Elderly Patients Achieving Clinical and Radiological Outcomes Comparable with Those of Younger Patients Following Minimally Invasive Transforaminal Lumbar Interbody Fusion

STUDY DESIGN: Retrospective analysis of prospective database. PURPOSE: To compare 2-year clinical and radiological outcomes after minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) among “middle-age” (50–64.99 years), “young-old” (65–74.99 years), and “old-old” (>75 years) patients. OVERVIEW OF LITERATURE: Owing to higher perioperative morbidity and mortality rates, elderly patients with degenerative lumbar conditions are occasionally denied surgical care, even after conservative treatment failure. MIS-TLIF advantages include reduced blood loss, reduced analgesia requirements, early mobilization, and shorter hospital stays. METHODS: Between 2007 and 2012, 22 patients (age >75 years) treated with 1-2 level MIS-TLIF were matched with “young-old” and “middle-age” patients (22 each) based on race, body mass index (BMI), diagnosis, spinal level, number of spinal levels operated upon, and bone graft type. Clinical outcomes included the Oswestry disability index (ODI), neurogenic symptom score (NSS), 36-item short form health survey (SF-36), and visual analogue scale (VAS) for back and leg pain. Radiological assessment included plain radiographs and preoperative magnetic resonance imaging (MRI) and plain radiographs at 1, 3, 6, and 24 months postoperatively. Fusion grade, loosening, cage migration, and adjacent segment degeneration were assessed. RESULTS: The groups had similar fluoroscopy time, operation duration, and postoperative analgesia type used. “Old-old” patients took longer to ambulate (1.6 days) and had longer hospital stays (6 days). All patients showed significant improvement in clinical outcome scores at all time-points compared with the preoperative status. “Middle-age” patients showed better ODI and SF-36 physical function scores than “old-old” patients preoperatively and 2 years post surgery. NSS, VAS (back and leg), and SF-36 mental function scores were similar between groups preoperatively and at every time-point postoperatively. Minimal clinical important differences (63.6%–95.5% at 2 years) were achieved. Grade 1 fusion occurred in a minimum of 80% patients in each group 2 years post surgery. Complication rates were similar. Adjacent segment disease occurred in 2 patients from the “young-old” group, with no significant differences between groups. CONCLUSIONS: MIS-TLIF showed comparable results in selected “old-old” patients compared with “young-old” and “middle-age” patients without increased complication risks.

“Project Eklavya”: To Transform the Indian Health Education System.

Abstract: Over 6.3 lakh students have taken this year's pre medial test in India. The total number of MBBS seats in the country is around 52,300. The current doctor population ratio is 1: 1700. The country needs 1, 00,000 graduates yearly to achieve a ratio of 1:1000. Since graduates from public and private funded medical institutions are not motivated to serve in rural settings, increasing the number of places or establishing new medical institutions may not be an effective solution to the issue, as observed by Hazarika. The medical education model proposed in this article, which includes common entry and exist test with flexibility of learning medical education, will make medical education available to all deserving candidates irrespective of their caste, creed, financial status and, most importantly, geographical location. Any deserving candidate from even the remotest part of the country can access the best medical education using the powerful tool of information technology and the vast medical educators’ pool of talent and experience available in the country and abroad.

Down's syndrome patient with multiple sialoliths in Stenson's duct.

The presence of multiple sialoliths (calculi) in parotid duct is considered extremely rare. Parotid duct sialoliths are usually small and single. Multiple calculi formation, in any case, is an uncommon finding in the salivary glands. Salivary lithiasis is comparatively common in the Wharton's duct due to its tortuous ascending course and chemical composition of saliva of submandibular gland. The mechanism of sialolith formation in Down's syndrome patients is not completely known, and there are seldom cases reported in the literature available. The present case report is a very rare combination of a Down's syndrome with multiple sialoliths in Stenson's duct of left parotid gland in a 21year old male patient.

Granulocytic sarcoma masquerading as Ewing's sarcoma: a diagnostic dilemma.

An eleven-year-old boy presented with a swelling in his left elbow. Radiologically the features were that of an Ewing's sarcoma involving the ulna. Histopathology showed small round cell tumor strongly positive for Monoclonal Imperial Cancer research fund 2 (MIC2) antigen. Similar cells in the bone marrow were involved with MIC2 positivity. The patient developed skin lesions, which on biopsy were found to be chloromas. The initial biopsies were reevaluated with special stains revealing granulocytic sarcomas in acute myeloid leukemia masquerading as Ewing's due to its MIC2 positivity. The possibility of myeloid neoplasms should be considered routinely with known MIC2 positive round cell tumors.