Do all Isler's type sacral fractures necessarily require surgical fixation?

INTRODUCTION: A unilateral vertical sacral fracture that exits medial or through the L5-S1 facet joint is considered to affect the lumbo-sacral integrity, and it is denoted as an indication for surgical fixation. However, no studies have analysed the outcomes after non-operative treatment of such injuries. METHODS: A retrospective review of all sacral fractures treated over a five-year period was performed to identify patients with Isler's fractures. Demographic and surgical data, all pre-operative and follow-up images (AP radiographs, CT images), functional outcomes based on VAS, SF-12 and return to work were documented for all patients. RESULTS: The incidence of Isler's fractures was 18% (34/181). The mean age was 42.12 ± 16.3 years. As per Isler's subtypes, fractures passed through L5-S1 joint in 13 (Type 2a) and medial to it in 15 (Type 2b), fractures of L5 or S1 facets in 3 (Type 1), Type 3 injuries were not detected. All patients had concomitant pelvic ring injuries. Sixteen fractures (neurologically intact, < 1 cm displacement, anterior ring stable, no facetal dislocation) were treated non-operatively while 18 patients underwent surgery. At a mean of 15.2 months, the fractures had united in all patients radiographically. The mean VAS score for low back pain (1.4 ± 1.01 vs 1.5 ± 0.79), ability to squat and sit cross-legged (56.3% vs 55.6%) and return to work (68.8% vs 66.7%), and Majeed score (77.2 ± 3.9 vs 79.6 ± 4.1) were similar in non-surgical and surgical groups, respectively, at the final follow-up. CONCLUSION: Our study indicates that 47% of Isler's fractures were mechanically stable and could be effectively treated non-operatively with good radiological and functional outcomes.

Risk factors for thirty-day morbidity and mortality after spinal trauma.

BACKGROUND: Traumatic Spinal Injuries (TSI) often follow high velocity injuries and frequently accompanied by polytrauma. While most studies have focussed on outcomes of spinal cord injuries, the incidence and risk factors that predict morbidity and mortality after TSI has not been well-defined. METHODS: Data of consecutive patients of TSI (n = 2065) treated over a 5-year-period were evaluated for demographics, injury mechanisms, neurological status, associated injuries, timing of surgery and co-morbidities. The thirty-day incidence and risk factors for complications, length of stay and mortality were analysed. RESULTS: The incidence of spinal trauma was 6.2%. Associated injuries were seen in 49.7% (n = 1028), and 33.5% (n = 692) patients had comorbidities. The 30-day mortality was 0.73% (n = 15). Associated chest injuries (p = 0.0001), cervical spine injury (p = 0.0001), ASIA-A neurology (p < 0.01) and ankylosing spondylitis (p = 0.01) correlated with higher mortality. Peri-operative morbidity was noted in 571 patients (27.7%) and were significantly associated with age > 60 (p = 0.043), ASIA-A neurology (p < 0.05), chest injuries (p = 0.042), cervical and thoracic spine injury (p < 0.0001). The mean length of stay in hospital was 8.87 days. Cervical spine injury (p < 0.0001), delay in surgery > 48 h (p = 0.011), Diabetes mellitus (p = 0.01), Ankylosing spondylitis (p = 0.009), associated injuries of chest, head, pelvis and face (p < 0.05) were independent risk factors for longer hospital stay. CONCLUSION: Key predictors of mortality after spinal trauma were cervical spine injury, complete neurological deficit, chest injuries and ankylosing spondylitis, while additionally higher age and thoracic injuries contributed to higher morbidity and prolonged hospitalisation. Notably multi-level injuries, higher age, co-morbidities and timing of surgery did not influence the mortality.

ISSLS PRIZE in basic science 2023: Lactate in lumbar discs-metabolic waste or energy biofuel? Insights from in vivo MRS and T2r analysis following exercise and nimodipine in healthy volunteers.

PURPOSE: To quantitatively assess the dynamic changes of Lactate in lumbar discs under different physiological conditions using MRS and T2r. METHODS: In step1, MRS and T2r sequences were standardized in 10 volunteers. Step2, analysed effects of high cellular demand. 66 discs of 20 volunteers with no back pain were evaluated pre-exercise (EX-0), immediately after targeted short-time low back exercises (EX-1) and 60 min after (EX-2). In Step 3, to study effects of high glucose and oxygen concentration, 50 lumbar discs in 10 volunteers were analysed before (D0) and after 10 days intake of the calcium channel blocker, nimodipine (D1). RESULTS: Lactate showed a distinctly different response to exercise in that Grade 1 discs with a significant decrease in EX-1 and a trend for normalization in Ex-2. In contrast, Pfirrmann grade 2 and 3 and discs above 40 years showed a higher lactate relative to proteoglycan in EX-0, an increase in lactate EX-1 and mild dip in Ex-2. Similarly, following nimodipine, grade 1 discs showed an increase in lactate which was absent in grade 2 and 3 discs. In contrast, exercise and Nimodipine had no significant change in T2r values and MRS spectrum of proteoglycan, N-acetyl aspartate, carbohydrate, choline, creatine, and glutathione across age groups and Pfirrmann grades. CONCLUSION: MRS documented changes in lactate response to cellular demand which suggested a 'Lactate Symbiotic metabolic Pathway'. The differences in lactate response preceded changes in Proteoglycan/hydration and thus could be a dynamic radiological biomarker of early degeneration.

Accelerated anterior vertebral growth resulting in kyphosis correction following posterior spinal instrumented fusion.

PURPOSE: To discuss the effect of posterior instrumented deformity correction and fusion on the progressive endochondral ossification of anterior vertebral body in a patient with congenital kyphosis secondary to type 1 vertebral anomaly. METHODS: A 15-year-old male patient presented with a progressively worsening congenital TL kyphosis of 52° magnitude secondary to a posterior hemivertebra. His pre-operative antero-posterior vertebral height ratio (APVHR) and anterior vertebral body defect ratio (AVBDR) on CT were 38% and 49%, respectively. He underwent posterior instrumented deformity correction with multilevel type 1 Schwab osteotomies and fusion. RESULTS: Over the next 3 years, his serial imaging revealed progressive endochondral ossification and gradual increase in the dimensions of the vertebral body. At the final follow-up, there was a significant restoration of the deficient anterior vertebral body, and the final APVHR and AVBDR were 81% and 90%, respectively. CONCLUSIONS: Restitution of posterior column integrity through stabilization can mitigate the compressive stresses across anterior column. Over a period of time, forces restraining the growth of anterior vertebral apophysis are alleviated, and the vertebra can potentially re-grow to near-normal dimensions in pediatric population. This phenomenon could be well-demonstrated in our patient during follow-up. LEVEL OF EVIDENCE I: Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

Advanced disc degeneration, bi-planar instability and pathways of peri-discal gas suffusion contribute to pathogenesis of intradiscal vacuum phenomenon.

PURPOSE: Intradiscal vacuum phenomenon (IDVP), despite being ubiquitous, is poorly understood. The dynamic passage of peri-discal gases into the degenerated disc is a commonly accepted theory. But the reasons behind its selective appearance in some discs are unevaluated. METHODS: 721 patients with chronic low back pain ± radiculopathy, were evaluated with AP and flexion-extension lateral radiographs and MRI. IDVP was classified based on its morphology and location. Radiographic parameters including sagittal translation, sagittal angulation, lateral listhesis, eccentric disc collapse, Pfirrmann's grade, disc height, Modic changes, anterior longitudinal ligament status, and primary spinal disease at the level of IDVP was analyzed. RESULTS: IDVP was present in 342 patients, and they had a higher mean age (57.2 ± 12.5 years) than controls (p < 0.001). Eccentric disc space narrowing (26.5% vs 1.3%, p < 0.01), coronal listhesis (7.83% vs 1.1%, p < 0.001), sagittal angular motion difference (11.3 ± 4.6°, p < 0.001), higher mean disc degeneration (4.36 ± 0.69, p < 0.001), ALL disruption (30.3% vs 2.2%, p < 0.001) and Modic changes (88.6% vs 17.5%, p < 0.001) were significantly higher in IDVP discs (vs. non-IDVP). Binary logistic regression analysis indicated sagittal angular motion difference was the most predictive factor. IDVP was classified into three types-dense type (47.5%), linear (29.5%), dot type (23%). Dense type matched radiological correlations of IDVP while dot types behaved like non-IDVP discs. CONCLUSION: Modic disc-endplate contacts, ALL disruption and coronal translation could be pathways for the passage of peri-discal gases into the degenerated disc. In the pathogenesis of IDVP, advanced disc degeneration, the presence of pathways of gas transfer and angular/coronal instability seem to play complementary roles.

The phenomenon of vertebral body drift in neurofibromatosis and its implications for surgical safety.

OBJECTIVE: To report on the phenomenon of body drift in neurofibromatosis scoliosis and discuss its implication on surgical safety. MATERIALS AND METHODS: Ten dystrophic neurofibromatosis scoliosis (NF) and ten adolescent idiopathic scoliosis (AIS) were studied by radiographs, CT, and MRI. The curve characteristics and a detailed analysis of the morphology of the apical and three adjacent vertebral segments above and below were done. The coronal alignment and the presence of a drift of the vertebral body in relationship to the lamina were carefully studied in both groups and compared. RESULTS: The mean cobb angle in the NF group was 77.6°, and 63.7° in the AIS group. All the studied vertebra in the NF group had extensive pedicle changes, which were more severe at the apical and periapical regions. Body drift was noted in 29 vertebral segments, with 9/10 of apical segments showing a significant drift. The body drift was associated with significant pedicle dystrophic changes and was independent of the curve magnitude. In comparison, in AIS, no body drift was noted despite a larger deformity and more severe vertebral rotation. CONCLUSION: The 'body drift' phenomenon was unique to neurofibromatosis scoliosis and was secondary to severe pedicle morphology changes. This was present even in curves less than 60° and could result in cord injury while instrumenting the concave pedicle. Therefore, a thorough preoperative assessment and planning by a 3D CT are mandatory.

Are Modic changes 'Primary infective endplatitis'?-insights from multimodal imaging of non-specific low back pain patients and development of a radiological 'Endplate infection probability score'.

PURPOSE: To probe the pathophysiological basis of Modic change (MC) by multimodal imaging rather than by MRI alone. METHODS: Nineteen radiological signs found in mild infections and traumatic endplate fractures were identified by MRI and CT, and by elimination, three signs unique to infection and trauma were distilled. By ranking the Z score, radiological 'Endplate Infection Probability Score' (EIPS) was developed. The score's ability to differentiate infection and traumatic endplate changes (EPC) was validated in a fresh set of 15 patients each, with documented infection and trauma. The EIPS, ESR, CRP, and Numeric Pain Rating Scale (NRS) were then compared between 115 patients with and 80 patients without MC. RESULTS: The EIPS had a confidence of 66.4%, 83% and, 100% for scores of 4, 5 and, 6, respectively, for end plate changes suggesting infection. The mean EIPS was 4.85 ± 1.94 in patients with Modic changes compared to - 0.66 ± 0.49 in patients without Modic changes (p < 0.001). Seventy-eight (67.64%) patients with MC had a score of 6, indicating high infection possibility. There was a difference in the NRS (p < 0.01), ESR (p = 0.05), CRP (p < 0.01), and type of pain (p < 0.01) between patients with and without MC. CONCLUSION: Multimodal imaging showed many radiological signs not easily seen in MRI alone and thus missed in Modic classification. There were distinct radiological differences between EPCs of trauma and infection which allowed the development of an EIPS. The scores showed that 67.64% of our study patients with Modic changes had EPCs resembling infection rather than trauma suggesting the possibility of an infective aetiology and allowing us to propose an alternate theory of 'Primary Endplatitis'.

Forequarter Replantation.

Traumatic forequarter amputations are rare injuries in which the arm, clavicle, scapula, and proximal shoulder muscles are avulsed from the body. Historically, forequarter amputation has been treated with hemorrhage control, wound debridement, and soft tissue coverage. To our knowledge, successful forequarter replantation has not been previously reported. We present a rare case of forequarter amputation treated successfully with replantation. At the 4.5-year follow-up after replantation, the patient had antigravity elbow flexion, modest shoulder elevation, modest extrinsic finger function, and crude sensation. We discuss relevant technical considerations that indicate that, despite challenges, forequarter replantation can be achieved with success.

Safety and Feasibility of Very Early Bronchoscopy-assisted Percutaneous Dilatational Tracheostomy in Anterior Cervical Spine Fixation Patients.

Background: Anterior cervical spine fixation (ACSF) is a common mode of stabilization of cervical spine injuries. These patients usually need a prolonged mechanical ventilation, so an early tracheostomy is beneficial for them. However, it is often delayed due to the close proximity to the surgical site, due to the concerns of infection, and increased bleeding. Percutaneous dilatational tracheostomy (PDT) is also considered a relative contraindication due to the inability to achieve adequate neck extension. Objectives: The objectives of our study are to assess the:Feasibility of performing a very early percutaneous dilatational tracheostomy in cervical spine injury patients, post-anterior cervical spine fixation.Safety in doing so with regard to surgical-site infection, early, and late complications.Benefits with regard to outcome measures like ventilator days and length of stay (LOS) in the intensive care unit (ICU) and hospital. Materials and methods: We performed a retrospective review of all patients who underwent anterior cervical spine fixation and bedside percutaneous dilatational tracheostomy in our ICU from 1st January 2015 to 31st March 2021. Results: Out of the 269 patients admitted to our ICU with cervical spine pathology, 84 were included in the study. About 40.4% patients had injury above C5 level (n-34) and 59.5% had below C5 level. About 86.9% patients had ASIA-A neurology. In our study, percutaneous tracheostomy was done at an average of 2.8 days from the cervical spine fixation. Average length of ventilator days post-tracheostomy was 8.32 days, ICU stay was 10.5 days, and hospital stay was 28.6 days. One patient developed anterior surgical-site infection. Conclusion: We conclude from our study that a very early percutaneous dilatational tracheostomy can be done in post-anterior cervical spine fixation patients as early as within 3 days without significant complications. How to cite this article: Paul AL, Varaham R, Balaraman K, Rajasekaran S, Balasubramani VM. Safety and Feasibility of Very Early Bronchoscopy-assisted Percutaneous Dilatational Tracheostomy in Anterior Cervical Spine Fixation Patients. Indian J Crit Care Med 2022;26(10):1086-1090.

Is fresh, leucodepleted, whole blood transfusion superior to blood component transfusion in pediatric patients undergoing spinal deformity surgeries? A prospective, randomized study analyzing postoperative serological parameters and clinical recovery.

PURPOSE: To compare the effectiveness of fresh whole blood (FWB) and blood component transfusion in improving clinical outcome and serological parameters in the early postoperative period following spinal deformity surgery. METHODS: Patients undergoing major spinal deformity surgeries involving ≥ 6 levels of fusion and expected blood loss ≥ 750 ml between September 2017 and August 2018 were included in the study. The patients were randomized into two groups: FWBG and CG, receiving fresh whole blood and component transfusions, respectively. RESULTS: A total of 65 patients with spinal deformities of different etiologies were included. The mean age was 14.0 and 14.9 years in FWB and CG, respectively. All other preoperative parameters were comparable. The mean fusion levels and surgical time were 11.1 and 221.20 min in FWB, as compared with 10.70 and 208.74minutes in CG, respectively. Intraoperative blood losses were 929 ml (FWBG) and 847 ml(CG), and the mean volumes of transfusion were 1.90 (FWBG) and 1.65 units (CG). FWBG was significantly superior to CG in the following clinical and laboratory parameters: duration of oxygen dependence [36.43 (FWBG) vs. 43.45 h (CG); P = 0.0256], mean arterial pH [7.442 (FWBG) vs. 7.394 (CG); p < 0.001], interleukin-6 [30.04 (FWBG) vs. 35.10 (CG); p < 0.019], mean duration of HDU stay [40.6 hours (FWBG) vs 46.51 hours (CG); p = 0.0234] and postoperative facial puffiness [7/30 in FWBG vs. 18/35 (CG) (P < 0.02)]. CONCLUSION: FWB transfusion can potentially improve the immediate postoperative outcome in patients undergoing major spinal deformity surgeries by reducing the duration of intensive care unit stay and oxygen dependence. The other potential benefits of this practice, based on our study, include a reduced inflammatory response (reduced lactate and IL-6) and postoperative facial puffiness. However, further large-scale validation studies in future are necessary to precisely determine the role of FWB in spine surgeries. LEVEL OF EVIDENCE II: Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

The catastrophization effects of an MRI report on the patient and surgeon and the benefits of 'clinical reporting': results from an RCT and blinded trials.

PURPOSE: Inappropriate use of MRI leads to increasing interventions and surgeries for low back pain (LBP). We probed the potential effects of a routine MRI report on the patient's perception of his spine and functional outcome of treatment. An alternate 'clinical reporting' was developed and tested for benefits on LBP perception. METHODS: In Phase-I, 44 LBP patients were randomized to Group A who had a factual explanation of their MRI report or Group B, who were reassured that the MRI findings showed normal changes. The outcome was compared at 6 weeks by VAS, PSEQ-2, and SF-12. In Phase-II, clinical reporting was developed, avoiding potential catastrophizing terminologies. In Phase-III, 20 MRIs were reported by both routine and clinical methods. The effects of the two methods were tested on four categories of health care professionals (HCP) who read them blinded on their assessment of severity of disease, possible treatment required, and the probability of surgery. RESULTS: Both groups were comparable initial by demographics and pain. After 6 weeks of treatment, Group A had a more negative perception of their spinal condition, increased catastrophization, decreased pain improvement, and poorer functional status(p = significant for all). The alternate method of clinical reporting had significant benefits in assessment of lesser severity of the disease, shift to lesser severity of intervention and surgery in three groups of HCPs. CONCLUSION: Routine MRI reports produce a negative perception and poor functional outcomes in LBP. Focussed clinical reporting had significant benefits, which calls for the need for 'clinical reporting' rather than 'Image reporting'.

Subclinical infection can be an initiator of inflammaging leading to degenerative disk disease: evidence from host-defense response mechanisms.

PURPOSE: There is considerable controversy on the role of genetics, mechanical and environmental factors, and, recently, on subclinical infection in triggering inflammaging leading to disk degeneration. The present study investigated sequential molecular events in the host, analyzing proteome level changes that will reveal triggering factors of inflammaging and degeneration. METHODS: Ten MRI normal disks (ND) from braindead organ donors and 17 degenerated disks (DD) from surgery were subjected to in-gel-based label-free ESI-LC-MS/MS analysis. Bacterial-responsive host-defense response proteins/pathways leading to Inflammaging were identified and compared between ND and DD. RESULTS: Out of the 263 well-established host-defense response proteins (HDRPs), 243 proteins were identified, and 64 abundantly expressed HDRPs were analyzed further. Among the 21 HDRPs common to both ND and DD, complement factor 3 (C3) and heparan sulfate proteoglycan 2 (HSPG2) were significantly upregulated, and lysozyme (LYZ), superoxide dismutase 3 (SOD3), phospholipase-A2 (PLA2G2A), and tissue inhibitor of metalloproteinases 3 (TIMP-3) were downregulated in DD. Forty-two specific HDRPs mainly, complement proteins, apolipoproteins, and antimicrobial proteins involved in the complement cascade, neutrophil degranulation, and oxidative-stress regulation pathways representing an ongoing host response to subclinical infection and uncontrolled inflammation were identified in DD. Protein-Protein interaction analysis revealed cross talk between most of the expressed HDRPs, adding evidence to bacterial presence and stimulation of these defense pathways. CONCLUSIONS: The predominance of HDRPs involved in complement cascades, neutrophil degranulation, and oxidative-stress regulation indicated an ongoing infection mediated inflammatory process in DD. Our study has documented increasing evidence for bacteria's role in triggering the innate immune system leading to chronic inflammation and degenerative disk disease.

Reliability, validity and responsiveness of the Dutch version of the AOSpine PROST (Patient Reported Outcome Spine Trauma).

PURPOSE: To validate the Dutch version of AOSpine PROST (Patient Reported Outcome Spine Trauma). METHODS: Patients were recruited from two level-1 trauma centers from the Netherlands. Next to the AOSpine PROST, patients also filled out SF-36 for concurrent validity. Descriptive statistics were used to analyze the characteristics. Content validity was assessed by evaluating the number of inapplicable or missing questions. Also floor and ceiling effects were analyzed. Internal consistency was assessed by calculating Cronbach's α and item-total correlation coefficients (itcc). Spearman correlation tests were performed within AOSpine PROST items and in correlation with SF-36. Test-retest reliability was analyzed using Intraclass Correlation Coefficients (ICC). Responsiveness was assessed by calculating effect sizes (ES) and standardized response mean (SRM). Factor analysis was performed to explore any dimensions within AOSpine PROST. RESULTS: Out of 179 enrolled patients, 163 (91.1%) were included. Good results were obtained for content validity. No floor or ceiling effects were seen. Internal consistency was excellent (Cronbach's α = 0.96, itcc 0.50-0.86), with also good Spearman correlations (0.25-0.79). Compared to SF-36, the strongest correlation was seen for physical functioning (0.79; p < .001). Also test-retest reliability was excellent (ICC = 0.92). Concerning responsiveness analysis, very good results were seen with ES = 1.81 and SRM = 2.03 (p < 0.001). Factor analysis revealed two possible dimensions (Eigenvalues > 1), explaining 65.4% of variance. CONCLUSIONS: Very satisfactory results were obtained for reliability, validity and responsiveness of the Dutch version of AOSpine PROST. Treating surgeons are encouraged to use this novel and validated tool in clinical setting and research to contribute to evidence-based and patient-centered care.

Delayed presentation of urinoma mimicking spondylodiscitis secondary to ureteric injury following carrot stick fracture in ankylosing spondylitis.

INTRODUCTION: Ureteric injuries are rarely associated with spinal trauma with an incidence of less than 1%. Missed injuries can lead to urinoma collection, urosepsis and even death. MATERIALS AND METHODS: A 75-year-old man presented 1 month following fall with high-grade fever and severe back pain mimicking spondylodiscitis clinically. Plain radiograph showed features of ankylosing spondylitis with a suspicious trans-discal injury at L3-L4. Hyper-intense fluid within L3/L4 disk space communicating to a large psoas collection measuring 13 × 6 cms mimicking spondylodiscitis with abscess formation was observed in magnetic resonance imaging (MRI). MRI with contrast enhancement demonstrated a leak through left ureter into the psoas muscle raising suspicion of a ureteric injury. Plain computerized tomography revealed a three-column fracture at L4, and a ureteric leak into the psoas collection with proximal hydronephrosis was seen after contrast administration, establishing the presence of a ureteric fistula resulting in urinoma. RESULTS: Following initial symptomatic improvement after ureteric stenting, the patient succumbed to urosepsis at 3 months. CONCLUSION: We report for the first time a post-traumatic urinoma secondary to ureteric injury clinically mimicking spondylodiscitis. Clinicians need to be aware of the possibility of ureteric injury in hyperextension lumbar fractures occurring in ankylosing spondylitis and treat them early to avoid urological complications.

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.

Unilateral sacroiliitis: differentiating infective and inflammatory etiology by magnetic resonance imaging and tissue studies.

PURPOSE: Unilateral sacroiliitis (US) is an uncommon disease with varied etiology. The differentiation between infective and inflammatory causes for US based on MRI alone is often difficult. We studied the efficacy of MRI findings in comparison with tissue studies in the diagnosis of US. METHODS: A retrospective analysis of patients who presented with US and evaluated with MRI, biopsy for histopathology and tissue cultures was performed. Patients with bilateral sacroiliitis, traumatic and postpartum sacroiliitis were excluded. Based on defined MRI criteria, the patients were divided into two groups-infective (group A) and inflammation (group B). RESULTS: In total, 33 patients (mean age-33.4 ± 17.2 years) with MRI features of US had presented with unilateral gluteal pain (100%) and positive Patrick's test (91.9%). Based on the MRI features of severe subchondral marrow edema, widening of joint space, intra-articular abscess and periarticular muscle abscess, infective sacroiliitis (A) was diagnosed in 20/33 (60.6% cases). A total of 13/33 (39.3%) patients had features of inflammation (B), based on the following MRI criteria-subchondral sclerosis with minimal edema, erosions, maintained joint space without abscess/destruction. Tissue evidence of infection was positive in 13/20 (65%) patients in group A while it was negative in all group B patients. CONCLUSION: MRI had high sensitivity (71%) and 100% specificity in diagnosing inflammatory sacroiliitis while it had low specificity, but 100% sensitivity for diagnosing infective sacroiliitis. Hence, patients diagnosed as inflammatory sacroiliitis in MRI are unlikely to benefit from further tissue studies while percutaneous biopsy is recommended in patients diagnosed in MRI as infective sacroiliitis.

Aneurysmal bone cyst of C2 treated with novel anterior reconstruction and stabilization.

PURPOSE: Aneurysmal bone cysts (ABC) form 1 % of primary bone tumors. Reported incidence rates are no more than 1.4 to 1,00,000. ABC of spine frequently involves posterior elements and commonly affects the lumbar spine (45 %). We present a case of C2 ABC for the challenges it poses due to the rarity of the lesion, tedious to access location, dilemmas relating to the suitable approach for tumor resection and technically demanding stabilization and reconstruction strategy post resection. METHODS: Clinical data analysis was performed to discuss a method of novel anterior column reconstruction following resection of a C2 aneurysmal bone cyst in a 8 year old child with anterior and posterior elements being involved. RESULTS: An 8-year-old girl with an aneurysmal bone cyst of the C2 vertebra underwent staged surgery following pre-operative embolisation. First a posterior approach tumor excision with posterior instrumented fusion was performed. Following which, using a modified anterior retropharyngeal approach anterior tumor excision and fibular graft reconstruction between the C1 lateral mass and C2 body was performed. Complete tumor clearance and stable reconstruction was successfully achieved in our patient. Patient showed excellent clinical outcome with radiological fusion. CONCLUSIONS: Preoperative embolisation in the treatment of ABC has supplemental advantage by reducing blood loss. Modified anterior retropharyngeal approach allows satisfactory clearance for C1-2 lesion and fibular strut graft between the C1 lateral mass and C2 body can provide a stable graft placement with good chance of fusion. Instability and spinal deformity, whether preexisting or post-excision, should be corrected with reconstruction and stabilization to offer best chance of cure in such cases.

Diagnostic accuracy of whole spine magnetic resonance imaging in spinal tuberculosis validated through tissue studies.

INTRODUCTION: Conventional diagnosis of spinal tuberculosis (TB) is based on a combination of clinical features, laboratory tests and imaging studies, since none of these individual diagnostic features are confirmatory. Despite the high sensitivity of MRI findings in evaluating spinal infections, its efficacy in diagnosing spinal TB is less emphasized and remains unvalidated through tissue studies. METHODOLOGY: We reviewed consecutive patients evaluated for spondylodiscitis with documented clinical findings, MRI spine, and tissue analysis for histopathology, TB culture and genetic TB PCR. MRI features documented include location, contiguous/non-contiguous skip lesions, para/intraosseous abscess, subligamentous spread, vertebral collapse, abscess size/wall, disc involvement, end plate erosion and epidural abscess. Based on the results, patients were divided into two groups-CONFIRMED TB with positive culture/histopathology and NON-TB. The efficacy of MRI findings in accurately diagnosing spinal TB was compared between the two groups. RESULTS: Among 150 patients, 79 patients were TB positive, and 71 were TB negative. Three MRI parameters showed significant differences (p < 0.001), namely subligamentous spread (67/79, 84.8%), vertebral collapse > 50% (55/79, 69.6%) and large abscess collection with thin abscess wall (72/79, 91.1%) being strongly predictive of TB. Combination of MRI findings had a higher predictive value. 97.5% of TB positive patients had at least one of these three MRI features, 89.8% patients had any two and 58.2% had all three. CONCLUSION: Our study validated different MRI findings with tissue studies and showed spinal infections with large abscess with thin wall, subligamentous spread of abscess and vertebral collapse were highly suggestive of spinal tuberculosis. These slides can be retrieved under Electronic Supplementary Material.

INFIX/EXFIX: Innovation managing pelvic fractures in difficult scenarios.

Pelvic fractures complicated by the presence of visceral injuries, open fractures and urethral or bladder injuries pose a significant challenge to treat. In these conditions internal fixation is usually contraindicated. External fixators, though a potential solution, have disadvantages like loss of reduction, pin tract infection and loosening. INFIX, a novel technique has been effective in managing anterior ring fractures and can be used as a substitute for internal fixation. We describe use of INFIX as EXFIX in three case scenarios where passing INFIX rod internally was precluded with favorable outcomes.

Pre-treatment of extracellular water soluble pigmented secondary metabolites of marine imperfect fungus protects HDF cells from UVB induced oxidative stress.

The present study explores the UVB-induced oxidative stress protective efficacy of the pigmented fungal metabolite (identified as DHICA: 5,6-dihydroxyindole-2-carboxylic acid - a melanin precursor) using human dermal fibroblast (HDF) cells. DHICA is a water soluble pigment of the marine Aspergillus nidulans strain SG 28. Preliminary compatibility studies revealed 95% HDF cell viability with 600 µM concentration of DHICA. HDF cells were exposed to UVB irradiation with and without DHICA pre-treatment and the morphological, physiological and molecular level changes were observed accordingly. The results suggested that UVB exposure increases reactive oxygen species (ROS) generation and subsequent DNA damage in HDF cells, whereas DHICA pre-treatment appreciably reduces ROS generation and DNA damage. DHICA pre-treatment upregulates the antioxidant enzyme expressions and reduces the number of cells in the sub-Go/G1 phase. Gene expression analysis of TNF-α, IL-6, COX-2, NF-κB, Bax and Caspase 3 suggested that pre-treatment with DHICA downregulates the above-mentioned genes and simultaneously upregulates Bcl2 expression. In vivo experiments with BALB/c mice suggested that the topical application of DHICA protected mice skin from UVB-induced oxidative stress (which increases the epidermal thickness as evidenced in the skin sectioning). Thus, DHICA application protects the cells from UVB induced oxidative stress and may find applications in sunscreen cosmetic preparations.