Geriatric spine fractures - Demography, changing trends, challenges and special considerations: A narrative review.

The aim of this manuscript was to summarize the demography and changing trends of geriatric spinal injuries and to enumerate the challenges and special considerations in the care of geriatric spinal injuries. PubMed, Scopus and Embase databases were searched for literature on geriatric spine fractures using MeSH terms 'aged', 'aged, 80 and over', 'elderly', 'spinal fracture/epidemiology', spinal fracture/therapy∗' and keywords pertaining to the same. The search results were screened for appropriate articles and reviewed. There is a high community prevalence of elderly vertebral fractures ranging from 18% to as high as 51%. The proportion of older patients among the spinal injured is rising as well. There is a higher chance of missing spinal injuries in the elderly and clinical guidelines may not be applicable to this patient group. Classification and surgical treatment are different from younger adult counterparts as the elderly osteoporotic spine behaves differently biomechanically. There is a high incidence of respiratory complications both for surgically and conservatively managed groups. Older age generally is associated with a higher complication rate including mortality.

A Computed Tomography-Based Assessment of the Anatomical Parameters Concerning S2-Alar Iliac Screw Insertion Using "Safe Trajectory Method" in Indian Population.

STUDY DESIGN: A retrospective computed tomography (CT)-based radiological analysis. PURPOSE: To obtain CT-based morphometric data for the S2 alar iliac (S2AI) screw in the Indian population presenting to School of Medical Sciences and Research, Greater Noida, we used the concept of "safe trajectory" by Pontes and his colleagues in a recent study. OVERVIEW OF LITERATURE: Although previous CT-based morphometric studies on the S2AI screw have been published for a variety of ethnic groups, morphometric data specifically for the Indian population are scarce. METHODS: We used the three-dimensional multiplanar reformatting software to conduct a retrospective CT analysis of 112 consecutive patients who met our exclusion criteria for various abdominal and pelvic pathologies. CT imaging planes were rotated between the S1 and S2 foramen until they matched the ideal S2AI screw trajectory, which was represented by the longest and widest iliac osseous channel observed in the axial CT section. Following the concept of a safe trajectory, S2AI screw morphometric parameters were measured on both sides of the pelvis using corresponding axial and sagittal CT images. RESULTS: In the sagittal and transverse planes on both sides of the pelvis, females had significantly higher screw trajectory angulation than males (p<0.001). On both sides of the pelvis, males had significantly greater iliac width, maximum screw trajectory length, and intrascrotal length than females (p<0.001). On both sides of the pelvis, the S2AI screw entry point in females was significantly deeper than in males from the skin margin (p<0.001). CONCLUSIONS: Based on our methodology, we discovered that the S2AI screw trajectory is significantly more caudal and lateral in females, the maximum screw length is sufficient for use in clinical practice regardless of gender, and that 8.5 mm or even larger screw diameters are feasible in the majority of the Indian population.

Multilevel thoracic and lumbar ligamentum flavum ossification in an achondroplasic-a rare presentation.

INTRODUCTION: Achondroplasia is a rare autosomal dominant condition characterized by stenosis in spinal canal. Multilevel Ossification of the ligamentum flavum in the spine is a rare occurrence which too can contribute to stenosed canal. CASE PRESENTATION: We report a case of an Indian achondroplasic dwarf with multilevel ossification of ligamentum flavum (OLF) at thoracic and lumbar segment. She presented in the outpatient department with bilateral weakness in legs with complete foot drop on the left side and was non-ambulatory. She was managed surgically by instrumentation with multiple interbody fusions with wide decompression and excision of OLF. The patient responded well to the surgery and became a walker after 2-year follow-up. DISCUSSION: Achondroplasic patients may present rarely with multiregional and multilevel OLF. It is important to identify them preoperatively so as to have good surgical outcome. Wide laminectomy, removal of the ossified ligament, and fusion with instrumentation resulted in the improvement of the patient's neurological symptoms and functions.

MRI-Based Morphometric Study Regarding Operative Windows of Oblique Lumbar Interbody Fusion in Indian Population.

BACKGROUND: The novel Oblique lumbar interbody fusion [OLIF] technique has been proposed as a solution to approach related complications of anterior lumbar interbody fusion [ALIF] and lateral lumbar interbody fusion [LLIF]. There exists no study concerning morphological evaluation of retroperitoneal oblique corridor for the Oblique lumbar interbody fusion (OLIF) technique in the Indian population. The aim of our study was (a) to measure magnetic resonance imaging (MRI) based anatomic parameters concerning OLIF operative windows from L2-L3 to L4-L5 level (b) to determine the feasibility of this technique following MRI-based morphometric evaluation in the Indian population. MATERIAL AND METHODS: We did retrospective MRI analysis of 307 consecutive patients following our exclusion criteria. Bare window, psoas major window and psoas major width were measured from axial T2 MRI image taken at mid disc level from L2-L3 to L4-L5 levels. RESULTS: The mean bare window size was largest at L2-L3 (1.39 cm) level followed by L3-L4 and L4-L5 level (1.28 and 0.62 cm respectively), and differences between them were statistically significant (P < 0.001). Females had statistically significant larger bare windows at L2-L3 and L3-L4 level than males (P < 0.001). With increasing age, there was a significant increase in bare window size at each level (P < 0.001). The mean psoas major window (PMO) and mean psoas major width (PMI) were largest at L4-L5 level (PMO = 1.27 cm, PMI = 3.61 cm) followed by L3-L4 and L2-L3 level (L3-L4: PMO = 1.19 cm, PMI = 2.36 cm; L2-L3: PMO = 0.88 cm, PMI = 1.39 cm), and differences among each level concerning both parameters were statistically significant (P < 0.001). Both parameters (PMO, PMI) were significantly larger in males than females at each level (P < 0.001). CONCLUSION: The OLIF technique is well suited for lumbar interbody fusion at L2 -L3 and L3-L4 level in the Indian population irrespective of age and sex. At L4-L5 level, overall 17.9 percent of the study population were unsuitable for this technique due to inaccessible bare window. In our opinion, this level may be better suited for OLIF approach in the elderly Indian population, especially for surgeons who are beginning to attempt this technique in their surgical practice. Preoperative MRI evaluation for the OLIF is important to assess its feasibility, as there exists significant age and gender differences in the Indian population for anatomic parameters concerning OLIF operative windows from L2-L3 to L4-L5 levels. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00393-7.

Experimental animal modelling for pressure injury: A systematic review.

INTRODUCTION: Pressure injury (PI) is a potentially serious condition that is often a consequence of other medical illnesses. It remains a challenge for the clinicians and the researcher to fully understand and develop a technique for comprehending pathogenicity, prevention and treatment. Several animal models have been created to understand the multifaceted cellular and biochemical processes of PI. There are numerous known intrinsic and extrinsic factors influencing the recovery of PI. Some of the important factors are friction, spinal cord injury, diabetes, nutrition, aging, infection, medication, obesity and vascular diseases. The dearth of optimal, pre-clinical animal models capable of mimicking the human PI remains a major challenge for its cure. An ideal animal model must endeavour the reproducibility, clinical significance, and most importantly effective translation into clinical use. METHODS: In this current systematic review, a methodological literature review was conducted on the PRISMA guidelines. PubMed/Medline, Research Scholar and Science Direct databases were searched. We conferred the animal models like mice, rats, pigs and dogs used in the PI experiments between January 1980 to January 2021. Typically, methods like Ischemia-reperfusion (IR), monoplegia pressure sore and mechanical non-invasive have been discussed. These were used to generate pressure injuries in small and large animal models. RESULTS AND CONCLUSION: Different animal models (mouse, rat, pig, dog) were evaluated based on ease of handling, availability for research, their size, skin type and the technical skills required. Studies suggest that mice and rats are the best-suited animals as their skin healing by contraction resembles the skin healing in humans. In most of the studies with mice and rats, the time taken for the recovery was between 1 and 3 weeks. Further, various techniques discussed in the current systematics review, supports the statement that the Ischemia-reperfusion (IR) method is the most suited method to study pressure injury. It is a controlled method that can develop different stages of PI and does not require any specialized setup for the application.

Comparison of Functional Outcomes Between Lumbar Interbody Fusion Surgery and Discectomy in Massive Lumbar Disc Herniation: A Retrospective Analysis.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: Lumbar disc herniation is one the most common condition responsible for low back and radicular pain. Although the symptoms are not proportional to the size of disc prolapse but massive disc herniation frequently needs surgical management. According to literature, the incidence of low back pain, recurrent disc herniation and segmental instability are more in discectomy whereas incidence of adjacent segment degeneration (ASD) is more after fusion surgery. There are very few studies that directly compare long-term functional outcome of both these procedures. We compared the functional outcome of both the procedures in this study. METHODS: All patients of massive disc prolapse, operated at our center between 2011 to 2017, were contacted. All the patients underwent either discectomy or transforaminal lumbar interbody fusion (TLIF). Functional outcomes of all the patients were collected using visual analogue scale (VAS) (back), VAS (leg), modified Oswestry Disability Index (mODI), Sciatica Bothersomeness Index (SBI), and McNab's criterion. Various complications were also analyzed. RESULTS: There were 144 patients in the discectomy group and 123 patients in the TLIF group. Mean duration of follow-up was 55.07 months and 51.86 months, respectively. Both the groups show no significant difference in VAS. Significant difference was seen in mODI and SBI favoring discectomy. McNab's criterion showed excellent result in 80% of patients of discectomy compared with 68% patients of TLIF. Overall complication rate in discectomy group was 11% whereas 13% in TLIF group. CONCLUSION: Both show good functional outcome but better in discectomy. Recurrent herniation and instability were noticed more with discectomy and ASD was more common after fusion surgeries. The choice of procedure should be individualized, and it also depends on surgical expertise, but in developing countries where resources are constrained, discectomy should be preferred.

A rare case of surgically managed multiple congenital thoraco-lumbar and lumbar block vertebrae with kypho-scoliosis and adjacent segment disease with myelopathy in a young female.

Spinal block vertebrae is a rare condition reported in 0.25% of South Asian population. This condition may not only result in deformity of lower back but also alter the bio-mechanics of spine leading to adjacent level degeneration and spinal canal stenosis. There is little literature evidence on surgical management of such a condition. Here we report a case of multiple congenital thoraco-lumbar and lumbar block vertebrae with lumbar kypho-scoliosis, adjacent segment disease and myelopathy in a young Asian female. She was operated with minimal possible instrumentation and decompression. Patient is pain free now and is able to walk without support, one year following the primary treatment.

Radiological protocol in spinal trauma: literature review and Spinal Cord Society position statement.

PURPOSE: The Spinal Cord Society constituted a panel tasked with reviewing the literature on the radiological evaluation of spinal trauma with or without spinal cord injury and recommend a protocol. This position statement provides recommendations for the use of each modality, i.e., radiographs (X-rays), computed tomography (CT), magnetic resonance imaging (MRI), as well as vascular imaging, and makes suggestions on identifying or clearing spinal injury in trauma patients. METHODS: PubMed was searched for the corresponding keywords from January 1, 1980, to August 1, 2017. A MEDLINE search was subsequently undertaken after applying MeSH filters. Appropriate cross-references were retrieved. Out of the 545 articles retrieved, 105 relevant papers that address the present topic were studied and the extracted content was circulated for further discussions. A draft position statement was compiled and circulated among the panel members via e-mail. The draft was modified by incorporating relevant suggestions to reach a consensus. RESULTS AND CONCLUSION: For imaging cervical and thoracolumbar spine trauma patients, CT without contrast is generally considered to be the initial line of imaging and radiographs are required if CT is unavailable or unaffordable. CT screening in polytrauma cases is best done with a multidetector CT by utilizing the reformatted images obtained when scanning the chest, abdomen, and pelvis (CT-CAP). MRI is indicated in cases with neurological involvement and advanced cervical degenerative changes and to determine the extent of soft tissue injury, i.e., disco-ligamentous injuries as well as epidural space compromise. MRI is also usually performed when X-rays and CT are unable to correlate with patient symptomatology. These slides can be retrieved under Electronic Supplementary Material.

Management and prognosis of acute traumatic cervical central cord syndrome: systematic review and Spinal Cord Society-Spine Trauma Study Group position statement.

PURPOSE: Spinal Cord Society (SCS) and Spine Trauma Study Group (STSG) established a panel tasked with reviewing management and prognosis of acute traumatic cervical central cord syndrome (ATCCS) and recommend a consensus statement for its management. METHODS: A systematic review was performed according to the PRISMA 2009 guidelines. Delphi method was used to identify key research questions and achieve consensus. PubMed, Scopus and Google Scholar were searched for corresponding keywords. The initial search retrieved 770 articles of which 37 articles dealing with management, timing of surgery, complications or prognosis of ATCCS were identified. The literature review and draft position statements were compiled and circulated to panel members. The draft was modified incorporating relevant suggestions to reach consensus. RESULTS: Out of 37 studies, 15 were regarding management strategy, ten regarding timing of surgery and 12 regarding prognosis of ATCCS. CONCLUSION: There is reasonable evidence that patients with ATCCS secondary to vertebral fracture, dislocation, traumatic disc herniation or instability have better outcomes with early surgery (< 24 h). In patients of ATCCS secondary to extension injury in stenotic cervical canal without fracture/fracture dislocation/traumatic disc herniation/instability, there is requirement of high-quality prospective randomized controlled trials to resolve controversy regarding early surgery versus conservative management and delayed surgery if recovery plateaus or if there is a neurological deterioration. Until such time decision on surgery and its timing should be left to the judgment of physician, deliberating on pros and cons relevant to the particular patient and involving the well-informed patient and relatives in decision making. These slides can be retrieved under Electronic Supplementary Material.

Smartphone app in self-management of chronic low back pain: a randomized controlled trial.

BACKGROUND: Mobile health (mHealth) is emerging as the most convenient way to deliver rehabilitation services remotely, and collect outcomes in real time, thus contributing to disease management by transferring care from hospital to home. It facilitates accessibility to healthcare, enhances patients' understanding of their condition, and their willingness to engage in self-management, giving way to high-quality care to the satisfaction of both patients and healthcare professionals. PURPOSE: The purpose of this study was to examine the effect of using a smartphone app (called Snapcare) on pain and function in patients suffering from chronic low back pain. METHODS: Ninety-three patients with chronic low back pain were recruited and randomly allocated to either the Conventional group (n = 48) receiving a written prescription from the Physician, containing a list of prescribed medicines and dosages, and stating the recommended level of physical activity (including home exercises) or the App group (n = 45) receiving Snapcare, in addition to the written prescription. Pain and disability were assessed at baseline and after 12 weeks of treatment. RESULTS: Both the groups showed significant improvement in pain and disability (p < 0.05). The App group showed a significantly greater decline in disability (p < 0.001). CONCLUSION: Health applications are promising tools for improving outcomes in patients suffering from various chronic conditions. Snapcare facilitated increase in physical activity and brought about clinically meaningful improvements in pain and disability in patients with chronic low back pain. These slides can be retrieved under Electronic Supplementary Material.

International Spinal Cord Society (ISCoS) database: Asian Spinal Cord Network (ASCoN) Pilot Project [IDAPP].

STUDY DESIGN: Global mapping project of ISCoS for traumatic spinal cord injury (T-SCI) highlighted paucity of data from low and middle income countries (LMICs). Recognizing this gap, IDAPP study of one year duration was proposed as the first step to develop an International SCI database. OBJECTIVES: Primary objective was to assess database variables, processes involved and web platform for their suitability with a view to provide guidance for a large scale global project. Secondary objective was to capture demographic and selected injury/safety data on patients with T-SCI with a view to formulate prevention strategies. SETTING: Nine centers from Asia. METHODS: All patients with T-SCI admitted for first time were included. International SCI Core Data Set and especially compiled Minimal Safety Data Set were used as data elements. Questionnaire was used for feedback from centers. RESULTS: Results showed relevance and appropriateness of processes, data variables and web platform of the study. Ease of entering and retrieval of data from web platform was confirmed. Cost of one year IDAPP study was USD 7780. 975 patients were enrolled. 790 (81%) were males. High falls (n = 513, 52%) as a cause and complete injuries (n = 547, 56%) were more common. There was a higher percentage of thoracic and lumbar injuries (n = 516, 53%). CONCLUSIONS: The study confirms that establishing the SCI database is possible using the variables, processes and web platform of the pilot study. It also provides a low cost solution. Expansion to other centers/regions and including non-traumatic SCI would be the next step forward.

Challenges in comprehensive management of spinal cord injury in India and in the Asian Spinal Cord network region: findings of a survey of experts, patients and consumers.

STUDY DESIGN: Online survey. OBJECTIVES: To understand the prevailing scenario of the comprehensive management of spinal cord injuries (SCI) in India and in the Asian Spinal Cord Network (ASCoN) region, especially with a view to document the challenges faced and its impact. SETTING: Indian Spinal Injuries Centre. METHODS: A questionnaire was designed which covered various aspects of SCI management. Patients, consumers (spinal injured patients discharged since at least 1 year) and experts in SCI management from different parts of India and the ASCoN region were approached to complete the survey. RESULTS: Sixty patients, 66 consumers and 34 experts completed the survey. Difference of opinion was noticed among the three groups. Disposable Nelaton catheters were used by 57% consumers and 47% patients. For reusable catheter, 31% experts recommended processing with soap and running water and 45% recommended clean cotton cloth bag for storage. Pre-hospital care and community inclusion pose the biggest challenges in management of SCI. More than 75% of SCI faced problems of access and mobility in the community. Awareness about SCI, illiteracy and inadequate patient education are the most important factors hindering pre- and in-hospital care. Inadequate physical as well as vocational rehabilitation and financial barriers are thought to be the major factors hindering integration of spinal injured into mainstream society. Strong family support helped in rehabilitation. CONCLUSIONS: Our study brought out that SCI in India and ASCoN region face numerous challenges that affect access to almost all aspects of comprehensive management of SCI.

Cost-effectiveness analysis of telephone-based support for the management of pressure ulcers in people with spinal cord injury in India and Bangladesh.

OBJECTIVE: To determine from a societal perspective the cost-effectiveness and cost-utility of telephone-based support for management of pressure ulcers. STUDY DESIGN: Cost-effectiveness and cost-utility analysis of a randomised clinical trial. SETTING: Tertiary centre in India and Bangladesh. METHODS: An economic evaluation was conducted alongside a randomised clinical trial comparing 12 weeks of telephone-based support (intervention group) with usual care (control group). The analyses evaluated costs and health outcomes in terms of cm2 reduction of pressure ulcers size and quality-adjusted life years (QALYs) gained. All costs were in Indian Rupees (INR) and then converted to US dollars (USD). RESULTS: The mean (95% confidence interval) between-group difference for the reduction in size of pressure ulcers was 0.53 (-3.12 to 4.32) cm2, favouring the intervention group. The corresponding QALYs were 0.027 (0.004-0.051), favouring the intervention group. The mean total cost per participant in the intervention group was INR 43 781 (USD 2460) compared to INR 42 561 (USD 2391) for the control group. The per participant cost of delivering the intervention was INR 2110 (USD 119). The incremental cost-effectiveness ratio was INR 2306 (USD 130) per additional cm2 reduction in the size of the pressure ulcer and INR 44 915 (USD 2523) per QALY gained. CONCLUSION: In terms of QALYs, telephone-based support to help people manage pressure ulcers at home provides good value for money and has an 87% probability of being cost-effective, based on 3 times gross domestic product. Sensitivity analyses were performed using the overall cost data with and without productivity costs, and did not alter this conclusion.

Demographics of tuberculosis of spine and factors affecting neurological improvement in patients suffering from tuberculosis of spine: a retrospective analysis of 312 cases.

OBJECTIVES: The purpose of the study was to study demographics of tuberculosis of spine and analyze factors that might affect neurological improvement in such patients. METHODS: Of the 638 suspected cases of spinal tuberculosis, 312 cases with confirmed diagnosis with at least 1-year follow-up were selected for retrospective analysis. Two hundred cases who presented with neurological deficit were further divided into three groups-completely improved, partially improved and no improvement according to American Spinal Injury Association impairment scale (AIS) grading. All continuous variables and categorical variables were compared across groups. RESULTS: A total of 209 (66.99%) patients had typical clinical presentation. A total of 264 (84.62%) had typical magnetic resonance imaging (MRI) presentation. Among 356 involved vertebrae, thoracic levels (T1-10) were most commonly affected in 163 (45.78%) followed by thoracolumbar (T11-L2) vertebrae in 98 (27.52%). In 250 patients (80.12%), disease was restricted to one or two adjoining vertebrae. At presentation, 112 (35.89%) patients were neurologically intact, whereas 97 (31%) were AIS D, 65 (20.83%) were AIS C, 8 (2.5%) were AIS B and 30 (9.61%) were AIS A. On statistical analysis, although three groups of patients with complete improvement, partial improvement and no improvement were similar in age, sex, radiological presentation, and co-morbidities and the presence of pulmonary tuberculosis, they were significantly different with regard to the levels of vertebral involvement, AIS grade at presentation, bladder and bowel involvement and its duration. CONCLUSIONS: In management of patients suffering from tuberculosis of spine, levels of vertebral involvement, AIS grade at presentation, bladder and bowel involvement and its duration significantly affect the final neurological improvement.

The reliability of measuring wound undermining in people with spinal cord injury.

OBJECTIVE: The objective of this study was to determine the reliability of measuring wound undermining in people with spinal cord injury (SCI). STUDY DESIGN: A psychometric study. SETTING: The study was conducted at the Indian Spinal Injuries Centre, New Delhi, India. PARTICIPANTS: Thirty people with a complete or incomplete SCI and a pressure ulcer with wound undermining were recruited. METHODS: Wound undermining was measured using the four cardinal points from a clock face (with 12 O'clock defined as towards the head). Inter-rater reliability was tested by comparing the wound undermining scores from two different assessors. Intra-rater reliability was tested by comparing the wound undermining scores from the same assessor on two different days. RESULTS: The intraclass correlation coefficients (95% confidence interval) for inter-rater and intra-rater reliability were 0.996 (0.992-0.999) and 0.998 (0.996-0.999), respectively. Repeat measurements by the same and different assessor were within 0.3 cm of each other, 80% and 83% of the time, respectively. CONCLUSION: Measurements of wound undermining have excellent reliability.

Telephone-based management of pressure ulcers in people with spinal cord injury in low- and middle-income countries: a randomised controlled trial.

STUDY DESIGN: A multicentre, prospective, assessor-blinded, parallel randomised controlled trial. OBJECTIVES: The objective of the trial was to determine the effectiveness of telephone-based management of pressure ulcers in people with spinal cord injury (SCI) in low- and middle-income countries. METHODS: One hundred and twenty people with SCI living in the community were recruited through three hospitals in India and Bangladesh between November 2013 and March 2016. Participants had sustained an SCI >3 months prior and had a pressure ulcer. Participants were randomly allocated (1:1) to a control or intervention group. Participants in the control group received no intervention. Participants in the intervention group received weekly advice by telephone for 12 weeks about the management of their pressure ulcers from a trained health-care professional. Outcomes were measured by a blinded assessor at baseline and 12 weeks. There was one primary outcome, namely, the size of the pressure ulcer and 13 secondary outcomes. RESULTS: The mean between-group difference for the size of the pressure ulcer at 12 weeks was 2.3 cm2 (95% confidence interval -0.3 to 4.9; favouring the intervention group). Eight of the 13 secondary outcomes were statistically significant. CONCLUSION: The results of our primary outcome (that is, size of pressure ulcer) do not provide conclusive evidence that people with SCI can be supported at home to manage their pressure ulcers through regular telephone-based advice. However, the results from the secondary outcomes are sufficiently positive to provide hope that this simple intervention may provide some relief from this insidious problem in the future.

Reliability of the International Spinal Cord Injury Musculoskeletal Basic Data Set.

STUDY DESIGN: Psychometric study. OBJECTIVES: To determine the intra- and inter-rater reliability and content validity of the International Spinal Cord Injury (SCI) Musculoskeletal Basic Data Set (ISCIMSBDS). SETTING: Four centers with one in each of the countries in Australia, England, India and the United States of America. METHODS: A total of 117 participants with a C2 to S1 neurological level and American Spinal Injury Association Impairment Scale A to D injury were recruited. The median (interquartile range) time since injury was 9 years (2-29). Fifty-seven participants were assessed by the same assessor, and 60 participants were assessed by two different assessors on two different occasions to determine the intra- and inter-rater reliability, respectively. Kappa statistics or crude agreement was used to measure reliability. Content validity was assessed through focus group interviews of people with SCI and health-care professionals. RESULTS: The intra-rater reliability ranged from κ=0.62 to 1.00 and crude agreement from 75% to 100% for each of the variables on the ISCIMSBDS. The inter-rater reliability ranged from κ=-0.25 to 1.00, with a diverse crude agreement ranging from 0% to 100%. The inter-rater reliability was unsatisfactory for the following variables: 'Date of fracture', 'Fragility fractures', 'Scoliosis, method of assessment', 'Other musculoskeletal problems' and 'Do any of the above musculoskeletal challenges interfere with your activities of daily living (transfers, walking, dressing, showers, etc.)?'. Results from validity discussions implied no major suggestions for changes. CONCLUSION: Overall, the ISCIMSBDS is reliable and valid, although 5 of the 12 variables may benefit from further refinement.

Erratum: Management of neglected sacral fracture with cauda equina syndrome: report of two cases with review of literature.

[This corrects the article DOI: 10.1038/scsandc.2015.20.][This corrects the article DOI: 10.1038/scsandc.2015.20.].

A case of severe and rigid congenital thoracolumbar lordoscoliosis with diastematomyelia presenting with type 2 respiratory failure: managed by staged correction with controlled axial traction.

INTRODUCTION: Congenital lordoscoliosis is an uncommon pathology and its management poses formidable challenge especially in the presence of type 2 respiratory failure and intraspinal anomalies. In such patients standard management protocols are not applicable and may require multistage procedure to minimize risk and optimize results. CASE DESCRIPTION: A 15-year-old girl presented in our hospital emergency services with severe breathing difficulty. She had a severe and rapidly progressing deformity in her back, noted since 6 years of age, associated with severe respiratory distress requiring oxygen and BiPAP support. She was diagnosed to have a severe and rigid congenital right thoracolumbar lordoscoliosis (coronal Cobb's angle: 105° and thoracic lordosis -10°) with type 1 split cord malformation with bony septum extending from T11 to L3. This leads to presentation of restrictive lung disease with type 2 respiratory failure. As her lung condition did not allow for any major procedure, we did a staged procedure rather than executing in a single stage. Controlled axial traction by halogravity was applied initially followed by halo-femoral traction. Four weeks later, this was replaced by halo-pelvic distraction device after a posterior release procedure with asymmetric pedicle substraction osteotomies at T7 and T10. Halo-pelvic distraction continued for 4 more weeks to optimize and correct the deformity. Subsequently definitive posterior stabilization and fusion was done. The detrimental effect of diastematomyelia resection in such cases is clearly evident from literature, so it was left unresected. A good scoliotic correction with improved respiratory function was achieved. Three years follow-up showed no loss of deformity correction, no evidence of pseudarthrosis and a good clinical outcome with reasonably balanced spine. CONCLUSION: The management of severe and rigid congenital lordoscoliotic deformities with intraspinal anomalies is challenging. Progressive reduction in respiratory volume in untreated cases can lead to acute respiratory failure. Such patients have a high rate of intraoperative and postoperative morbidity and mortality. Hence a staged procedure is recommended. Initially a less invasive procedure like halo traction helps to improve their respiratory function with simultaneous correction of the deformity, while allowing for monitoring of neurological deficit. Subsequently spinal osteotomies and combined halo traction helps further improve the correction, following which definitive instrumented fusion can be done.