Mid thoracic intra-spinal facet cyst with lumbar canal stenosis: a rare 'double crush'.

INTRODUCTION: Intraspinal synovial cysts occurrence causing spinal canal occlusion are mostly seen in mobile segments of the spine (lumbar and cervical). An appearance of the cyst in thoracic spine is a relatively rare occurrence. We present an interesting case of 'double crush' caused by Lumbar canal stenosis with a mid-dorsal Facet cyst. CASE PRESENTATION: A 67-year-old woman presented with complaints of back pain with neurogenic claudication with significant loss of touch sensation and motor power of MRC grade 3/5 in lower extremities bilaterally. However, patient was hyperreflexic with Babinski sign positive. She was unable to perform tandem walking test and complained of instability. MRI of lumbar spine revealed lumbar canal stenosis. However, in view of the UMN signs, an MRI of the dorsal spine was done. It revealed an extradural, well-delineated lesion along the dorsal aspect of spine at T6-7 level. Thus the patient had a 'double crush' due to the FC along with lumbar canal stenosis. CLINICAL FINDINGS CORRELATED WITH THE IMAGING: Two teams simultaneously operated the 2 pathologies and T6-7 laminectomy along with left sided TLIF at L4-5 level was performed. Presently she is asymptomatic for back pain, claudication distance has improved to 800 m. CONCLUSION: Our case reiterates the importance of thorough clinical examination to avoid missing a diagnosis. Our case is the first in literature to report a 'double crush' due to a proximal dorsal FC and distal LCS. Both the pathologies were tackled in a single setting by two operating teams with a good functional outcome.

Revisiting the Role of Intraoperative Ultrasound in Spine Surgery for Extradural Pathologies: Review and Clinical Usage.

OBJECTIVE: This case series looks at the role of intraoperative ultrasound in spine surgery for extradural pathologies. METHODS: Ten cases of different pathologies were included. Following posterior laminectomy, intraoperative ultrasound was used to determine the adequacy of decompression. The surgical approach and extent of surgery was then determined on the basis of ultrasound observations. Postoperative magnetic resonance imaging was done to correlate the ultrasound findings. RESULTS: We found intraoperative ultrasound to be a useful tool that is easy to use and interpret in spine surgery. The adequacy of decompression was well visualized. The finding also correlated with the decompression achieved on a postsurgery magnetic resonance imaging scan. CONCLUSIONS: Intraoperative ultrasound is a useful tool in routine spine surgery. It is effective and easy to read to determine decompression for various pathologies including disk herniation, epidural abscess, tumors, and deformity and reconstructive surgeries. This simple tool can help plan surgeries.

Posterior Stabilization Without Neural Decompression in Osteoporotic Thoracolumbar Fractures With Dynamic Cord Compression Causing Incomplete Neurological Deficits.

STUDY DESIGN: Prospective cohort study. OBJECTIVES: Management of osteoporotic vertebral compression fracture (OVCF) remains an unsolved problem for a spine surgeon. We hypothesize that instability at the fracture site rather than neural compression is the main factor leading to a neurological deficit in patients with OVCF. METHODS: In this study, the prospective data of patients with osteoporotic fractures with incomplete neurological deficits from January 2015 to December 2017 was analyzed in those who underwent posterior instrumented fusion without neural decompression. RESULTS: A total of 61 patients received posterior indirect decompression via ligamentotaxis and stabilization only. Of these 17 patients had polymethylmethacrylate (PMMA) augmented screws and in 44 patients no PMMA augmentation was done. The mean preoperative kyphosis was 27.12° ± 9.63°, there was an improvement of 13.5° ± 6.87° in the immediate postoperative period and at the final follow-up, kyphosis was 13.7° ± 7.29° with a loss of correction by 2.85° ± 3.7°. The height restoration at the final follow-up was 45.4% ± 18.29%. In all patients, back pain was relieved, and neurological improvement was obtained by at least 1 American Spinal Injury Association Impairment Scale in all except 3 patients. CONCLUSION: We propose that neural decompression of the spinal cord is not always necessary for the treatment of neurological impairment in patients with osteoporotic vertebral collapse with dynamic mobility. Dynamic magnetic resonance imaging is a valuable tool to make an accurate diagnosis and determine precise surgical plan and improving the surgical strategy of OVCF.

Role of Invasive Urodynamic Studies in Establishing Cauda Equina Syndrome and Postoperative Recovery.

STUDY DESIGN: Retrospective with prospective follow-up. OBJECTIVE: Confirming the diagnosis of CES based purely on symptoms and signs is unreliable and usually associated with high false positive rate. A missed diagnosis can permanently disable the patient. Present study aims to determine the relationship between clinical symptoms/ signs (bladder dysfunction) with UDS, subsequently aid in surgical decision making and assessing post-operative recovery. METHODS: A prospective follow-up of patients with disc herniation and bladder symptoms from January 2018 to July 2020 was done. All patients underwent UDS and grouped into acontractile, hypocontractile and normal bladder. Data regarding PAS, VAC, GTP, timing to surgery and onset of radiculopathy and recovery with correlation to UDS was done preoperatively and post operatively. RESULTS: 107 patients were studied (M-63/F-44). Patients with PAS present still had acontractile (61%) or hypocontractile (39%) detrusor and with VAC present, 57% had acontractile and 43% hypocontractile detrusors. 10 patients with both PAS and VAC present had acontractile detrusor. 82% patients with acute radiculopathy (<2 days) improved when operated <24 hrs while only 47% showed improvement with chronic radiculopathy. The detrusor function recovered in 66.1% when operated <12 hours, 40% in <12-24 hours of presentation. CONCLUSION: Adjuvant information from UDS in combination with clinicoradiological findings help in accurate diagnosis even in patients with no objective motor and sensory deficits. Quantitative findings on UDS are consistent with postoperative recovery of patient's urination power, representing improvement and can be used as a prognostic factor.

Two-Level Anterior Cervical Discectomy and Fusion versus Hybrid Total Disc Replacement for Bilevel Pathology with Cervical Radiculopathy/Myelopathy: A Comparative Study with a Minimum 2-Year Follow-up in an Indian Population.

STUDY DESIGN: Retrospective study. PURPOSE: To study the outcomes of two-level anterior cervical discectomy and fusion (2L-ACDF) versus hybrid total disc replacement (H-TDR) for cervical myeloradiculopathy. OVERVIEW OF LITERATURE: For bilevel disc issues of the cervical spine, 2L-ACDF has been a historical tool with numerous implants used at different time frames. Recent developments in total disc replacement at mobile level with fusion at a spondylotic level known as hybrid fixation have added a new armamentarium for such disorders. METHODS: An analysis of 49 consecutive patients who underwent 2L-ACDF (n=22) and H-TDR (n=27) from January 1, 2014 to December 31, 2017 was performed. Data were studied as retrieved from InstaPACS ver. 4.0 (Mediff Technologies Pvt. Ltd., Bengaluru, India) and medical records. RESULTS: Twenty-two patients with 2L-ACDF and 27 patients with H-TDR were included. The mean±standard deviation (SD) follow-up duration was 4.0±1.5 years in H-TDR and 3.1±1.1 years in 2L-ACDF. The mean±SD Neck Disability Index (NDI) decreased from 26.1±7.6 to 6.5±3.9 in the H-TDR group and from 27.6±7.2 to 6.4±4.8 in the 2L-ACDF group at final follow-up. Disc height at suprajacent level in the 2L-ACDF group was 4.12±0.48 mm, 4.10±0.45 mm, and 4.05±0.48 mm preoperatively, at 1-year, and final follow-up, respectively. Disc height at supradjacent level in the H-TDR group was 4.28±0.36 mm, 4.20±0.32 mm, and 4.19±0.34 mm preoperatively, at 1-year, and final follow-up, respectively. CONCLUSIONS: There was significantly improved NDI in both groups. Adjacent segment disc height loss was greater in the 2L-ACDF group than in H-TDR but not statistically significant (p =0.304). Supradjacent segment range of motion was greater in the 2L-ACDF group than in the H-TDR group (p =0.003). Both findings supported radiographic adjacent segment degeneration (ASD), but symptomatic ASD was absent in both groups.

Subaxial cervical Castleman's disease: A rare cause of myelopathy.

BACKGROUND: Castleman's disease (CD) is a rare lymphoproliferative disease of unknown origin which rarely affects the spine. Here, we present CD involving a lytic, destructive C3 lesion with extension into the spinal canal contributing to upper cervical cord compression. Notably, the lesion mimicked other primary bone lesions, metastatic tumors, and/or lymphoma. CASE DESCRIPTION: A 52-year-old male presented with progressive quadriparesis (i.e. weakness, instability of gait) and loss of dexterity in both hands over 2 weeks. The MRI, X-ray, and CT scans revealed a destructive lytic lesion involving the C3 vertebral body (i.e. including both anterior and posterior elements). The patient underwent a C3 total and C4 partial laminectomy followed by a C2-C4/5 instrumented fusion (i.e. included C2 pedicle screws/laminar screws, and C4/C5 lateral mass fixation). Histopathology showed a lymphoproliferative disorder with follicles of different sizes, central abnormal germinal structures, and a Mantle zone (i.e. expanded germinal centre with concentric layering with an "onionskin" appearance). These findings were all consistent with the diagnosis of CD (i.e. hyaline-vascular type). CONCLUSION: CD, a rare lymphoproliferative disease of unknown origin rarely affects the spine. Here, we presented a 52-year-old male with a C3 lytic lesion resulting in C3/4 cord compression that favorably responded to a C3/4 laminectomy with posterior instrumented fusion.

Misplaced S1 screw causing L5 radiculopathy, rare and unusual presentation: a report of 2 cases.

Many spine surgeons are not optimally acquainted with anatomy anterior to sacrum. Screw malposition injuring these structures can lead to unwanted lethal consequences. We report unusual cases of acute radiculopathy due to misplaced bicortical sacral screw causing L5 nerve root impingement on anterior sacrum. A 39/M patient complained of severe rest pain (VAS 9/10) post TLIF in region of L5 dermatome with sensory deficit along the right lateral leg and straight leg raise less than 30°. X-ray revealed S1 screw protruding beyond the second cortex with a straight trajectory. CT scan revealed a protrusion of 11.4mm beyond anterior cortex. The patient was taken for re-surgery and the trajectory and length of screw was revised. Sciatic pain completely disappeared immediately after surgery. A 61/M patient operated elsewhere with instrumented decompression and fusion with screws passed at L4, L5 and S1 level for lumbar canal stenosis, post-surgery patient developed new onset radicular symptoms in right lower limb. Patient was managed conservatively in the form of L5 selective nerve root block. Pain and numbness improved. Bicortical purchase of S1 screw though improves pull out strength, is associated with a risk of neurovascular complications. Surgeons should be alerted to the misplacement of S1 pedicle screws to avoid involvement not only anterior to the anteromedial neurovascular tissue, but also anterolateral to the arrangement of the L5 nerve root.

A Rare Case of Sphingomonas paucimobilis Spondylodiscitis Managed Surgically.

INTRODUCTION: Sphingomonas paucimobilis is an opportunistic pathogen and a rare cause of human infection. This case report shows bacteremia with pyogenic spondylodiscitis in lumbosacral spine caused by Sphingomonas and discusses its clinical diagnosis, treatment, and literature reviews. CASE REPORT: Patient presented with severe low back pain, inability to walk and fever following a L5-S1 decompression elsewhere, which corresponded clinico-radiologically with a picture of a spondylodiscitis on radiographs, magnetic resonance imaging, and computed tomography. His blood culture was positive for S. paucimobilis. He was treated successfully by surgical debridement, stabilization, and fusion along with intravenous Linezolid followed by oral therapy, based on the antibiotic susceptibility profile. Repeat blood culture was negative after 7 weeks of antibiotic therapy. Patient improved symptomatically with radiographs showing good fusion at 1 year follow-up. S. paucimobilis, though a low virulence organism, is an emerging pathogen and should be dealt with cautiously. CONCLUSION: This reiterates the importance of culture as unusual organisms may be isolated and appropriate antibiotics form the mainstay of treatment.

Should Implant Breakage Be Always Considered as Implant "Failure" in Spine Surgery: Analysis of Two Cases and Literature Review.

The advancement in the material of spinal implant and technique of spinal instrumentation has led to an increase in spine surgeries. The final desired outcome of spine surgery involving instrumentation is fusion. There is a race among implants to fail and bone to fuse. If there is a formation of pseudoarthrosis or failure to fuse then implants are bound to fail. The most common presentation of pseudoarthrosis is implant breakage. Hence, should we label every implant that has presented with breakage as a "failure"? In this article, we have discussed our experience of two cases presented to us with implant breakage but which were managed successfully with conservative methods. Both of our cases did well without any surgical intervention. We have follow-ups of seven years in one case and five years in the other. Every patient with pseudoarthrosis does not require surgical management and hence, every implant breakage should not be labeled as implant "failure".

Management of AO-type C thoracolumbar fractures during COVID-19 pandemic using distractor device: a novel technique.

STUDY DESIGN: Prospective cohort study. INTRODUCTION: Management of the severe thoracolumbar (TL) spine fracture-dislocation injuries have been further complicated by the COVID-19 pandemic. The need to optimize resources and minimize the personnel in the operating room (OR) led us to develop a novel technique to reduce TL fracture-dislocations (AO type-C) using an orthopedic distractor device (ODD). METHODS: This prospective study was conducted at a tertiary care spine center with a study duration from March 2020 to May 2020 coinciding with the nationwide lockdown and travel restrictions imposed in view of the COVID-19 crisis. Only patients with AO type C fracture-dislocation managed using the ODD operated by a single surgeon were included in the study. RESULTS: Of 12 cases, the most commonly affected level was D12-L1. Nine patients were American Spinal Injury Association Impairment Scale (AIS) A at presentation, two patients were AIS B, and one AIS C. The mean operative time was 125 min and mean blood loss was 454 ml. Eight patients remained AIS A, one patient improved from AIS B to C. Two patients became independent walkers, one remained AIS B. The post-operative VAS score improved to a mean value of 2.33. The improvement in kyphosis was 26.24° immediate postoperatively and maintained at 25.9°, percentage height loss reduced to 2.75% immediate postoperatively and maintained at 3.16% at 3 months follow-up. CONCLUSIONS: Management of TL fracture-dislocations in COVID times of health care resource scarcity can be challenging. Single surgeon with ODD is a useful technique for achieving good results in these injuries.

Iatrogenic postoperative spondylodiscitis attributed to Burkholderia cepacia infection in an immunocompetent patient.

BACKGROUND: Pyogenic spondylodiscitis (PS) is a rare infection involving the intervertebral disk space, adjacent vertebral endplates, and vertebral bodies. PS occurs in the elderly and immunocompromised patients, and is an uncommon cause of initial and/or postoperative PS. There are only seven cases involving this organism reported in literature. CASE DESCRIPTION: Here, we present a 35-year-old male who following a lumbar discectomy developed a postoperative iatrogenic PS uniquely attributed to Burkholderia cepacia. The patient was successfully managed with postoperative surgical debridement and antibiotic therapy. CONCLUSION: Rarely, B. cepacia may be the offending organism resulting in a postoperative lumbar PS.

Ligamentum Flavum Cyst: Rare Presentation Report and Literature Review.

Ligamentum flavum cysts (LFC) are uncommon and their differentiation from other Juxta-facetal cysts & epidural cystic lesions is difficult based on imaging techniques. We present one such rare case of ligamentum flavum cyst with relevant review of the literature. An eighty-eight years male presented with progressively worsening radicular symptom in the left lower limb. His neurological examination was unremarkable. Magnetic resonance imaging of lumbar spine revealed an epidural cystic lesion narrowing the left lateral recess. Intra-operatively, a mass was found originating from ventral surface of ligamentum flavum. Pathological examination was suggestive of fibro-collagenous tissue without synovial lining. The exact pathogenic mechanism for the formation of LFCs is not well understood. Association with segmental instability and degenerative conditions of spine is postulated. They are commonly seen at the mobile junctional levels of the spine. Persistent micro-traumatic events with abnormal movement maybe contributory to their origin. They present either with radiculopathy or neurogenic claudication symptoms owing to compressive effect on adjacent neural structure. LFC should be considered as a differential in patients with radicular pain or claudication symptoms with epidural cystic lesion seen on MRI. Complete excision of such lesion provides excellent pain relief in symptomatic individuals.

Spinal Injury in Indian Children: Review of 204 Cases.

STUDY DESIGN: Retrospective study. OBJECTIVE: The purpose of the study was to analyze the epidemiological parameters and associated factors after spinal cord injury (SCI) in children, in the last 14 years admitted at a tertiary care center (Indian Spinal Injury Centre [ISIC], New Delhi, India). METHOD: The demographic and injury-related data was analyzed descriptively. The incidence, type, and level of injury were compared across the age groups using a χ2 test. Wherever appropriate, Fisher exact test was used. RESULTS: There were 1660 pediatric trauma cases admitted at ISIC from 2002 to 2015, where 204 cases presented with spine injuries. The average age of children sustaining spine injury was 15.69 years (3-18 years of range). There were 15 patients in the age group 0 to 9 years, 27 patients in the age group 10 to 14 years, and 162 patients in the age group 15 to 18 years. This difference in spine injury incidence among the age groups was statistically significant. Fall from height was a common mode of injury. In our sample, boys were 3 times more likely to be injured than girls. Burst fractures were common among the type of injuries. CONCLUSION: Our study confirms the predominance of cervical spine injury and the high incidence of multilevel contiguous with a lesser percentage of noncontiguous multilevel spinal involvement. SCIWORA (spinal cord injury without radiological abnormality) incidences were in a similar context to the literature available. There was a very low incidence of death. Neurological improvement was seen in 8 operated cases and 4 conservatively treated cases.

Use of Topical Tranexamic Acid to Reduce Blood Loss in Single-Level Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Nonrandomized, prospective, and case-controlled study. PURPOSE: To evaluate the efficacy and cost-effectiveness of topically applied tranexamic acid (TXA) during different phases of spine surgery. OVERVIEW OF LITERATURE: Perioperative blood loss is the leading cause of postoperative anemia associated with prolonged stays in hospital and long recovery times. The direct and indirect costs involved pose a significant economic challenge in developing countries. There is no consensus for topical use of tranexamic acid in spine surgery. METHODS: Patients requiring a single-level TLIF were divided into two groups. In the TXA group (n=75), the wound surface was soaked with TXA (1 g in 100 mL saline solution) for 3 minutes after exposure, after decompression, and before wound closure, and in the control group (n=175) using only saline. Intraoperative blood loss drain volume was recorded on each of the first 2 days immediately after surgery. An estimated cost analysis was made on the basis of the length of hospital stay and the blood transfusion. RESULTS: IBL for the control group was 783.33±332.71 mL and for intervention group 410.57±189.72 mL (p<0.001). The operative time for control group was 3.24±0.38 hours and for intervention group 2.99±0.79 hours (p<0.695). Hemovac drainage on days 1 and 2 for control group was 167.10±53.83 mL and 99.33±37.5 mL, respectively, and for intervention group 107.03±44.37 mL and 53.38±21.99 mL, respectively (p<0.001). The length of stay was significantly shorter in the intervention group (4.8±1.1 days) compared to control group (7.0±2.3 days). The cost of treatment in the intervention group was US dollar (USD) 4,552.57±1,222.6 compared with that in the control group USD 6,529.9±1,505.04. CONCLUSIONS: Topical TXA is a viable, cost-effective method of decreasing perioperative blood loss in major spine surgery with fewer overall complications than other methods. Further studies are required to find the ideal dosage and timing.

Clinico-Radiological Outcome of Single-Level and Hybrid Total Disc Replacement with Spineart Baguera®-C for Cervical Myeloradiculopathy: Minimum 2-Year Follow-Up Study in Indian Population.

CONTEXT: Cervical radiculopathy and myelopathy is one of the most frequent ailments encountered by spine surgeon. Motion-preserving surgeries in cervical spine is a standard of care due to its certain advantages such as biomechanical anatomical conformity, reduced chances of adjacent segment degeneration, and revision surgeries. While there is abundant data from some centers, data from developing countries are still limited. AIMS: The aim was to study the clinico-radiological outcome of single-level and hybrid total disc replacement (TDR) with Spineart Baguera®-C cervical prosthesis for cervical myeloradiculopathy. SETTINGS AND DESIGN: Retrospective study. MATERIALS AND METHODS: Retrospective analysis of the 29 consecutive patient undergoing single level TDR and hybrid fixation (i.e., TDR with anterior cervical discectomy and fusion) with Spineart Baguera®-C cervical prosthesis for myeloradiculopathy from January 1, 2014 to December 31, 2017, was done. Radiological features and outcome were studied from data collected on Insta-picture archiving and communication system. STATISTICAL ANALYSIS USED: SAS 9.4 was used for all computations. Results on continuous measurements were presented as mean and standard deviation (min-max) and results on categorical measurements were presented as numbers (n) and percentages. RESULTS: Twenty-nine patients were included in the study. The mean age was 43.31 ± 9.04 years with 14 males and 15 females. The most common level of TDR was C5-C6 (72.41%). The mean follow-up duration was 3.14 years ± 1.13 years (2-5 years). The mean hospital stay was 4.93 ± 2.12 days. The mean neck disability index (NDI) at admission was 27.24 ± 7.66 which decreased to 6.41 ± 4.29 at final follow-up. CONCLUSIONS: Two-year data on treatment with Spineart Baguera®-C cervical prosthesis shows significantly improved NDI, visual analog scale (arm) with maintenance of movement of the prosthesis.

Radiological protocol in spinal trauma: literature review and Spinal Cord Society position statement.

PURPOSE: The Spinal Cord Society constituted a panel tasked with reviewing the literature on the radiological evaluation of spinal trauma with or without spinal cord injury and recommend a protocol. This position statement provides recommendations for the use of each modality, i.e., radiographs (X-rays), computed tomography (CT), magnetic resonance imaging (MRI), as well as vascular imaging, and makes suggestions on identifying or clearing spinal injury in trauma patients. METHODS: PubMed was searched for the corresponding keywords from January 1, 1980, to August 1, 2017. A MEDLINE search was subsequently undertaken after applying MeSH filters. Appropriate cross-references were retrieved. Out of the 545 articles retrieved, 105 relevant papers that address the present topic were studied and the extracted content was circulated for further discussions. A draft position statement was compiled and circulated among the panel members via e-mail. The draft was modified by incorporating relevant suggestions to reach a consensus. RESULTS AND CONCLUSION: For imaging cervical and thoracolumbar spine trauma patients, CT without contrast is generally considered to be the initial line of imaging and radiographs are required if CT is unavailable or unaffordable. CT screening in polytrauma cases is best done with a multidetector CT by utilizing the reformatted images obtained when scanning the chest, abdomen, and pelvis (CT-CAP). MRI is indicated in cases with neurological involvement and advanced cervical degenerative changes and to determine the extent of soft tissue injury, i.e., disco-ligamentous injuries as well as epidural space compromise. MRI is also usually performed when X-rays and CT are unable to correlate with patient symptomatology. These slides can be retrieved under Electronic Supplementary Material.

Surgical Trend Analysis for Use of Cement Augmented Pedicle Screws in Osteoporosis of Spine: A Systematic Review (2000-2017).

STUDY DESIGN: Systematic review. OBJECTIVES: (1) Study indications for cement-augmented pedicle screws (CAPS) in patients with osteoporosis. Have they changed over the years (2000-2017)? Are there any differences in usage of CAPS based on the geographical region? (2) What were the outcome of the studies? (3) What are the complications associated with this technique? METHODS: Electronic database and reference list of desired articles were searched from the database (2000-2017). Articles were selected discussing indications, clinical and radiological outcomes, and complications in cases of preexistent osteoporosis treated surgically using CAPS. RESULTS: Seventeen studies were identified; 3 were comparative studies and had a control arm (cemented vs noncemented screws). Most studies originated from Europe (10) or Asia (7). Painful vertebral fracture with or without neurological deficit, Kummell's lesion, deformity and failure to respond to conservative treatment are the common indications for cement augmentation. Visual analogue scale score was the most commonly used to assess pain and average improvement after surgery was 6.1. Average improvement in kyphosis was 13.21° and average loss of correction at the end of the study was 3°. Cement leak was the most common complication observed and pulmonary cement embolism was the most dreaded complication. Nevertheless, majority of cement leaks discussed in studies were asymptomatic. CONCLUSION: CAPS are being increasingly used in osteoporotic spine. Pain scores, functional quality of life, and neurological function indices were studied. CAPS improved anchorage in osteoporotic vertebra and helped improve/maintain clinical and radiological improvement. Common risks of cement leak were observed.