Percutaneous wide bore needle biopsy for spinal lesions using the kyphoplasty cannula-a technical note.

PURPOSE: Management of vertebral and discovertebral lesions depends on highly specific modalities like biopsy and histopathology. The transpedicular and transforaminal routes have gained popularity for obtaining samples for diagnosing these lesions. Sample inadequacy plays an important part in lowering the diagnostic accuracy. Present study introduces a technical modification by using a kyphoplasty cannula and pituitary forceps through it thus improving sample adequacy and diagnostic accuracy. METHODS: Seventy-one patients with radiological evidence of spinal lesions from T1 to S1 were included. After obtaining samples via the transpedicular route they were sent for aerobic, anaerobic, acid fast bacilli & fungal cultures, Mycobacterium Tuberculosis/Radio Immuno Frequency (MTB/RIF) Assay and histopathological examination. In lesions with minimal vertebral erosions the transforaminal route was used to obtain samples from the disc space. RESULTS: Sixty-eight patients (95.8%) had a definite diagnosis of which 37 patients (54.4%) tested positive for vertebral osteomyelitis/discitis. All the samples were found to be adequate on histopathological examination. The remaining 3 patients showed chronic inflammation and responded to oral and intravenous antibiotics. None of the patients underwent repeat biopsy. There were no perioperative complications. CONCLUSIONS: Percutaneous transpedicular biopsy has evolved as the intervention of choice in diagnosing radiologically proven vertebral body lesions. Our technique of using a pituitary forceps through a cannula is highly effective in getting an adequate representative sample with excellent accuracy in diagnosis. This procedure is beneficial for soft tissue lesions and for infective pathology especially discitis.

Surgical outcomes of posterior occipito-cervical decompression and fusion for basilar invagination: A prospective study.

STUDY DESIGN: A Prospective Study. OBJECTIVE: To assess results of posterior occipito-cervical decompression and fusion operated with intra-operative traction/manipulation and instrumented reduction in cases of Basilar Invagination(BI). METHODS: Total 22 patients of 8-65 years with diagnosed BI were operated for posterior occipito-cervical fusion by intra-operative traction/manipulation and instrumented reduction. Fusion was done using autologous bone graft taken from iliac crest. Immediate post-operative, first month and then every 3 months' follow-up examination were done for minimum period of 2 years. RESULTS: 22 patients (10 males,12 females) with mean age of 23.9 years having BI were included. 11 patients had C1 occipitalization, 4 had platybasia and 9 had atlanto-axial dislocation (AAD). 1 patient with os odontoideum with kyphotic deformity expired on 4th postoperative day due to respiratory insufficiency (mortality rate 4.54%). Neurological improvement by at least by one grade according to RANAWAT's and/or NURICK'S scale was observed in 17/21 patients (80.95%). 3 patients remained static and 1 had neuro-worsening. Mean mJOA score of 13.14 improved to 16.24. All had reduction of dens below foramen magnum according to McRae, chamberlain line and Ranawat index. Bone graft fused in all patients as confirmed with CT scan and dynamic X-rays. 1 wound dehiscence and 1 asymptomatic implant loosening were seen on follow-up. CONCLUSION: Surgical treatment of BI with intra-operative traction/manipulation, instrumented reduction and posterior occipito-cervical fusion can achieve good correction of radiology, functional performance and clinical neurology as well as excellent fusion rates without adverse effects of trans-oral surgery.

Sensitivity and Specificity of Gene Xpert in the Diagnosis of Spinal Tuberculosis: A Prospective Controlled Clinical Study.

STUDY DESIGN: Prospective matched cohort study. OBJECTIVE: To evaluate the sensitivity and specificity of Gene Xpert in the diagnosis of spinal tuberculosis. METHODS: From January 2016 to August 2018, Gene Xpert results were prospectively studied in 68 patients of clinicoradiologically suspected spinal tuberculosis (STB) and a control group (CG) of 92 patients, all of whom underwent computed tomography-guided/C-arm-guided/open surgical biopsy. Sensitivity, specificity, positive predictive value, and negative predictive value are obtained using standard equations. RESULTS: Out of 68 cases of STB, Gene Xpert was positive in 62 (true positive: 62/68) and negative in 6 (false negative: 6/68). Gene Xpert was negative for all 92 cases of CG (true negative: 92/92, false positive 0/92). Thus, in our series, sensitivity of Gene Xpert is 91.18%, specificity is 100%, positive predictive value is 100%, and negative predictive value is 93.88%. Out of all cases of STB, 62/68 (91.18%) were Gene Xpert positive, but only 35/64 (54.69%) was acid-fast bacilli (AFB) culture positive and 53/60(88.33%) was histopathologically conclusive of TB. Also, Gene Xpert was positive in 7/7 (100%) cases of STB in which histopathology were inconclusive and 25/29 (86.21%) cases of STB in which AFB culture was negative. CONCLUSION: In STB, Gene Xpert clearly outperforms AFB culture and histopathology due to its high sensitivity and specificity apart from being rapid in diagnosis. Hence it is justified to diagnose spinal tuberculosis by Gene Xpert though histopathology is confirmative and AFB culture remains the gold standard.

Unplanned return to operation room (OR) following growing spinal constructs (GSCs) in early onset scoliosis (EOS)-a multi-centric study.

PURPOSE: To evaluate the incidence and risk factors associated with the unplanned return to OR in EOS. METHODS: Medical records of 51 patients of EOS operated at three different centres using various types of GSCs were evaluated for complications requiring unplanned surgeries. Data were analysed to find out rate of unplanned surgeries in relation to the aetiology, age and Cobb angle at index surgery, type of implant, cause of unplanned surgery, and management required. RESULTS: Out of 51 patients, three did not meet inclusion criteria. Forty-eight patients of EOS operated by GSCs with a mean age of 6.7 years (range 2-12 years) with an average follow-up of 67.3 months were studied. There were 30 congenital, 10 idiopathic, 4 syndromic, and 4 neuromuscular cases. Thirty-nine out of 48 patients had one or more unplanned surgeries on follow-up (81.25%). Out of total 248 surgeries following index procedure, 82 were unplanned surgeries (33.06%), including 53 implant revisions, 12 implant-removal, 14 debridement, and 2 flaps. The common complications were 24.14% rod/screw breakage, 42.53% anchor pull-out, 16.09% infections, 6.90% wound dehiscence, and 4.6% neuro deficits. Unplanned surgeries were significantly higher in syndromic (58.8%) and neuromuscular (52.9%) than congenital (27.2%) and idiopathic (37.8%) cases (p < 0.05). Age at index procedure < 5 years had higher unplanned surgeries than age > 5 years (2.5 and 1.23 per patient, respectively,  p < 0.05). Type of implant and initial Cobb angle did not significantly affect the rate of unplanned surgeries (p  > 0.05) CONCLUSION: GSCs in EOS require a frequent revisit to operation room which should be well understood by the surgeon and parents.