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.

A novel technique of managing an irreducible posteriorly displaced type 2 odontoid fracture: A case report.

Background: Type 2 odontoid fractures with posterior displacement are rare. Most acute cases reported in the literature are readily reduced with traction alone. Here, we reviewed the management of a chronic, posteriorly displaced odontoid fracture that was managed with a unique posterior reduction maneuver. Case Description: A 58-year-old male with a chronic type 2 retro-odontoid displaced fracture was managed with traction and an anterior force applied to the displaced odontoid fragment using rods attached to bilateral C1 lateral mass screws. Notably, this included a simultaneous cantilever maneuver using a lever placed between the C1 and C2 facet joints. Following reduction, an atlantoaxial fusion was performed. The postoperative course of the patient was uneventful and the bone union was achieved in 1 year. Conclusion: Closed reduction is rarely successful in chronic posteriorly displaced type 2 odontoid fractures. These cases require meticulous open reduction and fixation.

Is Ultrasound (US)-Guided Platelet-Rich Plasma Injection More Efficacious as a Treatment Modality for Lateral Elbow Tendinopathy Than US-Guided Steroid Injection?: A Prospective Triple-Blinded Study with Midterm Follow-up.

Background: Lateral elbow tendinopathy (LET) has an array of modalities described for its management. The present study analyzed two modalities used for managing the condition. Methods: The present study included 64 non-athletes with LET who failed conservative treatment that included avoiding strenuous activities, ice-fomentation, non-steroidal anti-inflammatory drugs, bracing, and physiotherapy for 6 months. A random allocation of the participants was done, with one group injected with platelet-rich plasma (PRP) and the other group with corticosteroids. The procedure was performed by the same blinded orthopedic surgeon after localizing the pathology using ultrasound. Visual analog scale (VAS) scores, disabilities of the arm, shoulder and hand (DASH) scores, Patient-Rated Tennis Elbow Evaluation (PRTEE) scores, and handgrip strengths were recorded by blinded observers other than the surgeon administering the injection. Results: The average age of the patients was 40 years. The mean VAS score at the latest follow-up of 2 years in the PRP group was 1.25 and it was significantly better than the score of 3.68 in the steroid group (p < 0.001). The mean DASH score at the latest follow-up of 2 years in the PRP group was 4.00 and it was significantly better than the score of 7.43 in the steroid group (p < 0.001). The mean PRTEE score at the latest follow-up of 2 years in the PRP group was 3.96 and it was significantly better than the score of 7.53 in the steroid group (p < 0.001). The scores were better in the steroid group at a short-term follow-up of 3 months (p < 0.05), while they were better in the PRP group at a long-term follow-up of 2 years (p < 0.05). Hand-grip strength was comparable in the PRP group (84.43 kg force) and steroid group (76.71 kg force) at the end of the 2-year follow-up with no statistically significant difference (p = 0.149). Conclusions: Corticosteroid injections alleviated symptoms of LET over short-term follow-up providing quicker symptomatic relief; however, the effect faded off over the long term. PRP injections provided a more gradual but sustained improvement over the long-term follow-up, indicating the biological healing potential of PRP.

Hemi-hamate arthroplasty for the management of chronic proximal interphalangeal joint fracture dislocations: Analysis of 21 cases in Indian population and review of the literature.

Background: Chronic fracture-dislocations involving the proximal interphalangeal (PIP) joint are challenging cases. We conducted this study to analyze the outcomes following hemi-hamate autograft reconstruction of such injuries and to compare our results with the existing literature. Methods: A retrospective analysis of 21 patients with chronic dorsal PIP fracture-dislocations that were managed with hemi-hamate autograft reconstruction was done. The average articular surface involvement was 64%. The average duration between injury and surgery was 9.4 weeks (range, 6-16). Quick DASH (Disabilities of Shoulder and Hand) scores, VAS (Visual Analog Scale) scores, range of motion of the PIP joints, DIP (distal interphalangeal) joints, and MCP (metacarpophalangeal) joints were measured during serial follow-up visits. Results: Union and graft incorporation was seen in all cases. The average Quick DASH score at four weeks post-surgery was 66 and it improved to eight at one year (p-value<0.05). The average VAS score at four weeks post-surgery was 7.66 and it improved to 2.09 at one year (p-value<0.05). The mean flexion of the MCP joint improved from 52.85° at the end of four weeks to 72.38° at one year (p-value<0.05). The average flexion at the PIP joint improved from 10.47° at the end of four weeks to 70.47° at one year (p-value<0.05). The average DIP flexion improved from 38.33° at the end of four weeks to 62.38° at one year (p-value<0.05). The average hand grip strength was 85% of the normal side. Conclusion: Hemihamate autograft reconstruction is a suitable procedure for the management of chronic PIP joint fracture-dislocations, especially in cases with extensive involvement of the articular surface. Level of evidence: III.

Diagnosis of Intraosseous Hibernoma of an Appendicular Skeleton in an Adult - A Rare Case Report.

Introduction: Hibernoma is an uncommon benign tumor composed of multivacuolated brown adipocytes described in the literature a decade back. Intraosseous hibernomas are extremely rare with propensity to affect axial skeleton. Involvement of appendicular skeleton has been reported only twice in the literature till date. Case Report: We present a case of solitary, painless mass in the left proximal tibia mimicking neoplasm in a 35-year-old male. The plain radiographs revealed a lytic lesion with well-defined margin at the junction of metaphyseal-diaphyseal region of the left proximal tibia. The lesion was hyperintense on T2 and hypointense on T1 with heterogenous enhancement on contrast imaging. FDG-PET showed high uptake of fluorodeoxyglucose. Histopathological examination revealed the presence of multivacuolated cytoplasm with abundant mitochondria suggestive of hibernoma. On immunohistochemistry, the cells were positive for S-100. Conclusion: The findings of imaging modalities are non-specific and histopathological examination is required to confirm the diagnosis of hibernoma. Intraosseous hibernoma needs to be considered as a differential diagnosis of sclerotic bone lesion. Further, evaluation with regular follow-up with imaging will be required if the mass undergoes any clinical changes. Both radiologists and pathologists, need to be aware of this rare entity to avoid misdiagnosis of the uncommon lesion.

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.

A case of cervical OPLL and DISH mimicking stroke.

Background: Ossification of the posterior longitudinal ligament (OPLL) is a progressive disorder that mostly involves the cervical spine. It is more prevalent in East Asian countries. Patients typically present with the gradual onset of myelopathy, while about 5% show rapid progression. Case Description: A 51-year-old diabetic and hypertensive male presented with a left-sided hemiparesis following trivial trauma. The first diagnosis was a stroke, but the subsequent workup proved negative. Subsequently, the MRI and CT studies demonstrated significant cord compression due to OPLL extending from C2 to C7. There was also a heterogeneous hyperintense intramedullary cord signal indicative of edema/myelomalacia in the retro- odontoid region. The CT also diagnosed C2-C7 diffuse idiopathic skeletal hyperostosis. Conclusion: Patients with cervical myelopathy due to OPLL rarely present about 5% of the time with the acute onset of neurological deficit following minor trauma. Certainly, one must consider high cervical OPLL as responsible for hemiparesis in a patient whose brain MR has ruled out a stroke.

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).

Extensive Synovial Chondromatosis of the Knee Managed by open radical synovectomy: A Case Report with review of literature.

Introduction: Synovial chondromatosis of the knee is an unusual, rare, benign metaplastic neoplasm of the synovium, characterized by the formation of focal cartilaginous nodules in the synovium. It predominantly involves the anterior compartment of knee and extensive, disseminated involvement is rarely reported. Diagnosis is usually established with clinicoradiological imaging and confirmed by histology. The paucity of literature on the management of synovial chondromatosis puts an orthopedician in dilemma regarding the optimal surgical intervention. Case Report: We report a case of 50-year-old male who presented with severe pain and swelling in his left knee associated with functional incapacitation. Magnetic resonance imaging demonstrated diffuse proliferation of synovium with mild effusion displaying multiple, disseminated calcific nodules. We managed the case by open removal of loose bodies and radical synovectomy through combined anterior and posterior approach. At 4 years follow-up, there are no clinical or radiological signs of recurrence. Conclusion: Extensive involvement of the knee with calcific nodules is extremely rare. Treatment is controversial which usually includes removal of loose bodies combined with an open or arthroscopic synovectomy. Our case report recommends single stage, open retrieval of loose bodies combined with radical synovectomy to decrease the incidence of recurrence in extensive synovial chondromatosis. To the best of our knowledge, disseminated synovial chondromatosis of the knee, managed by open, combined approach, has been reported only once in the literature.

Analysis of Functional Outcomes Following Surgical Management of Neglected Multiple Carpometacarpal Dislocations: A Series of four Cases and Review of Literature.

Introduction: Dislocation of the carpometacarpal (CMC) joint is a rare injury that results following high-velocity trauma. Although there are a few anecdotal reports of isolated CMC joint dislocations, there is scarce literature concerning dislocations involving multiple joints, especially those that are neglected and present late after injury. The injury is often missed when the patient presents to the surgeon since the swelling obscures the characteristic deformity, and the fracture may not be apparent on radiographs. When missed at the initial presentation, they can frequently result in pain, swelling, reduced grip strength, and arthritis. Such injuries require surgical management, along with prompt post-operative physiotherapy to enable the patient to regain satisfactory grip strength and range of motion. Case Report: We retrospectively analyzed four cases of multiple CMC joint dislocations that were managed surgically at our tertiary apex center. The average duration between injury and presentation to our center was five weeks. We used the quick disabilities of the arm, shoulder, and hand (DASH) scores and the maximum handgrip strength to assess the functional outcomes and the visual analog scale (VAS) to assess the pain at regular intervals. All patients showed an improvement in the Quick DASH scores, VAS scores, and the handgrip strength at the latest follow-up. All patients were able to return to their occupation. Conclusion: Early diagnosis and stabilization followed by early mobilization is the key to managing multiple CMC dislocations. The cases that present late are generally associated with contracted soft-tissue structures that prevent the relocation of the injury. Such cases require open reduction, along with a release of the contracted structures and internal fixation. Supervised physiotherapy in the post-operative period is essential to regain a satisfactory range of motion and grip strength.

Recurrent symptomatic vertebral hemangioma in pregnancy managed with decompression and vertebroplasty.

BACKGROUND: Vertebral hemangioma is a benign vascular tumor of the spine that occurs in the endothelial lining of blood vessels. The majority of these lesions are detected incidentally on routine magnetic resonance imaging scans. Rarely, lesions can increase in size and result in neurological deterioration. CASE DESCRIPTION: A 19-year-old post-partum female, presented with paraplegia due to a recurrent vertebral hemangioma with exophytic extension into the epidural space resulting in spinal cord compression. Early decompressive surgery facilitated adequate early recovery of neurological function. CONCLUSION: Exophytic vertebral hemangiomas that have extended into the spinal canal resulting in cord compression require urgent surgical decompression.

A rare case of an expansile spinopelvic aneurysmal bone cyst managed with embolization, excision, and fusion.

BACKGROUND: Aneurysmal bone cysts (ABC) are benign osteolytic lesions of the metaphyseal regions of long bones that typically contribute to rapid bony expansion. Here, we present an ABC involving the spinopelvic region in a 15-year-old male that required embolization, surgical excision, and fusion. CASE DESCRIPTION: A 15-year-old male, presented with gradually progressive painful lower back swelling of 4 months' duration. Once the diagnosis of an ABC was established based on a combination of X-ray, MR, and CT studies, he underwent selective arterial embolization, extended surgical excision (i.e. curettage), with a posterior fusion. Two years postoperatively, the patient remained neurologically intact without radiographic evidence of lesion recurrence. CONCLUSION: Large expansile ABC involving the vertebral bodies should be managed with preoperative selective arterial embolization, surgical decompression/curettage, and spinopelvic fixation.