Deformity Correction with Interbody Fusion Using Lateral versus Posterior Approach in Adult Degenerative Scoliosis: A Systematic Review and Observational Meta-analysis

This study was designed to systematically review and meta-analyze the functional and radiological outcomes between lateral and posterior approaches in adult degenerative scoliosis (ADS). Both lateral (lumbar, extreme, and oblique) and posterior interbody fusion (posterior lumbar and transforaminal) are used for deformity correction in patients with ADS with unclear comparison in this cohort of patients in the existing literature. A literature search using three electronic databases was performed to identify studies that reported outcomes of lateral (group L) and posterior interbody fusion (group P) in patients with ADS with curves of 10°–40°. Group P was further subdivided into minimally invasive surgery (MIS-P) and open posterior (Op-P) subgroups. Data on functional, radiological, and operative outcomes, length of hospital stay (LOHS), fusion rates, and complications were extracted and meta-analyzed using the random-effects model. A total of 18 studies (732 patients) met the inclusion criteria. No significant difference was found in functional and radiological outcomes between the two groups on data pooling. Total operative time in the MIS-P subgroup was less than that of group L (233.86 minutes vs. 401 minutes, p <0.05). The total blood loss in group L was less than that in the Op-P subgroup(477 mL vs. 1,325.6 mL, p <0.05). Group L had significantly less LOHS than the Op-P subgroup (4.15 days vs. 13.5 days, p <0.05). No significant difference was seen in fusion rates, but complications were seen except for transient sensorimotor weakness (group L: 24.3%, group P: 5.6%; p <0.05). Complications, such as postoperative thigh pain (7.7%), visceral injuries (2%), and retrograde ejaculation (3.7%), were seen only in group L while adjacent segment degeneration was seen only in group P (8.6%). Lateral approach has an advantage in blood loss and LOHS over the Op-P subgroup. The MIS-P subgroup has less operative time than group L, but with comparable blood loss and LOHS. No significant difference was found in functional, radiological, fusion rates, pseudoarthrosis, and complications, except for transient sensorimotor deficits. Few complications were approach-specific in each group.

Variability in Management Practices and Surgical Decision Making in Spinal Tuberculosis: An Expert Survey-Based Study

Methods@#Seventeen fellowship-trained spinal TB experts representing different geographical regions of India completed an online survey consisting of questions pertaining to the conservative management of spinal TB (antitubercular therapy) and 30 clinical case vignettes including a wide spectrum of presentations of spinal TB with no or minimal neurological deficit. The variability in the responses for questions and case wise variability with respect to surgical decision making was assessed using the index of qualitative variation (IQV). The average tendency to operate (TTO) was calculated for various groups of respondents. @*Results@#High variability was observed in all questions regarding conservative spinal TB management (IQV > 0.8). Among the 30 case vignettes, 14 were found to have high variability with respect to surgical decision making (IQV > 0.8). With respect to levels of fixation, all but two cases had poor or slight agreement. Younger age and practice in a government or tertiary care teaching hospital were factors associated with a higher TTO. @*Conclusions@#Significant variability was detected in treatment practices for the management of spinal TB among experts. Most of the case vignettes were found to have significant heterogeneity with respect to surgical decision making, which reflects a significant lack of consensus and lacunae in literature.

Evaluation of pedicled flaps for type IIIB open fractures of the tibia at a tertiary care center

Background@#Soft tissue coverage plays a vital role in replacing the vascularity of the underlying bone in Gustilo type IIIB fractures. The aim of this article was to evaluate the feasibility of local pedicled flaps in type IIIB fractures at a tertiary care center. @*Methods@#We included all cases of open Gustilo-Anderson type IIIB fractures of the tibia treated with local flap coverage from January 2017 to February 2019. We carried out a retrospective analysis to investigate the relationships of complications, hospital stay, and cost-effectiveness with the choice of flap, infective foci, site and size of the defect, and type of fixation. @*Results@#Out of 138 Gustilo type IIIB fractures analyzed in our study, 27 cases had complications, of which 19 (13.76%) involved flap necrosis, four (2.89%) were infections, three (2.17%) involved partial necrosis, and one (0.72%) was related to bone spur development. Flap complications showed a statistically significant association with the perforator flap category (propeller flaps in particular) (P=0.001). Flap necrosis showed a significant positive correlation with cases treated within 3 weeks after trauma (P=0.046). A significant positive correlation was also found between defect size and the duration of hospital stay (P=0.03). @*Conclusions@#Although local flaps are harvested from the same leg that underwent trauma, their success rate is at least as high as microvascular flaps as reported from other centers. Amidst the local flaps, complications were predominantly associated with perforator flaps.

Evaluation of pedicled flaps for type IIIB open fractures of the tibia at a tertiary care center

Background@#Soft tissue coverage plays a vital role in replacing the vascularity of the underlying bone in Gustilo type IIIB fractures. The aim of this article was to evaluate the feasibility of local pedicled flaps in type IIIB fractures at a tertiary care center. @*Methods@#We included all cases of open Gustilo-Anderson type IIIB fractures of the tibia treated with local flap coverage from January 2017 to February 2019. We carried out a retrospective analysis to investigate the relationships of complications, hospital stay, and cost-effectiveness with the choice of flap, infective foci, site and size of the defect, and type of fixation. @*Results@#Out of 138 Gustilo type IIIB fractures analyzed in our study, 27 cases had complications, of which 19 (13.76%) involved flap necrosis, four (2.89%) were infections, three (2.17%) involved partial necrosis, and one (0.72%) was related to bone spur development. Flap complications showed a statistically significant association with the perforator flap category (propeller flaps in particular) (P=0.001). Flap necrosis showed a significant positive correlation with cases treated within 3 weeks after trauma (P=0.046). A significant positive correlation was also found between defect size and the duration of hospital stay (P=0.03). @*Conclusions@#Although local flaps are harvested from the same leg that underwent trauma, their success rate is at least as high as microvascular flaps as reported from other centers. Amidst the local flaps, complications were predominantly associated with perforator flaps.

Is Anterior-Only Fixation Adequate for Three-Column Injuries of the Cervical Spine?

Methods@#Twenty-one patients undergoing ACDF/ACCF with a bone graft/metallic cage treatment for cervical injuries involving all three columns from January 2016 to July 2018 were included in the study. All of the patients were followed up monthly for the first 3 months and then every 6 months, until their last follow-up visit. @*Results@#Nineteen patients had AO type C injuries and were managed with ACDF, and two patients with AO type B injuries were managed with ACCF. Fifteen had a complete spinal cord injury, while six had an incomplete spinal cord injury (American Spinal Injury Association B, C, and D). The mean segmental kyphosis at presentation of 12.2°±4.4° improved in the postoperative period to -7.2°±2.5°. At their final follow-up, all the patients showed clinical improvements when assessed by the Visual Analog Scale (6.8–1.8), Oswestry Disability Index score (59.7–34.9), and Spinal Cord Independence Measure score (24.8–36.4). One patient in the ACDF group needed a secondary posterior fixation because of instability. @*Conclusions@#An anterior approach to the cervical spine in cervical fracture dislocations is an effective treatment showing an optimal recovery rate in terms of patient-reported outcomes and structural stability, with the added advantages of less blood loss and the fact that the technique requires less instrumentation.

Evaluation of Challenges in Diagnosis of Spontaneous Subacute Pyogenic Spondylodiscitis in Immunocompetent Patients: Experiences from a Tertiary Care Center

STUDY DESIGN: Prospective clinical study. PURPOSE: We evaluated the challenges faced during diagnosis and management of patients with subacute pyogenic discitis and discussed various clues in clinical history, radiologic and hematologic parameters of these patients that helped in establishing their diagnosis. OVERVIEW OF LITERATURE: Present literature available shows that in patients with subacute spondylodiscitis and infection with less virulent organisms, the clinical picture often is confusing and the initial radiologic and hematologic studies do not contribute much toward establishing the diagnosis. METHODS: Demographic pattern, predisposing factors, clinical presentation, comorbidities, microbiology, treatment, neurologic recovery, and complications of 11 patients were prospectively reviewed regarding their contribution toward the conformation of diagnosis of subacute pyogenic discitis. RESULTS: Mean age at presentation was 46.0 years with average preoperative Oswestry Disability Index and Visual Analog Scale scores of 83.4 and 7.18, respectively. Mean follow-up duration was 12.0 months. The most common site of infection was the lumbar spine, followed by the thoracic spine (n=1). Infective organisms were isolated in only 45% of cases. Staphylococcus aureus was the most common causative organism isolated. CONCLUSIONS: Diagnosing subacute spondylodiscitis in a patient presenting with subacute low backache poses a diagnostic challenge. Clinical and radiologic picture are deceiving, and bacteriologic results often are negative, further complicating the picture. A detailed medical history along with clinical, radiologic, and biochemical parameters prevents missing the diagnosis. Serial serum C-reactive protein and alkaline phosphatases were more reliable blood parameters in cases of subacute presentation.

Severe Rigid Scoliosis: Review of Management Strategies and Role of Spinal Osteotomies

Severe rigid curves pose a considerable challenge to the treating spine surgeon. In our practice, approximately 30%–40% of patients with scoliosis present late with severe rigid scoliosis (>90° and <30% correction on bending films). Controversy still exists with regard to the ideal surgical strategy for correcting these rigid curves. Rigid scoliosis often presents in the form of either sharp angular or rounded deformities. Rounded deformities can be effectively managed with an anterior release to loosen the apex and posterior instrumentation (with osteotomies, if required). In contrast, severe rigid scoliosis, which is a sharp angular deformity, is not very amenable to anterior release and is best managed by posterior-only vertebral column resection and posterior instrumentation.

Management of Tuberculous Infection of the Spine

Spinal tuberculosis accounts for nearly half of all cases of musculoskeletal tuberculosis. It is primarily a medical disease and treatment consists of a multidrug regimen for 9-12 months. Surgery is reserved for select cases of progressive deformity or where neurological deficit is not improved by anti-tubercular treatment. Technology refinements and improved surgical expertise have improved the operative treatment of spinal tuberculosis. The infected spine can be approached anteriorly or posteriorly, in a minimally invasive way. We review the various surgical techniques used in the management of spinal tuberculosis with focus on their indications and contraindications.