Functional outcome of transforaminal lumbar inter body fusion: an experience at a tertiary care centre

Objective: To assess functional outcome of transforaminal lumbar inter body fusion [TLIF] with specific reference to improvement in pain by visual analogue score [VAS] and Oswestry disability index [ODI]

Study Design: Quasi-experimental study

Place and Duration of Study: The study was conducted at the Department of Spine Surgery of a tertiary care hospital in Rawalpindi from May 2004 to May 2013

Material and Methods: Thirty nine patients who underwent TLIF and completed one year of follow up in our department during the study period were included in the study. Cases were evaluated clinically and radiologically preoperatively and assessed for pain with VAS and general well being with ODI. After TLIF they were reassessed at 1, 3, 6 months and 1 year for improvement in VAS and ODI. Patient satisfaction and work status after surgery was also recorded at 1 year of follow up

Results: Out of 39 cases 19[48.7%] were operated for degenerated disc disease [DDD], 11[28.2%] for spinal stenosis and 7[17.9%] for spondylolisthesis and 2[5.2%] for trauma. A total of 28[71.79%] were males and 11[28.21%] were females. Common levels operated were 12 [30.8%] at L4-5, 11 [28.2%] at L5-S1, and 12[30.8%] at L4,5-S1, 2[5.1%] at L2-4 and 1[2.6%] each at L3-4 and L3-5. At 1 year of follow up median VAS score improved significantly from 7 to 2 and median ODI improved significantly from 76 to 34. Regarding patient satisfaction 26 [66.7%] patients were satisfied, 9 [23.1%] were partially satisfied and 4 [10.2%] were not satisfied with the surgical outcome

Conclusion: TLIF is a safe and effective procedure for reducing chronic low back pain as a result of DDD, instability and spondylolisthesis

Surgical treatment of upper cervical spine injuries [C1-C2]: experience in 26 patients

To describe the spectrum of operations in unstable upper cervical spinal injuries in [atlanto-axial] region at our unit. A cross-sectional study. Spine Unit, Department of Orthopedics, Combined Military Hospital [CMH], Rawalpindi from Jan 2001 to Dec 2008. Frequency of different kind of operations in 26 patients operated for upper cervical spinal injuries was reviewed. A performa was made for each patient and records were kept in a custom built Microsoft access database. Average age of patients studied was 27 years with male pre dominance. Total 12[46%] patients had Atlanto-axial instability, 8[31%] had Hangman's fracture and 6[23%] patients had odontoid peg fracture. While 11[42%] patients had no neurological deficit according to American spinal injury association impairment scale [AIS-E] and 15[58%] had partial neurological deficit. The patients were divided into three groups. Group A had odontoid peg fracture, Group B had atlanto-axial instability and Group C had Hangman's fracture. The spine was approached posteriorly in 19[73%] cases and anteriorly in 7[27%]. Pedicle screw fixation was done in 6[23%] patients, odontoid peg screw fixation in 6[23%], Gallie's fusion in 5[19%], occipito-cervical fusion in 4[15%], posterior transarticular fixation in 3[12%], anterior transarticular fixation and decompression in others, 9[60%] patients improved neurologically postoperatively and there was no deterioration of neurological status. Nonunion in two [8%] cases and implant failure in one [4%] were complications. Upper cervical injuries [C1-C2] are rare and their management is complex, necessitating lot of experience for their management. Early diagnosis and appropriate treatment is essential for good outcome. Each injury has to be managed at its own merit and a single operation may not be appropriate in all situations. General guidelines can be drawn from our study for the management of these cases on modern lines

Surgical treatment in lumbar spondylolisthesis: experience with 45 patients

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. 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. Majority of our patient were in 4[th] and 5[th] 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. 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

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. Case series. Spine Unit, Orthopaedic Department, Combined Military Hospital, Rawalpindi, from April 2001 to December 2008. 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. 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. 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

Outcome of instrumented spinal fusion for chronic low back pain: review of 100 patients

Objective of this study was to evaluate the outcome of instrumented spinal fusion in selected patients with Chronic Low Back Pain [CLBP] in our setup. Quasi-experimental study. Spine Unit, Orthopaedic Department, Combined Military Hospital, Rawalpindi, Pakistan. Jan 2002 to Dec 2007. Consecutive first one hundred patients were selected from spine unit database that underwent instrumented spinal fusion for chronic low back pain lasting more than one year, due to degenerative disease of spine. Average age was 42 years. There were 62 males and 38 females. Diagnosis included; spinal stenosis [26%], failed disc surgery [22%], spondylolisthesis [19%], degenerative disc disease [17%], and instability [16%]. Operations performed; Pedicle Screw Fixation [PSF] with Postero-lateral Fusion [PLF] in 3% patients. Trans Laminar Facet Screw [TLFS] with PLF in 24% patients. Anterior Lumbar Inter-body Fusion [ALIF] in 9% patients. Posterior Lumbar Inter-body Fusion [PLIF] in 40% patients and Trans-foraminal Lumbar Inter-body Fusion [TLIF] in 24% patients. Average follow up was for 30 months. 86% patients had full spinal fusion. 71% patients were fully satisfied with treatment, 28% were partially satisfied. Post-operatively, on average, visual analogue scale [VAS] showed 48 points significant improvement and Oswestry Disability Index [ODI] showed 53 points significant improvement. Instrumented Spinal Fusion is effective in our set up for relieving symptoms and improving functional outcome in selected patients with debilitating Chronic Low Back Pain due to degenerative disease of spine. Single fusion technique is not ideal for all types of patients and surgeon has to be versatile and trained in using different fusion techniques as the situation demands

Pain relief after vertebroplasty for osteoporotic and osteolytic compression fractures

To find out the role of percutaneous cement vertebroplasty [PCV] in osteoporotic and osteolytic compression fractures of the vertebral bodies using polymethyl methacrylate [PMMA] bone cement in early pain relief. Quasi-experimental study. This study was conducted in Spinal Unit, Orthopaedic Department, Combined Military Hospital, Rawalpindi, Pakistan from Nov 2005 to May 2007. Ten patients with sixteen osteoporotic and osteolytic fractures were treated with PCV using PMMA. Seven patients out of these had osteoporotic vertebral compression fractures [OVCF] and three had compression fractures secondary to spinal metastases [SM]. Six patients were males and four were females. Average age among OVCF was 66 years and among SM was 54 years. Patients were followed up on 1[st] post op day, two weeks and six weeks after PCV Patient satisfaction, relief in pain, early mobilization, restoration of vertebral height and complications were noted. Nine out of ten patients were fully satisfied with PCV Eight patients had excellent pain relief [p value < 0.001]. Eight patients were mobilized within two hours of the procedure. There was one major cement leak inside spinal canal causing paraparesis. In this patient immediate exploration, decompression and pedicle screw fixation was done. He had complete neurological recovery post-operatively. Three patients had minor asymptomatic cement leaks. One patient had prolonged ileus, which settled ultimately. In carefully selected cases, PCV is shown to be very efficacious in relieving the pain associated with both osteoporotic and osteolytic compression fractures. It is a minimally invasive procedure that has gained widespread acceptance as the standard of care for compression fractures unresponsive to traditional forms of treatment

Role of moss miami pedicle screw system in unstable spinal injuries

To find out the role of instrumentation with MOSS Miami [by DePuy, Johnson and Johnson] implants to treat patients with unstable thoraco-lumbar spinal fractures and dislocations in terms of stability achieved and improvement in neurological status. Quasi-experimental study. This study was conducted in orthopaedic department of Combined Military Hospital Rawalpindi from Oct 2001 to Oct 2004. 80 patients with unstable spinal injuries were operated during above time period. 48 patients underwent posterior transpedicular MOSS Miami instrumentation of thoraco-lumbar spine. Instability was defined according to White and Panjabi's criteria. Neurological deficit was defined according to American Spinal Injuries Association [ASIA] Impairment Scale [AIS]. Those with complete injury were placed in group I [29 cases] and rest were assigned group II [19 cases]. All cases were treated by open reduction and short segment internal fixation using MOSS Miami pedicle screw system. Patients were followed up 2 weeks, 6 weeks, 3 months, 6 months and yearly after operation. Patients were observed for correction of deformity, spinal fusion, improvement in neurological status, loss of reduction over time, back pain and rehabilitation. All data was put in a dedicated MS Access Data Base and analysed using SPSS. It was observed that those with complete neurological deficit only 5 cases improved out of 29 cases and the mean AIS improvement was 0.39 / case. Out of those with partial neurological deficit, all cases showed improvement. There was no deterioration in neurological status. Mean AIS improvement was 1.4 / case. Solid spinal union was observed in 45 cases out of 48 cases at the end of 3 months. 03 cases had implant related complications. The vertebral deformity was completely restored in 32 cases and incompletely in 16 cases. Loss of reduction was 2.5 [degree sign] on average. MOSS Miami pedicle screw system is safe and effective for posterior short segment fixation of unstable thoraco-lumbar fractures

Spinal surgery in earthquake victims

Objective of present paper is to document the operations performed in earthquake spinal injury patients and to analyze the results of surgery. This is a quasi-experimental study. This study was conducted at the department of Orthopaedic and Spinal surgery at Combined Military Hospital [CMH], Rawalpindi. Study started after earthquake in Pakistan on 8[th] of October 2005 and ended in August 2006. 250 patients with spinal injury were admitted at the three main army hospitals at Rawalpindi [CMH, MH and AFIRM] after earthquake on 8[th] October 2005. Out of these, 110 patients underwent 120 major spinal operations. 12 patients were received from other units for revision surgery. 75% of the patients were civilians and 25% were army personnel and their families. Average age was 28 years and range was 8-65 years. 56% patients were females and 44% were males. 46% patients had complete neurological deficit and 54% had incomplete neurological deficit. Most common associated injuries were fractures of tibia and fibula. Most common level of injury was at T12/L1 [55%]. After surgery almost all patients had rehabilitation at AFIRM. Post-operatively excellent [>75%] or good [50-75%] correction of deformity was achieved in 90% of patients. 92% patients had mild or no pain, post-operatively. Neurological improvement was seen in all patients with incomplete deficit except four. Some patients with complete deficit also showed improvement. Overall there was 1.5 AIS improvement per patient. At last follow up 46% patients were walking independently and 51% were independent in wheel chair. Spinal surgery in patients with unstable spines after major disaster should be carried out by properly trained surgeons as soon as possible and in a setup where facilities for proper rehabilitation are available as it carries best prognosis for these high risk and at times paralyzed patients