Intraoperative Neurophysiological Monitoring in Corrective Surgery of Scoliosis - Experience at a Tertiary Care Hospital.

OBJECTIVE: To evaluate the role of intraoperative neurophysiological monitoring (IONM) in reducing the postoperative neurologic deficit following corrective surgery of scoliosis. STUDY DESIGN: Observational Study. Place and Duration of the Study: Spine Surgery Department, Combined Military Hospital, Rawalpindi, from December 2022 to May 2023. METHODOLOGY: The study included 170 cases of scoliosis operated under multimodal IONM. Decreased amplitude of ≥50% in SSEP or 70-80% in MEPs were considered warning signs. Cases were divided into two groups: Group 1 (signal drop) and Group 2 (no signal drop). Group 1 was subdivided into Group 1a (true positive), Group 1b (false positive) and Group 1c (intermediate positive). Group 2 was subdivided into Group 2a (true negative) and Group 2b (false negative). RESULTS: Evoked potential changes were observed in 27 (15.9%) cases. This includes transient drop of signals in 16 (9.4%) and sustained drop of signals in 11 (6.5%) cases. Among sustained signal drop, 9 (5.29%) cases had exhibited postoperative neurological deficit whereas 2 (1.17%) cases did not show postoperative neurological deficit (false positive). Multimodal IONM in the current study shows sensitivity of 100%, specificity of 98.6%, positive predictive value of 92.6%, and negative predictive value of 100%. CONCLUSION: Multimodal IONM reduces the incidence of postoperative neurological deficit in corrective surgery of scoliosis by effectively detecting neurologic injury during surgery. Monitoring events alert surgical team to exercise immediate corrective measures which likely results in recovery of lost signals and predict the favorable outcome. KEY WORDS: Intraoperative monitoring, Motor evoked potentials, Neurological deficit, Scoliosis, Somatosensory evoked potentials.

An experience with soft transforaminal lumbar interbody fusion in postoperative discitis not responding to conservative treatment.

OBJECTIVE: To determine the effect of soft Transforaminal Interbody Lumbar Interbody Fusion (sTLIF) in postoperative discitis not responding to conservative treatment. METHODS: This cross-sectional study was conducted in Department of Spine Surgery, CMH Rawalpindi from August 2016 to July 2019. Patients who underwent discectomy were observed and those presenting with postoperative discitis were included in the study. Pain was noted on visual analogue scale before and after the intervention and differences in two readings were noted. Data was collected on predesigned proforma. Statistical analysis was done on SPSS 20.0. RESULTS: Mean age of these patients was 45±12.34 years. The mean pain score on VAS before treatment was 8.33±0.65 and after treatment was 2±0.95. There was statistically significant reduction in pre-treatment and post-treatment pain on VAS (p=0.000). CONCLUSIONS: Postoperative discitis is present among a small number of patients after spine surgery and pain is significantly reduced after the treatment of discitis with TLIF.

Outcome of hemivertebra resection in congenital thoracolumbar kyphosis and scoliosis by posterior approach.

OBJECTIVE: To find out the long term outcome of deformity correction by hemivertebra resection in congenital thoracolumbar spinal deformities by a single posterior approach. METHODS: This is a retrospective study carried out at the Department of Spine Surgery, Combined Military Hospital, Rawalpindi, Pakistan from April 2006 to April 2013. All operated patients having single level hemivertebrae of thoracolumbar spine with at least two years follow up were included. Data was analyzed using SPSS ver. 17. RESULTS: There were 24 patients with mean age of 17 years (SD=8.41). Male to female ratio was 9(37.5%): 15(62.5%). Mean operation time was 4.23 hours (SD=1.2). Mean blood loss was 787 ml (SD=479). Mean follow up was for 5 years and 7 months (SD=30 months). Mean pre-op scoliosis was 51 degrees (SD=22), which improved to 20 degrees (SD=15) on last follow up (61% improvement). Mean pre-op kyphosis was 42 degrees (SD=35), which improved to 13 degrees (SD=15) on last follow up (69% improvement). Mean pre-op sagittal shift was 22mm (SD=24.9), which improved to 6mm (SD=9.37) on last follow up (73% improvement). Mean pre-op coronal shift was 34mm (SD=27.1), which improved to 8mm (SD=8.58) on last follow up (76% improvement). Five patients had complications. One proximal junctional kyphosis, one implant failure, one transient deficit and two wound infections. CONCLUSIONS: Posterior resection of hemivertebrae for congenital thoracolumbar deformities gives excellent correction of deformity in experienced hands and has acceptable complication rate.

Assessment with Oswestry disability index in surgically treated patients with lumbar spondylolisthesis: experience in 96 patients.

OBJECTIVE: To assess the outcome of surgical treatment in spondylolisthesis of lumbosacral region using Oswestry disability Index. METHODS: The quasi-experimental study was conducted at the Combined Military Hospital, Rawalpindi from 2006 to 2013 and comprised surgically treated patients with spondylolisthesis. The patients with degenerative and isthmic types with follow-up of at least two years were included. A performa was designed for each patient and records were kept in a custom-built database. Oswestry disability index was used as the assessment tool and assessment was done pre-operatively, at 1, 3 and 6 months and then at 1 year and 2 years. RESULTS: There were 96 patients with mean pre-op Oswestry disability index score of 81.06% (range 42.22-100, SD ±11.99). L5-S1 was affected in 44 (45.83%) patients, L4-L5 in 30 (31.25%), L4-5-S1 in 7 (7.29%) and multi or high level was found in the rest of the cases. One level was involved in 77 (80.2%), 2 in 11 (11.45%), 3 in 7 (7.29%) and 4 in 1 (1.04%). The slip grade as per Meyerding grades was 1 in 31 (32.29%), II in 39 (40.62%), III in 19 (19.79%), IV in 5 (5.2%) and 2 (2.08%) had spondyloptosis. Mean follow-up was 42 months (range 24-63). Mean Oswestry disability score at 1 month was 38.51% (range 11- 62.22%, SD ±11.75); at 6 months 10.02% (range 0-40%, SD ±6.99); at 1 year 4.62% (range 0-24%, SD ±5.36) and at 2 years 4.21% (range 0-15%, SD ±4.2). CONCLUSIONS: Surgical treatment of spondylolisthesis gives excellent long-term result in most patients.

Multi level lumbosacral spinal fusion including lumbo-Sacral (L5-S1) junction fixation in adult deformity surgery; is postero- lateral fusion at (L5-S1) alone adequate?

BACKGROUND/AIMS: To assess the revision rate at L5-S1 when only posterior fixation with pedicle screws is done with multi-level spinal fixation. PATIENTS AND METHODS: The Retrospective quasi experimental study was conducted at the Combined Military Hospital, Rawalpinidi and comprised data from 2009 to 2014 of patients in whom multi-level posterior decompression including lumbosacral junction (L5-S1) with laminectomy and posterior fixation with pedicle screws was done till L3 and higher. Those with known cause of implant failure like osteoporosis, osteomalacia and infection were excluded. Patients were followed up and need for revision at L5-S1 level was assessed. RESULTS: Of the 22 cases, 5(23%) were males and 17(77%) were females with an overall mean age of 64±10.38 years (range 48-84 years). Mean number of levels fixed was 5.22±1.15 the highest level of fixation being T11. Mean follow-up was 08±3.22 months and focused only at the failure of fixation at L5-S1. Two (9%) cases showed implant loosening and required revision at L5-S1 because of screw cut out. CONCLUSIONS: Properly placed pedicle screws were adequate with fusion for multilevel spinal fixations.

Outcome of surgical treatment of cervical spondylotic myelopathy: Experience in 120 patients.

OBJECTIVES: To document the outcome of spinal surgery in patients of cervical spondylotic myelopathy. METHODS: The quasi-experimental study was conducted at the Department of Spine Surgery at Combined Military in a tertiary care hospital in Rawalpindi from 2006 to 2013. A pre-designed proforma was used for each patient and records were kept a custom-built computer database. Neurik grading was used to assess neurological status preoperatively, at 6 months, 1 year and 2 years. RESULTS: There were 120 patients with a mean age of 60.08 years (range 26-82, standard deviation 13.13). Of them 108 (90%) were males and 12 (10%) females. The preoperative neurologic status was Nurick\'s grade 0 in 6 (5%) patients There were 120, I in 9 (7.5%), II in 23 (19.16%), III in 28 (23.33%) and IV in 19 (15.83%) and V in 35 (28.16%). The spine was approached anteriorly in 48 (40%) patients and posteriorly in 72 (60%). Single level was involved in 23 (19.16), two in 30 (25%), three in 22 (18.33%) and four in 45 (37.5%) cases. Anterior cervical disc excision and fusion was done in 26 (21.67%), anterior corpectomy and fusion with bone graft or a cage in 21(17.5%) cases, laminoplasty in 9 (7.5%), laminectomy with lateral mass screw fixation with reconstruction titanium plate in 37 (30.83%) or with rod 24 (20%). In 3 (2.5%) cases only decompressive laminectomy was done. At 6 months Nurick 0 was in 26 %21.67%), I in 14 (11.67), II in 17 (14.16), III in 21 (17.5), IV in 29 (24.16%) and V in 13 (10.83). At one year Nurick grade was 0 in 38 (32.67%, I in 16 (13.33%), II in 14 (11.67), III in 15 (12.5%), IV in 23 (19.16) and V in 14 (11.67%). At the end of 2 years Neurik grade was 0 in 40 (33.33%), I in 15 (12.5%), II in 13 (10.83%), III in 16 (13.33%), IV in 22 (18.33% and V in 14 (11.67%). CONCLUSIONS: Single, double and triple levels with predominantly anterior cervical spondylotic myelopathy pathology can be operated anteriorly while multi-level disease with lordotic spine should be approached posteriorly.

Surgical management of contiguous multilevel thoracolumbar tuberculous spondylitis.

INTRODUCTION: Tuberculous spondylitis (TBS) is the most common form of extra-pulmonary tuberculosis. The mainstay of TBS management is anti-tuberculous chemotherapy. Most of the patients with TBS are treated conservatively; however in some patients surgery is indicated. Most common indications for surgery include neurological deficit, deformity, instability, large abscesses and necrotic tissue mass or inadequate response to anti-tuberculous chemotherapy. The most common form of TBS involves a single motion segment of spine (two adjoining vertebrae and their intervening disc). Sometimes TBS involves more than two adjoining vertebrae, when it is called multilevel TBS. Indications for correct surgical management of multilevel TBS is not clear from literature. MATERIALS AND METHODS: We have retrospectively reviewed 87 patients operated in 10 years for multilevel TBS involving the thoracolumbar spine at our spine unit. Two types of surgeries were performed on these patients. In 57 patients, modified Hong Kong operation was performed with radical debridement, strut grafting and anterior instrumentation. In 30 patients this operation was combined with pedicle screw fixation with or without correction of kyphosis by osteotomy. Patients were followed up for correction of kyphosis, improvement in neurological deficit, pain and function. Complications were noted. On long-term follow-up (average 64 months), there was 9.34 % improvement in kyphosis angle in the modified Hong Kong group and 47.58 % improvement in the group with pedicle screw fixation and osteotomy in addition to anterior surgery (p < 0.001). Seven patients had implant failures and revision surgeries in the modified Hong Kong group. Neurological improvement, pain relief and functional outcome were the same in both groups. CONCLUSION: We conclude that pedicle screw fixation with or without a correcting osteotomy should be added in all patients with multilevel thoracolumbar tuberculous spondylitis undergoing radical debridement and anterior column reconstruction.

Tuberculosis of the craniovertebral junction.

PURPOSE: Tuberculosis (TB) of craniovertebral junction (CVJ) occurs in 1-5 % of cases of TB spondylitis. This can be a life-threatening condition due to mass effect of infective process or resultant instability. Surgical indications for TB of CVJ are not clear from literature. METHODS: We have reviewed all the patients with TB of CVJ admitted at our center between 2005 and 2010. RESULTS: There were 15 patients including 10 males and 5 females. Average age was 38 years and average duration of symptoms was 8 months. All patients were started on multidrug antituberculous chemotherapy and skull traction. Those patients who failed to respond in 4-6 weeks and had persistent instability or neurological deficit were offered surgery. Rest was treated conservatively by immobilisation or traction. All five patients who were surgically treated had occipitocervical fusion (OCF) with titanium screws and plate/rod construct combined with posterior decompression if needed. Only one patient needed anterior surgery in addition to OCF at a later stage. All patients improved neurologically whether they were treated surgically or conservatively. Only difference was that surgically treated patients had earlier pain relief, mobilisation, neurological improvement and lesser complications. CONCLUSION: We recommend that all patients with TB of CVJ with instability and neurological compromise, who fail to respond to 4-6 weeks of antituberculous chemotherapy and skull traction should be offered occipitocervical fusion with or without posterior decompression. Anterior surgery will be needed only in those few cases who do not improve neurologically after OCF.

Surgical treatment in lumbar spondylolisthesis: experience with 45 patients.

BACKGROUND: Spondylolithesis is forward slipping of upper vertebra in relation to its lower one, which at times requires surgery. The objective of present study is to document the outcome of surgical treatment in spondylolisthesis of lumbosacral region. METHODS: We reviewed outcome of surgery in 45 patients with spondylolisthesis. Improvement in pain intensity, neurological status and union achieved after surgery was studied. All patients requiring surgical treatment were included in the study. The patients were operated by single spine surgeon. A Performa was made for each patient and records were kept in a custom built Microsoft access database. RESULTS: Majority of our patient were in 4th and 51th decade with some male domination. Pain was main indication for surgery which was excruciating in 6. severe in 33, and moderate in 6 cases. The neurological status was normal in 34 cases while 11 patients had some deficit. L5-S1 was affected in 26, L4-L5 in 13 and multi or high level was found in rest of cases. Slip grade was measured with Meyerding grades, 18 had grade II, 15 had I, 9 had III and 3 had IV spondylolisthesis. Posterior lumbar inter body fusion (PLIF) was done in 24 patients, posterolateral, transforaminal lumbar inter body and anterior inter body fusion in others. Translaminar screw fixation, transpedicular transdiscal transcorporial and Delta fixation in some cases. Pedicle screw fixation was done in most cases, AO fixator internae and 4.5 mm screw in others. Average follow up was 2 years and 5 months, max 5 years and minimum 6 months. Pain relief was achieved in 82%, neurological improvement 60% and union in 91% cases. There was no deterioration of neurological status, two implant failure and one wound infection. CONCLUSION: Surgical procedure for Spondylolisthesis must be individualised. Young patients with spondylolysis can be treated with osteosynthesis and sparing of motion segment. PLIF provides satisfactory results in majority of low to moderate cases with some reduction. Transpedicular transdiscal transcorprial and delta fixation is good procedure for severe slips in adult.

Epidemiology of non-disaster spinal injuries at a spine unit.

OBJECTIVE: To describe the demography, types of injuries and their management in all non-disaster spinal injury patients admitted to the Spine Unit of a tertiary care hospital in Pakistan from 2001-2008. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Spine Unit, Orthopaedic Department, Combined Military Hospital, Rawalpindi, from April 2001 to December 2008. METHODOLOGY: Data of all new non-disaster spinal injury patient admissions, kept in a custom-built database at Spine Unit, was analyzed. Demography, type of injuries and their management was described in percentages. RESULTS: Five hundred and twenty one non-disaster patients were selected out of a total 671 new admissions with spinal injuries. Mean age was 39.1 years and 77% were males. Mechanisms of injury included; fall in 62% and road traffic accidents in 32%. Fracture dislocations and burst fractures were equally distributed (36% each). Most of the injuries (43.6%) were at T11-L1 level. Forty three percent patients had complete spinal cord injury (SCI), 33% had incomplete SCI and 24% did not have any SCI. Eight patients had concomitant spinal injury at a different level. Twelve percent patients had associated other major injuries. Seventy percent patients were treated surgically. Average follow-up was for 4 years. CONCLUSION: Non-disaster spinal injury was frequent in young males usually due to fall or road traffic accident. It involved fracture dislocation or burst fracture at T11-L1, level in most cases requiring surgical treatment.

Staged corrective surgery for complex congenital scoliosis and split cord malformation.

Congenital scoliosis associated with split cord malformation raises the issue on how to best manage these patients to avoid neurologic injury while achieving satisfactory correction. We present the case of a 12-year-old girl who first presented when she was 11-year old with such combination but without much physical handicap or neurological deficit. The corrective surgery offered at that time was refused by the family. She again presented after 1 year with documented severe aggravation of the curve resulting in unstable walking and psychological upset. Her imaging studies showed multiple malformations in lower cervical and thoracic spine and a split cord malformation type 2 (fibrous septum with diplomyelia) at the apex of the deformity. A one-stage correction was deemed neurologically too risky. We therefore performed during a first stage a thoracotomy with anterior release. This was followed by skeletal traction with skull tongs and bilateral femoral pins. After gradual increase in traction weights a reasonable correction was achieved without any neurological deficit, over the next 10 days. A second-stage operation was done on the 11th day and a posterior instrumented fusion was performed. Post-operative recovery was uneventful and there were no complications. She was discharged with a Boston Brace to be worn for 3 months. At 2-year follow-up the patient outcome is excellent with excellent balance and correction of the deformity. In this grand round case, we discuss all the different option of treatment of congenital scoliosis associated with split cord malformation. In a medical environment where spinal cord monitoring is lacking, we recommend an initial release followed by skull and bifemoral traction over several days to monitor the neurologic status of the patient. Once optimal correction is achieved with the traction, a posterior instrumentation can be safely done.

Os-odontoideum leading to atlanto-axial instability--report of surgery in four cases.

Os odontoideum can lead to atlantoaxial instability, which can be either reducible or a fixed dislocation. We present surgical management in four patients with os odontoideum at our center. Two of these had reducible dislocations and were managed by posterior transarticular screw fixation. Other two had fixed dislocations necessitating posterior decompression and occipitocervical fixation.