Radiographic Analysis of the Sagittal Alignment of Spine and Pelvis in Asymptomatic Indian Population

Methods@#In total, 100 participants were studied by using their anteroposterior and lateral radiographic images of whole of pelvic and spinal area. Additionally, various spinal and pelvic parameters were also measured. Subsequently, the outcomes were analyzed with respect to age, sex, and body mass index (BMI). The correlation between different parameters and differences in these parameters between Indians and other races/ethnicities along with population groups were also analyzed. @*Results@#There was a significant increase in thoracic kyphosis (TK) from T1–T12 and T4–T12 with increasing age. Lumbar lordosis (LL), sacral translation (sagittal vertical axis), and pelvic tilt were significantly higher among females. Additionally, sacral slope (SS), pelvic incidence, C7 sagittal offset, and T9 sagittal offset were also higher in females. TK (T4–T12 and T1–T12), LL, SS, and pelvic incidence showed a significant correlation with BMI. As compared to European population, TK, segmental LL, and sacral translation were found to be significantly lesser in Indian population. @*Conclusions@#There is a statistically significant difference between Indians and other races/ethnicities and population groups with respect to TK, LL, and sacral translation. The values obtained can be considered as the physiological normal values for Indian population. Importantly, these values can serve as the reference values for future studies.

Long-Term Functional Outcomes of Endoscopic Decompression with Destandau Technique for Lumbar Canal Stenosis

Methods@#The clinical records of 953 patients who were operated between 1998 and 2008 were analyzed in 2018. Along with patient characteristics, information about return to daily activities, complication rates, and functional outcomes using Prolo score was assessed. @*Results@#L4–L5 was the most common level for which surgery was performed. Two-level decompression was performed in 116 patients; 89.5% patients were able to return to their daily activities after 2 weeks. Functional outcomes as per the Prolo score were reported by patients as excellent, good, and poor in 89.85%, 1.59%, and 8.55%, respectively. Repeat surgery was required at same level in 16 patients and at a different level in 21 patients. Total 605 patients (63.49%) were symptom-free during the 70-month followup, while 344 complained of residual back pain, and four complained of persistent leg pain. @*Conclusions@#ULBD using the Endospine system achieves adequate decompression in most cases and is a good alternative to open laminectomy, with the advantage of avoiding damage to the structural integrity of the spine and preserving soft tissue attachments.

Long-Term Functional Outcomes of Endoscopic Decompression with Destandau Technique for Lumbar Canal Stenosis

Methods@#The clinical records of 953 patients who were operated between 1998 and 2008 were analyzed in 2018. Along with patient characteristics, information about return to daily activities, complication rates, and functional outcomes using Prolo score was assessed. @*Results@#L4–L5 was the most common level for which surgery was performed. Two-level decompression was performed in 116 patients; 89.5% patients were able to return to their daily activities after 2 weeks. Functional outcomes as per the Prolo score were reported by patients as excellent, good, and poor in 89.85%, 1.59%, and 8.55%, respectively. Repeat surgery was required at same level in 16 patients and at a different level in 21 patients. Total 605 patients (63.49%) were symptom-free during the 70-month followup, while 344 complained of residual back pain, and four complained of persistent leg pain. @*Conclusions@#ULBD using the Endospine system achieves adequate decompression in most cases and is a good alternative to open laminectomy, with the advantage of avoiding damage to the structural integrity of the spine and preserving soft tissue attachments.

Anatomic Considerations of Anterior Transarticular Screw Fixation for Atlantoaxial Instability

STUDY DESIGN: Cadaveric, observational study.PURPOSE: Atlantoaxial instability (AAI) is characterized by excessive movement at the C1–C2 junction between the atlas and axis. An anterior surgical approach to expose the upper cervical spine for internal fixation and bone grafting has been developed to fix AAI. Currently, no anatomic information exists on the anterior transarticular atlantoaxial screw or screw and plate fixation between C1 and C2 in the Indian population. The objective of this study is to assess the anatomic landmarks of C1–C2 vertebrae: entry point, trajectory, screw length, and safety of the procedure.OVERVIEW OF LITERATURE: Methods outlined by Magerl and Harms are the optimal approaches among the dorsal techniques. Contraindications for these techniques include aberrant location of vertebral arteries, fractures of C1–C2 posterior structures. In these cases, anterior transarticular fixation is an alternative. Several available screw insertion trajectories have been reported. Biomechanical studies have demonstrated that adequate rigidity of this fixation is comparable with posterior fusion techniques.METHODS: Direct measurements using Vernier calipers and a goniometer were recorded from 30 embalmed human cadavers. The primary parameters measured were the minimum and maximum lateral and posterior angulations of the screw in the sagittal and coronal planes, respectively, and optimum screw length, if it was placed accurately.RESULTS: The posterior and lateral angles of screw placement in the coronal and sagittal planes ranged from 16° to 30° (mean±standard deviation [SD], 23.93°±3.93°) and 8° to 17° (mean±SD, 13.3°±2.26°), respectively. The optimum screw length was 25–38 mm (mean±SD, 28.76±3.69 mm).CONCLUSIONS: If the screw was inserted without lateral angulation, the spinal canal or cord could be violated. If a longer screw was inserted with greater posterior angulation, the vertebral artery at the posterior or posterolateral aspect of the C1 superior facet could be violated. Thus, 26° and 30° of lateral and posterior angulations, respectively, are the maximum angles permissible to avoid injury of the vertebral artery and violations of the spinal canal or atlanto-occipital joint.

Role of Additional Coronal Magnetic Resonance Imaging in Decompression and Reconstruction with or without Segment Salvage in Thoracic Spine Tuberculosis

STUDY DESIGN: Retrospective and observational study.PURPOSE: The present study aimed to develop guidelines for segment salvage or sacrifice based on the amount and status of the remnant portion of the vertebra as assessed by coronal magnetic resonance imaging (MRI) in addition to sagittal and axial images in thoracic spine tuberculosis (TB).OVERVIEW OF LITERATURE: Indications for surgery have not changed significantly since the ‘middle path regimen’ was proposed by Tuli. Goals of modern surgical management of spinal TB include debridement of diseased vertebrae, spinal cord decompression, deformity correction, and spine stabilization. However, the extent of decompression has not been defined previously. Too less decompression will lead to compromised neurological recovery, whereas large extent of decompression is associated with increased surgical morbidity and longer segment to reconstruct.METHODS: Sixty-five patients with thoracic spine TB were divided into two groups (segment salvage/sacrifice) based on the thickness of the subchondral bone and endplate morphology of the vertebra as seen on MRI. The operative procedure in the form of instrumentation with Hartshill loop rectangle and sublaminar wire using the simultaneous anterior posterior approach in lateral position (versatile approach) was performed. The patients were analyzed for postoperative fusion, improvement in kyphosis angle, and followed up for development of complications.RESULTS: This method of deciding the level of fixation and segment salvage based on coronal MRI in addition to the sagittal and axial images provided good result in 64 of 65 patients, except for one patient in the segment sacrifice group who had graft buckling and resultant kyphosis.CONCLUSIONS: For segment salvage, having a clear three-dimensional idea about the viable remnant bone is important. Viable salvaged segment reduces the morbidity of the procedure, length of the construct, and unnecessary debridement without compromising on the neural recovery and fusion rate. Hence, additional cone down coronal cuts must be required when MRI is suggestive for spinal TB because it will help in the decision making.