Multisegmental cervical ossification of the posterior longitudinal ligament: anterior vs posterior approach.

AIMS: To determine the surgical approach in patients with multisegmental (four or more segments) OPLL of the cervical spine. METHODS AND MATERIALS: Data of 27 patients who had undergone either an anterior (corpectomy with excision of OPLL and interbody fusion = 14 patients) or posterior approach (laminectomy = 12, laminoplasty = 1 patient) for the multisegmental cervical OPLL was analyzed retrospectively. The patients in each group were statistically similar in respect to preoperative factors such as age, duration of symptoms, preoperative modified Japanese orthopedic association score, OPLL thickness, effective canal diameter, and antero-posterior cord compression ratio. The clinical outcome was assessed by the Harsh grading system and recovery rate was assessed by Hirabayashi method. RESULTS: There was no statistical difference in the outcome, and recovery rate. Nine patients developed complications after anterior approach in contrast to one after posterior approach. CONCLUSIONS: In patients with multisegmental cervical OPLL, there was no significant difference in the short-term recovery rate and outcome between two groups. The immediate postoperative complications were less in patients who had undergone posterior approach. From our analysis, it appears that the posterior approach is probably the preferred method of treatment in a multisegmental OPLL in absence of preoperative kyphosis.

C3-4 level cervical spondylotic myelopathy.

Cervical spondylotic myelopathy (CSM) is uncommon at the C3-4 level. Fourteen patients with C3-4 CSM were treated over a period of 3 years. The radiological factors contributing to CSM at the C3-4 level were studied. These factors included the assessment of static and dynamic canal diameters, retrolisthesis, posterior osteophytes and degenerative spinal segmental fusion on plain X-rays; and, the antero-posterior cord compression ratio (APCR) on magnetic resonance imaging (MRI). The clinical status of the patients was assessed by the modified Japanese orthopedic association scale (mJOAS). The mean difference between the static and dynamic canal diameters was statistically significant at C3-4 (p < 0.01). The APCR obtained at different levels showed a significant compression at the C3-4 level in comparison to the lower level. There was a correlation between the APCR and the preop mJOAS, r=0.6 (p< 0.05). The mean mJOAS improved from 9.35 to 14.35 at follo-up. The recovery rate calculated using the modified Hirabayashi rate was 66.9%. Degenerative changes at lower cervical segments predispose to increased mobility and spondylotic changes at the C3-4 level. The patients in this study were young as compared to those reported in the international literature.

Congenital absence of the posterior elements of C2 vertebra: a case report.

A rare case of the complete absence of the posterior elements of C2 is reported. The patient presented with neck pain without any neurological deficits and radiology revealed a mobile, partially reducible dislocation of the C2 over C3 vertebra. A posterior fusion utilizing a contour rod, sublaminar wire fixation, and onlay bone grafts between the occiput and the C3 vertebra was performed for spinal stability.

Efficacy of low dose intradermal hepatitis B vaccine: results of a randomized trial among health care workers.

BACKGROUND: Hepatitis B virus (HBV) infection is an occupational health hazard among the healthcare workers. Vaccination against HBV has been established to be the most effective preventive strategy. The present study was designed to assess the efficacy of low dose intradermal HBV vaccine among the nursing staff in a tertiary care hospital setting. PATIENTS AND METHODS: Staff nurses working in our hospital were included in the study as vaccine recipients. Each staff nurse was tested for HBsAg and anti-HBs (commercial ELISA). Those who tested negative for both the above markers were randomized to receive either three doses of intramuscular (i.m.) HBV vaccine (20 micrograms m each dose) at 0, 1 and 6 month interval or three doses of intradermal HBV vaccine (2 micrograms m each dose) at similar intervals. Each vaccine recipient was tested for the presence of anti HBs (commercial ELISA) at the end of 1 month and 1 year after the last dose of the vaccine. The anti-HBs titres were also estimated simultaneously in them. RESULTS: Out of 153 staff nurses screened, 19 were either positive for HBsAg (n = 1) or anti HBs (n = 18). 96(72%) of the remaining 134 nurses agreed to receive HBV vaccine (i.m.--48, intradermal--48). At the end of 1 month after last dose of the vaccine, all vaccinees in both the group tested positive for anti-HBs. However the anti-HBs titres at 1 month were significantly higher among intramuscular vaccinees than the nurses receiving the vaccine through intra-dermal route (253 +/- 127.7 mIU/ml vs 151.3 +/- 92.8 mIU/ml, P < 0.001). Eighty four (85.5%) of these 96 vaccine recipient were available for evaluation of anti-HBs titre at the end of 1 year after the last dose of vaccine (1M group = 40, Intradermal group = 44). All the nurses continued to be positive for anti-HBs at the end of 1 year but the anti HBs-titre among i.m. vaccine recipient continued to remain at a significantly higher level than the similar titre among the intradermal vaccine recipients (256.4 +/- 124.7 mIU/ml vs 121.6 +/- 122.4 mIU/ml p < 0.001). CONCLUSION: Intradermal route for HBV vaccine had similar immunogenic efficacy as the conventional intramuscular route, but the dose required in the former route is one tenth of the intramuscular route. Therefore intradermal route may reduce the cost of HBV vaccine markedly.

Endoscopic sclerotherapy in children with extrahepatic portal venous obstruction.

BACKGROUND: Extrahepatic portal vein obstruction (EHPVO) is a common cause of variceal bleeding in children in India. There is paucity of data regarding the results of treatment with endoscopic sclerotherapy. METHODS: Fifty-nine children (mean age 11 +/- 3.8 years; range 7 months to 12 years; 36 males and 23 females) were studied from February 1990 to September 1999. EHPVO was diagnosed on the basis of portal cavernoma on ultrasonography in 55 patients and on splenoportovenogram in 4 patients. Endoscopic sclerotherapy was caried out at weekly intervals for the first three weeks and at 3 weekly intervals thereafter till complete or near complete thrombosis was achieved. All patients were followed up with check endoscopy every 3-6 months after thrombosis of oesophageal varices. RESULTS: Over a mean follow up of 25.4 months (range 3 to 87 months) total thrombosis was achieved in 53 (89.8%) of 59 children. The mean number of sclerotherapy sessions required were 7.5 +/- 2.2. The mean number of blood transfusions required per bleeding episode was 3.8 +/- 3.2. Of the 59 children 21 (35.6%) rebled, of which 17 (28.8%) bled during and 4(6.8) after thrombosis of varices. Seven (11.9%) children had more than one episode of bleeding. Once thrombosis of the varices was achieved 15 (26%) of 59 children developed fresh varices on follow up. Gastric varices were detected in 47 (60%) children. In 39 (66%) children it was present at the onset and in 8 (13.5%) children it developed after thrombosis of oesophageal varices. Bleeding from gastric varix occurred in 7(9%) children. Ascites developed in 6(10.6%) children. One child developed oesophageal stricture. There were 3 (5%) deaths. Two died due to upper gastrointestinal bleed while on sclerotherapy schedule and one died due to cerebral abscess. CONCLUSION: EHPVO is an important and common cause of upper gastrointestinal bleeding in children in Western India. EST is safe and useful in controlling oesophageal variceal bleeding in children.

Colonic tuberculosis: colonoscopic appearance and clinico-pathologic analysis.

BACKGROUND: There has been a resurgence of interest in intestinal tuberculosis because of acquired immunodeficiency syndrome (AIDS) epidemic sweeping our country. Role of colonoscopy and colonoscopy directed histology for diagnosing the disease have been emphasised since last few years. AIMS AND OBJECTIVES: To know the colonoscopic features in patients with intestinal tuberculosis and to study the clinicopathological findings in the same. METHODS: We studied twenty-one patients with intestinal tuberculosis referred to us between 1993-1997. Colonoscopy was done in all patients and biopsy specimens were collected from the site of lesion during the procedure. RESULTS: Ileocaecal disease was found in 9 patients, ileocaecal with contiguous ascending colon involvement in eight and segmental colonic tuberculosis in four cases. The colonoscopic findings included nodules in seven patients, nodules with ulcerations in three, ulcerations alone in seven, nodules with strictures in three and polypoidal mass in one patient. Eight cases revealed granuloma on histopathology. CONCLUSIONS: Though bacteriological and histological assessment of tissue is essential to differentiate tuberculosis from other disorders, we stress the importance of colonoscopic appearances in diagnosing tuberculosis. We also recommend antituberculous chemotherapy in patients with high clinical suspicion of tuberculosis on the basis of colonoscopic appearance alone after ruling other causes on histopathological examination.

Foreign bodies in gut.

BACKGROUND: Foreign body ingestion is common and a frightening experience to the patients and relatives. We report our experience with 102 patients, (78 children and 24 adults), with foreign body ingestion. METHODS: After locating foreign bodies radiologically, 34 (43.6%) foreign bodies in children and 13 (54.2%) foreign bodies in adults were removed endoscopically. General anesthesia was used in 32 children and overtube was used for all sharp foreign bodies. RESULTS: In our study, 78 (76%) patients were below 12 years of age. Coins (79.5%) were commonest foreign bodies in children while dentures (25%) were commonest in adults. Foreign bodies were most commonly sited in stomach (25.6%) in children and esophagus (58.3%) in adults. In 41 (52.6%) children and in three (12.5%) adults, i.e. total 44 out of 102 (43.1%) patients passed foreign bodies spontaneously. The largest foreign body that passed spontaneously was 4-cm long nail in a child. In 34 (43.6%) children and in 13 (54.2%) adults foreign bodies were removed endoscopically. Only 3.8% children and 33.3% adults required surgery. CONCLUSIONS: There was no mortality in our series. Majority of foreign bodies do not require any intervention. Sharp foreign bodies are commonest indication for surgery. However, endoscopic removal is safe, effective and is the method of choice for most patients.

A comparative study of various surgical treatments of hepatic hydatidosis with special reference to capitonnage.

Nine patients treated by different modalities of surgical treatment were evaluated and the results were compared in terms of complications and total number of hospitalisation days. Most common complaint was pain abdomen and the commonest finding was an abdominal lump. After initial treatment of the cavity with a scolicidal agent the cyst was deroofed and the remaining cyst was dealt with in 3 different ways: (a) Three patients underwent simple drainage. (b) Marsupialisation was done in 3 cases. (c) Remaining 3 patients had capitonnage offered to them as the form of treatment. Complication rates in group (a) and (b) were 33% and 67% respectively and the average hospital stay was 13 and 20 days respectively while group (c) had no complication and the average hospital stay was 8.3 days.

Volvulus of descending colon with anomalous mesocolon.

Volvulus of the cecum, transverse colon and sigmoid colon is common. A patient with isolated volvulus of the descending colon, leading to gangrene of that segment, is reported.