.7-8.1 mm). Right side mean pars height in males was 5.90 ± 1.2 (range: 3.7-9.4 mm), and in females, it was 6.11 ± 1.04 (range: 3.8-9.3 mm). Left-sided mean pars height in males was 6.0 ± 1.1 (range: 3.2-9.4 mm) as compared to females, in which it was 5.77 ± 1.23 (range: 4.1-9.3 mm). The mean lateral angulation angle in males was 9.99° ± 1.70° (8.1°-15°), while in females, it was 10.15° ± 1.73° (8.1°-15°). The mean sagittal angulation in males was 26.33° ± 3.32° (21.0°-32.80°), while in females, it was 27.18 ± 3.05 (21.0°-32.10°). The average screw length in males was 41.74 ± 5.63 (34-54.8 mm), whereas in females, it was 41.35 ± 4.77 (34-54.8 mm). CONCLUSION: This study provides a morphometric database which is characteristic of the C1-C2 vertebrae in the normal Indian population with regard to the anatomic feasibility of the TAS fixation for various C1-C2 pathologies. The C2 pars width and height measured in the current study can guide the selection of TAS screws in the Indian population. This study could serve in providing the baseline anatomic parameters assessed in the healthy individuals to design and develop customized screws and related implant assembly which might provide wider clinical applicability.

Surgical outcomes of single stage surgery for Tandem spinal stenosis (TSS) in elderly and younger patients: A comparative study.

STUDY DESIGN: Retrospective study. OBJECTIVE: To evaluate and compare the outcomes of single stage surgery for Tandem Spinal Stenosis (TSS) in elderly (Age ≥65 years) and younger patients (Age <65 years). SUMMARY OF BACKGROUND DATA: Tandem spinal stenosis among elderly is common and often missed diagnosed with delayed presentation. Literature evaluating efficacy and safety of single staged surgery for TSS in elderly patients is scanty. METHODS: Analysis of 74 patients with TSS managed with single stage posterior surgery from 2007 to 2016 was done. A total of 62 patients who satisfied our inclusion criteria were evaluated and subdivided into two groups based on age; Study group (age ≥65years)] (n = 32) and control group (age <65years) (n = 30). Perioperative, clinical/radiological parameters and postoperative complications and recovery rate were noted. RESULTS: The Mean ODI and mJOA showed significant improvement post-operatively in both groups however there was no significant difference between the two groups at final follow-up. There was no statistical difference in operative time, blood loss and hospital stay between the groups. As per Odom's criteria, 78.1% had excellent to good results in study group, while 83.3% had excellent to good results in control group. Postoperative complications were more in elderly group however, there was no significant difference among neurological or cardiopulmonary complications between both groups. CONCLUSIONS: Single stage surgery is safe & efficacious modality with less morbidity and optimal results in elderly patients with proper preoperative risk assessment. Our study showed that increased age does not proved to be deterrent in the outcome of single staged surgery in tandem spinal stenosis.

"A decade with micro-tubular decompression": Peri-operative complications and surgical outcomes in single and multilevel lumbar canal stenosis.

PURPOSE: We present ten years experience with micro-tubular decompression (MTD) performed for single and multilevel lumbar canal stenosis (LCS) assessing the peri-operative complications and mid-term surgical outcome. The aims of this study were to review the incidence of peri-operative complications and classification of complications and define risk factors to prevent it while negotiating the learning curve. METHODS: A retrospective review of prospectively collected data over a period of ten years involving 625 patients who underwent single/multilevel lumbar MTD. Peri-operative clinical-radiological parameters, post-operative complications, clinical outcome (VAS and ODI), and satisfactory outcomes in the form of Wang and Bohlmann's criteria were evaluated. The peri-operative complications were divided into five broad categories based on their time of occurrence, severity, and system affected. The comparison between the patients with and without complications was done to evaluate the causative risk factors. RESULTS: The overall incidence of the peri-operative complication was 12.96% over ten years with higher rate (29.8%) during the initial three years of practice and lower rate (8.78%) in the last seven years. The most common peri-operative complications were urinary tract infections (UTI). The risk factors for complications with MTD revealed in statistical analysis were presence of one or more comorbidities, L4-L5 single-level stenosis, bilateral stenosis with ipsilateral and bilateral decompression done through unilateral approach, and multilevel MTD done through single incision for multilevel LCS. More than 95% patients operated with MTD showed excellent to good outcome as per the Wang and Bohlmann's criteria at the final follow-up. CONCLUSION: This study represents 12.96% overall incidence of peri-operative complications with higher rate (29.8%) during the initial three years of practice and lower rate (8.78%) in the last seven years with MTD for single/multilevel LCS with. MTD is an effective procedure with substantial clinical benefits in the form of excellent to good clinico-radiological outcomes at two year follow-up. However, there is a learning curve associated with the adoption of the technique. The described classification for peri-operative complications is helpful to record, to evaluate, and to understand the aetiology and risk factors based on its duration of occurrence in the peri-operative period.

Surgical outcomes of posterior trans-facetal decompression and stabilisation in tuberculous spondylodiscitis with neuro-deficit.

STUDY DESIGN: Retrospective study. PURPOSE: To evaluate the functional, neurological and radiological outcomes of posterior trans-facetal decompression and stabilisation in tuberculous spondylodiscitis patients with neuro-deficit. OVERVIEW OF LITERATURE: Spinal tuberculosis mainly involves anterior column and for that anterior approach has been the most frequently used surgical technique in the past as it allows direct access to the infected tissue providing a good decompression. However, anterior surgery is associated with higher morbidity which can be reduced by posterior trans-facetal approach. MATERIALS AND METHODS: The study included 100 Tuberculous Spondylodiscitis patients with neuro-deficit who underwent posterior trans-facetal decompression and stabilisation from 2009 to 2014. Demographic data, clinical parameters (back pain score-VAS, ODI), neurological status (Frankel's grade), radiological parameters (Kyphosis angle) and complications were evaluated. RESULTS: Out of the total 100 patients there were 58 males and 42 females. 84 patients had thoracic and 16 had thoracolumbar region involvement. The mean age of the patients was 34.7 years. The extent of fixation was 2 segments in 52 patients and >2 segments in 48 patients. Postoperatively significant improvement in VAS (pre-op 6.5 ± 0.65 to post-op 1.73 ± 0.64) and ODI (pre-op 76.54 ± 6.96 to post-op 30.5 ± 6.56) were noted. The mean kyphosis angle was corrected from 22.33° ± 5.59° to 5.14° ± 1.32°. 86 patients showed at least 1 grade of improvement in neurology (Frankel's grading) and there was no deterioration in any patient. 3 patients developed superficial infection and 2 had an intra-operative dural tear. 94 patients showed bony fusion at 2 years follow-up. CONCLUSION: Posterior trans-facetal decompression and stabilisation is an effective procedure in the management of thoracic & thoracolumbar tuberculous spondylodiscitis patients with neuro-deficit. It offers circumferential decompression with stabilisation and also maintains kyphosis correction.

Study of Patients with Bilateral Knee Osteoarthritis Undergoing Total Knee Replacement Procedure with Coexisting Lumbar Spondylosis Symptoms.

STUDY DESIGN: This is a prospective cohort study involving patients who were followed for 2 years after total knee replacement (TKR) to determine changes in lumbar spine and knee symptoms. PURPOSE: The objectives of this study were to determine the percentage of patients undergoing bilateral TKR who present with coexisting lumbar spine problems and determine if TKR relieves lumbar spine symptoms. OVERVIEW OF LITERATURE: No studies quantify the percentage of TKR patients who experience relief of lumbar spine symptoms after TKR surgery. METHODS: The study included 200 patients (164 females, 36 males) undergoing primary TKR. Follow-up was performed at 4 weeks, 3, 6, 12, and 24 months. Lumbar spine and knee symptom improvements were assessed using the Oswestry Disability Index (ODI) and Oxford Knee Score, respectively. RESULTS: All 200 patients undergoing bilateral TKR presented with radiographic lumbar spine degenerative pathology; 60% (n=120) of the patients presented with moderate to severe clinical symptoms of lumbar spondylosis, including 54% (n=108) with degenerative lumbar spondylosis and lumbar canal stenosis and 6% (n=12) with degenerative spondylolisthesis. Of the 120 patients who presented with lumbar spine problems, 90% (n=108) reported improvement in their symptoms; the ODI score improved from 42.5%±4.1% preoperative score to 15.6%±2.3% postoperative score (p-value<0.001). Of the 12 patients with no improvement, 10 patients underwent percutaneous procedures for their lumbar spine pathology with good results, one patient underwent surgery, and one declined any intervention. CONCLUSIONS: A significant number of patients (60%) undergoing bilateral TKR also present with symptomatic lumbar spine problems. Patients with mild to moderate lumbar spine degenerative symptoms and no associated severe radiating pain on activity are more likely to experience relief of their symptoms post-TKR.

Safety, efficacy, surgical, and radiological outcomes of short segment occipital plate and C2 transarticular screw construct for occipito-cervical instability.

OBJECTIVE: Our study aims to assess the safety, efficacy, clinicoradiological, functional, neurological outcomes, and complications of posterior occipitocervical fixation using an occipital plate and C1-2 transarticular screw (TAS) construct. STUDY DESIGN: This was a retrospective analysis of prospectively collected data. METHODS: Data of 27 patients who underwent occipital plate and C1-2 TAS construct at a single institute from 2010 to 2015 were collected and analyzed. Demographics, clinical parameters (Visual Analog Score, Oswestry Disability Index, and modified JOA score), radiological parameters - mean atlantodens interval, posterior occipitocervical angle, occipitocervical-2 angle, surgical parameters (operative time, blood loss, hospital stay, and fusion), and complications were evaluated. RESULTS: The mean age of the patients was 54.074 ± 16.52 years (18-81 years), the mean operative time was 116.29 ± 12.23 min, and the mean blood loss was 196.29 ± 38.94 ml. The mean hospital stay was 5.22 ± 1.28 days. The mean ± standard deviation follow-up duration was 62.52 ± 2.27 months. There was a significant improvement in clinical parameters and radiological parameters postoperatively. One patient with implant failure, one patient with pseudoarthrosis, one with neurological deterioration, two wound complications, and two dural tears were noted. CONCLUSION: Posterior occipitocervical reconstruction with O-C1-2 TAS construct provided excellent clinical outcomes, radiological outcomes, optimal correction of malalignment in the occipitocervical region, and with biomechanically sound fixation. Extending the instrumentation into the subaxial spine will lead to a decrease in the range of motion, increased surgical time, blood loss, more extensive muscle damage, and also increase the costs.

Is Older Age a Contraindication for Single-Level Transforaminal Lumbar Interbody Fusion?

STUDY DESIGN: Retrospective cohort. PURPOSE: This study's primary objective was to compare the clinico-radiological outcomes and incidence of perioperative complications of transforaminal lumbar interbody fusion (TLIF) at lower lumbar levels for elderly and younger patients. The secondary objective was to evaluate the effect of age on clinical outcomes and patient satisfaction in the two groups. OVERVIEW OF LITERATURE: The lumbar interbody fusion surgery in elder age has been reported to produce a higher complication rate and suboptimal results. Literature evaluating efficacy and safety of TLIF in elderly population is scanty. The effect of age on clinical outcome and the overall patient satisfaction after TLIF has been understudied. METHODS: This retrospective study was conducted from 2011 to 2017 with 121 patients, who underwent TLIF and were divided into two cohorts based on age (group A, >65 years and group B, <65 years). Perioperative clinical/radiological parameters, postoperative complications, and satisfactory outcomes were evaluated in both groups. A statistical analysis between two matched groups was performed with logistic regression analysis and Student t-test. RESULTS: The mean age was 73.8±4.5 years in group A and 47.3±12.7 years in group B. There was no statistical difference in surgical time (p=0.15), mobilization, or hospital stay (p=0.15) between the two groups. There were no statistically significant differences noted in the Oswestry Disability Index, Visual Analog Scale, or Wang's outcome score between the two groups at final follow-up. Postoperative complications not affecting outcome were common in the elderly group, but there was no statistically significant difference noted among neurological or cardiopulmonary events between the two groups. CONCLUSIONS: In judiciously selected patients with proper preoperative risk assessment and optimized medical co-morbidities, TLIF surgery can have successful results, in terms of clinical outcome and satisfaction, in the elderly. Older age should not be a contraindication for TLIF in patients with degenerative lumbar disease.

Perioperative Complications of Minimally Invasive Transforaminal Lumbar Interbody Fusion (MI-TLIF): 10 Years of Experience With MI-TLIF.

STUDY DESIGN: A prospective study. OBJECTIVES: We present a largest study until date performed over a period of 10 years assessing the perioperative complications. The primary aim of this study was to review the incidence of perioperative complications of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) in single-level lumbar degenerative diseases. METHODS: A prospective study performed over a period of 10 years involving 560 patients who underwent single-level lumbar MI-TLIF. Perioperative clinical and radiological parameters, postoperative complications, and satisfactory outcomes in the form of Wang's criteria were evaluated. All patients were scrutinized into 5 different categories based on the descriptive classification for perioperative complications suggested by the authors. RESULTS: The mean age was 61.8 ± 12.7 years and male to female ratio was 0.8:1. The overall incidence of the perioperative complication was 25.5%. In all, 19.64% patients developed single complication, 4.64% patients were with 2 complications, and 1.25% patients developed 3 complications from the described categories. A total of 16.78% patients developed early (<6 months postsurgery) and 8.75% patients developed late (>6 months postsurgery) complications. CONCLUSION: This study showed 25.5% incidence of perioperative complications in MI-TLIF for degenerative lumbar disease over a period of 10 years with a higher incidence rate during the initial 3 years of practice. The described classification for perioperative complications is helpful to record, to evaluate and to understand the etiology based on its duration of occurrence in the perioperative period. MI-TLIF is an effective procedure with substantial clinical benefits in the form of excellent to good clinical-radiological outcomes.

Dural Leak: Is It Deterrent to Outcomes in Spine Surgery?: 10 Years Retrospective Analysis of Incidence, Management Protocol, and Surgical Outcomes.

STUDY DESIGN: Retrospective case-control study. OBJECTIVES: To review the incidence of dural leaks, evaluate the efficacy of primary closure of durotomy and to study its effect on clinical outcome. The secondary aim is to classify the dural leaks and proposing a treatment algorithm for dural leaks. SUMMARY OF BACKGROUND DATA: Dural leaks are described as one of the fearful complications in spine surgery. Literature evaluating the actual incidence, ideal treatment protocol, efficacy of primary repair techniques and its effects on long-term surgical outcomes are scanty. METHODS: It was a retrospective analysis of 5390 consecutively operated spine cases over a period of 10 years. All cases were divided into two groups-study group (with dural leak-255) and control group (without dural leak-5135). Dural leaks were managed with the proposed treatment algorithm. Blood loss, surgical time, hospital stay, time for return to mobilization, pain free status, and clinical outcome score (ODI, VAS, NDI, and Wang criteria) were assessed in both groups at regular intervals. The statistical comparison between two groups was established with chi-square and t-tests. RESULTS: The overall incidence of dural leaks was 4.73% with highest incidence in revision cases (27.61%). There was significant difference noted in mean surgical blood loss (P 0.001), mean hospital stay (P 0.001), time to achieve pain-free status after surgery, and return to mobilization between two groups. However, no significant difference was noted in operative time (P 0.372) and clinical outcome scores at final follow-up between the two groups. CONCLUSION: Primary closure should be undertaken in all amenable major dural leak cases. Dural leaks managed as proposed by the author's treatment algorithm have shown a comparable clinical outcome as in patients without dural leaks. Dural leak is a friendly adverse event that does not prove a deterrent to long-term clinical outcome in spine surgeries. LEVEL OF EVIDENCE: 4.

Learning Curve of Microendoscopic Discectomy in Single-Level Prolapsed Intervertebral Disc in 120 Patients.

STUDY DESIGN: Retrospective study of prospectively collected data. OBJECTIVE: To evaluate learning curve of tubular microendoscopic discectomy (MED) in lumbar prolapsed intervertebral disc (PIVD) patients based on surgical and clinical parameters and delineate the challenges faced in early cases while practicing MED in large series of patients. METHODS: This study was an institutional review board-approved retrospective study of the first 125 consecutive patients with single-level lumbar PIVD managed with tubular MED from 2008 to 2016 with a minimum 2-year follow-up. A total of 120 patients available at final follow-up were divided into quartiles (30 each) as per the date of surgery, with each consecutive group serving as a control for the previous group. Preoperatively and postoperatively clinical parameters (pain scores [Visual Analogue Scale; VAS], functional disability [Oswestry Disability Index; ODI] score, modified MacNab criteria), perioperative parameters (operative time, blood loss, hospital stay), technical issues (guide wire migration, tube docking-related problems, dural tear), and postoperative complications (postoperative leg pain, neural injury, infection, recurrence) were evaluated. Statistical analysis-logarithm curve-fit regression analysis and ANOVA test. RESULTS: The sample consisted of 75 males and 45 females (mean age: 42.54 years) with no significant difference among the quartiles. There was significant difference (P < .005) noted in mean operative time (quartile 1, 87.33 minutes; quartile 2, 58.5 minutes) and mean blood loss (quartile 1, 76.33 mL; quartile 2, 32.66 mL) between quartile 1 and quartile 2, with no further significant reduction in quartile 3 and quartile 4. Significant difference (P < .005) in clinical parameters (VAS preoperative/postoperative 5.28/0.99; ODI preoperative/postoperative 32.18/12.08) were noted but was not associated with surgical experience. Overall, 90% (108 out of 120) of the patients had good to excellent results according to the modified MacNab criteria. The mean hospital stay did not show any significant difference among the quartiles. Guide wire migrated issues, neural injury, dural tear, and tube docking-related problems were significantly reduced after quartile 1. However, recurrence occurred at any phase. Infection occurred in one patient in quartile 1. Although blood loss and operative time showed a declining trend, it was not significant after quartile 2. So asymptote lay in quartile 1 and we recommend that novice surgeon should perform 25 to 30 cases to achieve mastery in this technique. CONCLUSION: For mastering the art of tubular MED for lumbar PIVD and to reduce its learning curve, novice surgeons can avoid the challenges and problems faced during initial cases with improvement in surgical skills by practicing on cadavers, wet labs, and bone-saw models following certain recommendations that we have after achieving asymptote. Familiarity with instrumentation, communication between surgical team, and defined expectations from radiology technicians are key to reduce the learning curve.

Drug sensitivity patterns in Xpert-positive spinal tuberculosis: an observational study of 252 patients.

PURPOSE: To evaluate the sensitivity patterns of anti-tubercular drugs in Xpert MTB-positive spinal tuberculosis (TB) patients and to formulate the guidelines for early start of empiric anti-tubercular treatment (ATT) in MDR-TB spine based on resistance pattern in this large series. METHODS: It was a cross-sectional observational study of 252 consecutive patients who were Xpert MTB-proven spinal TB cases with retrospective analysis of prospective data. The Xpert MTB/RIF (Mycobacterium tuberculosis/rifampicin) assay was used to diagnose spinal TB and RIF resistance. All patients underwent drug sensitivity testing (DST) to 13 commonly used anti-tubercular drugs using BACTEC MGIT-960 system. The drug sensitivity pattern of primary and secondary anti-tubercular drugs was recorded and compared. RESULTS: The DST study revealed 110 (43.6%) cases of multi-drug resistant (MDR-resistance to both isoniazid and rifampicin) and 24 (9.5%) cases of non-MDR-TB spine. The widespread resistance was found for both isoniazid (91%) and rifampicin (85%), followed by streptomycin (61.9%). The least resistance was found for kanamycin, amikacin and capreomycin and no resistance found for clofazimine. CONCLUSION: The Xpert MTB/RIF assay is an efficient technique for the rapid diagnosis of spinal TB and suspected MDR-TB; however, it is recommended to do culture and DST in all patients with spinal TB to guide the selection of appropriate second-line drugs when required. In cases of non-availability of culture and DST, it is suggested to use data from large series such as this to plan the best empirical ATT regimen. These slides can be retrieved under Electronic Supplementary Material.

Diagnostic Efficacy, Sensitivity, and Specificity of Xpert MTB/RIF Assay for Spinal Tuberculosis and Rifampicin Resistance.

STUDY DESIGN: A cross-sectional observational study. OBJECTIVE: This study aims to determine the diagnostic accuracy, sensitivity, and specificity of the Xpert MTB/RIF assay (Mycobacterium Tuberculosis/Rifampicin resistance) for the detection of spinal Tuberculosis (TB) and rifampicin (RIF) resistance. SUMMARY OF BACKGROUND DATA: The Spinal TB is often a paucibacillary extra pulmonary tuberculosis which gives a major challenge in early diagnosis and initializing the correct anti-tubercular treatment (ATT). Due to its rapidity and sensitivity, the dependence and reliability on the Xpert MTB/RIF assay has increased in the last few years. The studies describing accuracy of the Xpert MTB/RIF assay in spinal TB are scanty. METHODS: This institutional review board-approved study included 360 diagnosed spinal TB patients. To determine the accuracy of the Xpert MTB/RIF assay, it was compared with other diagnostic tests like histopathology, acid fast bacilli (AFB) smear, culture, and drug sensitivity testing (DST). RESULTS: The Xpert MTB/RIF assay showed 86.3% sensitivity and 85.3% specificity when compared with culture for the diagnosis of Spinal TB and showed 75.86% sensitivity, 96.12% specificity for RIF resistance when compared to DST. Four cases were false positive and 11 cases were false negative for RIF resistance on the Xpert MTB/RIF assay. CONCLUSION: The Xpert MTB/RIF assay is an efficient technique for the rapid diagnosis of spinal TB; however, a clinician should not solely rely on it for starting ATT. As there are false results also with this test which should be read cautiously and be well correlated with culture and DST pattern to guide the start of sensitive drug regimen only. The purpose is to prevent exposure of the second line drugs to false cases found on the Xpert MTB/RIF assay and avoid emergence of new acquired drug resistance. LEVEL OF EVIDENCE: 4.