Rare Indication of Atlantoaxial Fusion-failed Conservative Management of Primary Atlantoaxial Osteoarthritis.

Introduction: Osteoarthritis of the atlantoaxial joint is a significant cause of occipitocervical pain, which is often missed and has an increasing prevalence with age. The patients typically present with occipitocervical pain and restricted and painful neck rotations. Despite the primary reliance on conservative management for this pathology, surgical intervention becomes crucial for those not responding to standard conservative treatment. The presented case series highlights the rarity of the requirement of surgical intervention in the management of Atlantoaxial osteoarthritis (AAOA) and the clinical outcomes of surgical management in AAOA. Case Report: This paper presents a case series of four patients who were managed surgically with atlantoaxial fusion, from a database of 108 patients with AAOA. The case series includes three males and one female with a mean age of presentation being 67.5 years. All four patients presented with occipitocervical pain, and painful neck movements and were diagnosed with AAOA on the anteroposterior open mouth view radiographs showing changes of osteoarthritis such as bone erosions, sclerosis, osteophytes. The patients were managed conservatively with non-steroidal anti-inflammatory drugs, intra-articular steroid injections, and cervical collar immobilization. Those not responding to conservative management and with incapacitating pain were managed surgically with atlantoaxial fusion procedures. Conclusion: In a group of patients with a painful and debilitating degenerative AAOA only a small proportion of cases require surgical intervention. In this cohort, only 3.70 % of patients required surgery, highlighting the rarity of surgical intervention required in the management of AAOA. Nevertheless, when conducted, atlantoaxial fusion has proved to be efficacious with a low rate of serious complications and the patient self-rated outcome in terms of post-operative visual analog scale score and neck disability index scores indicating a high degree of satisfaction with the procedures.

Transforaminal Endoscopic Ventral Stenosis Decompression in Calcified Lumbar Disc Herniation: A Long Term Outcome in 79 Patients.

BACKGROUND: Calcified lumbar disc herniations (CLDH) causing calcified ventral stenosis pose a therapeutic challenge to the treating surgeon due to their neural adhesions, location, and hardness. METHODS: This retrospective study analyzed all the cases of CLDH/calcified ventral stenosis managed by transforaminal endoscopic lumbar discectomy with a minimum follow-up of 24 months. The preoperative images were analyzed for the level, migration; and grade (Lee's migration zones), and location (Michigan State University classification). Detailed surgical technique and intraoperative parameters including the duration of surgery and complications have been recorded. The clinical parameters including visual analog scale (VAS), Oswestry disability index (ODI), length of stay in hospital, days of return to basic work, and patient satisfaction index were analyzed. Postoperatively the images were analyzed for the adequacy of decompression. RESULTS: The mean VAS for back pain and leg pain was 4.7 ± 2.6 (0-9), and 7.45 ± 2.2 (1-10), respectively. The mean preoperative ODI was 78.2 ± 13.2 (63.2-95.6). Nineteen patients (24%) had neurological deficits preoperatively. The mean duration of surgery was 90.5 ± 15.8 (58-131) minutes. Postoperative magnetic resonance imaging revealed adequate decompression in 97.5% (n = 77). The mean duration of hospital stay was 1.05 ± 0.22 (1-2) days, and the postoperative back and leg pain VAS was 1.14 ± 1.2 (0-3) (P < 0.05) and 1.7 ± 0.5 (0-6) (P < 0.05), respectively. The ODI at final follow-up was 6.5 ± 3.7 (2.2-18) (P < 0.05). Neurological recovery occurred in 17 (89.5%) patients and they returned to basic work/jobs in 19.5 ± 3.3 (14-26) days. The mean patient satisfaction index was 1.18 ± 0.47 (1-2) at a mean follow-up of 5.52 ± 2.91 (2-12.75) years. CONCLUSIONS: Transforaminal endoscopic lumbar discectomy is a complete, safe, and efficacious procedure in patients with CLDH with earlier recovery considering the surgery is performed with the patient being awake.

Long-term functional and radiological outcomes of cervical disc arthroplasty at a tertiary level spine center in India: A retrospective cohort analysis with minimum 2 years of follow-up.

Context: Cervical disc arthroplasty (CDA) was developed for the treatment of cervical disc disease with the potential advantages of preservation of physiological motion at a discal level, thereby potentially reducing adjacent level stresses and degeneration, which were a known complication of anterior cervical arthrodesis. The objective of this study was the assessment of long-term functional and radiological outcomes overtime in all the patients who underwent CDA from 2011 to 2019 at our institute. Materials and Methods: Forty-eight patients who underwent CDA (2011-2019) with a minimum 2-year follow-up were retrospectively evaluated. The functional outcome included the Visual Analog Score (VAS) and Neck Disability Index (NDI). Radiographs were assessed for range of motion (ROM) at the index surgical level, presence of heterotopic ossification (HO), and adjacent segment degeneration. Results: The mean follow-up was 5.79 ± 2.96 (2.16-11.75) years. Significant improvement (P < 0.05) was observed in the VAS (8.91 ± 2.52 [preoperative] to 0.89 ± 1.27 [follow-up]) and NDI (65.5% ±23.06% [preoperative] to 4.79 ± 3.87 [follow-up]) score. Motion at index level increased significantly from 5.53° preoperatively to 7.47°, and 92% of the implanted segments were still mobile (referring to the threshold of ROM > 3°). HOs are responsible for the fusion of 4/50 (8%) levels at the last follow-up. Distal and proximal adjacent disc degeneration occurred in 36% and 28% of patients, respectively. No migration of the implant was observed on the radiograph. Conclusion: Our study showed favorable clinical outcome of CDA with preservation of ROM at the index surgical level. CDA can be a promising alternative to anterior cervical arthrodesis when properly indicated.

Comparative Study on Accuracy of Intra-Operative Computed Tomography-Navigation Based Pedicle Screw Placement With Skin vs Bone Fixed Dynamic Reference Frame in Minimally Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: To compare the accuracy of intra-operative navigation-assisted percutaneous pedicle screw insertion between bone fixed and skin fixed dynamic reference frame (DRF) in Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). METHODS: Between October 2018 and September 2022, patients who underwent MIS-TLIF were included in this study with DRF fixed either on bone (group B) or skin (group S). Pedicle screws were inserted under the guidance of intra-operative Cone bean Computed tomography (cbCT) based navigation. Accuracy of pedicle screw placement was immediately checked by a final intra-operative cbCT Spin. RESULTS: Among 170 patients, group B included 91 patients and group S included 79 patients. Out of total 680 screws, 364 screws (group B) and 316 screws (group S) were placed. Patient's demographic data and distribution of screws showed no statistically significant difference. The accuracy showed no significant difference between both the groups (94.5% in group B and 94.3% in group S). CONCLUSION: Skin fixed DRF can serve as an alternate way for placement and avoids extra incision with similar accuracy in pedicle screw insertions with bone fixed DRF using intra-operative CT guided navigation in MIS TLIF.

Does MR Signal Intensity Change have Prognostic Value in Multilevel Cervical Myelopathy? A Single-Center, Prospective Study.

Background and Objective: Neurological recovery in cervical myelopathy remains unpredictable. There is contradictory literature regarding the prognostic value of magnetic resonance imaging (MRI) in such cases. The objective of the present study is to evaluate the morphological changes in the spinal cord in cervical spondylotic myelopathy and compare them with clinical outcome. Materials and Methods: This is a single-center, prospective, observational study. All patients with multilevel (two or more levels) cervical spondylotic myelopathy undergoing anterior spine surgery were included in the study. Patient demographics and radiological findings were recorded. MRI was repeated immediately post-op and at 1-year follow-up. MRI classification system based on axial images was used to evaluate presurgery and postsurgery changes and correlate them with clinical information. Results: The study comprised 50 patients (40 males and 10 females) with a mean age of 59.5 years. Average duration of symptoms before surgery was 6.29 months. Thirty-four patients underwent two-level decompression, while 16 patients underwent more than two-level decompression. Average duration of follow-up was 26.82 months. Mean pre-op Nurick grade was 2.84, and mean recovery rate was 56.73. Most common pre-op MRI type was type 1. Analysis of data by logistic regression showed better recovery rate with lower age, lower pre-op Nurick grade, and lower pre-op MRI type. Conclusion: MR classification based on signal intensity changes in axial images have been found to correlate with recovery rate.

'Higher the grade-smaller the pedicle': a study of pedicle dimensional variations in 100 cases of high grade lytic spondylolisthesis.

PURPOSE: To measure the pedicle dimensions in high grade lytic spondylolisthesis (HGL) and to classify them, which helps the spine surgeon in proper selection of pedicle screws. METHODS: A study of CT scans in 100 consecutive patients between Jan 2017 and April 2021 diagnosed as single-level HGL on standing radiographs. Pedicle height (PH), Pedicle width (PW), Differential pedicle height (DPH), Screw length (SL) and Transverse pedicle angle (TPA) were measured and analyzed. PH and PW were classified into four grades as-grade A less than 5.0 mm, grade B between 5.0 and 6.0 mm, grade C between 6.0 and 7.0 mm, and grade D above 7.0 mm. RESULTS: 5 males and 95 females with mean age of 49.1 years. PH in 44% lytic vertebra were grade A, B (less than 6 mm) and the rest 56% had grade C, D (greater than 6 mm). PH averaged 6.6 mm in grade 3 HGL, 5.61 mm in grade 4 HGL. Change in PW, SL and TPA was not statistically significant with regards to grade or level of listhesis. A total of 37 cases were noted to have DPH (25 cases had a difference < 2 mm and 12 had a difference > 2 mm). CONCLUSION: 44% of the PH in lytic vertebra was grade A and B (less than 6 mm) that stresses the importance of pre-op CT assessment and planning the appropriate screw dimensions. Change in PH was statistically significant with regards to the grade of listhesis (P-value < 0.01). Differential pedicle height also need to be looked for.

A comparative morphometric analysis of operative windows for performing OLIF among normal and deformity group in lower lumbar spine.

PURPOSE: To assess the radiological morphometric parameters of OLIF surgical technique in lower lumbar spine among normal and in patients with adult degenerative spine (levoscoliosis and dextroscoliosis). METHOD: Standing AP radiographs and MRI in supine position were taken. Patients were divided into 3 groups based on Cobbs' angle into normal, levo and dextro scoliosis. Moros classification was used to calculate bare window (BW), vascular window (VW), Psoas window (PW), psoas major height (pmh) and width (pmw) at lower lumbar levels and measurements were done on PACS. RESULTS: Seventy five patients (25 in each group) were assessed. BW has trend from L2-L3 > L3-L4 > L4-L5 in dextro and levoscoliosis. PW has trend from L3-L4 > L2-L3 > L4-L5 in levoscoliosis and normal group. VW has trend from L4-L5 > L3-L4 > L2-L3 in dextro and levoscoliosis; pmw has trend from L4-L5 > L3-L4 > L2-L3 in Levo and dextroscoliosis; pmh has trend from L4-L5 > L3-L4 > L2-L3 in levoscoliosis and normal group. CONCLUSION: BW was noted to be highest at L3-4, lowest at L4-5 in normal group. VW was constant, BW showed a reverse trend with PW across all the levels. Though levoscoliosis group of patients had significantly higher BW, psoas retraction issues are to be kept in mind in view of anatomically taught psoas.

Gorham-Stout disease: A multirod lumbar reconstruction with off-label suppression-remission therapy.

Background: Gorham-Stout disease (GSD), a fibro-lymphovascular entity in which tissue replaces the bone leading to massive osteolysis and its sequelae, rarely leads to spinal deformity/instability and neurological deficits. Here, we report a 12-year-old female who was diagnosed and treated for GSD. Case Description: A 12-year-old female presented with back pain, and the inability to walk, sit, or stand attributed to three MR/CT documented L2-L4 lumbar vertebral collapses. Closed biopsies were negative. However, an open biopsy diagnosed GSD. She underwent a dorsal-lumbar-to-pelvis fusion (i.e., T5-T12 through L5/S1/S2) using multilevel pedicle screw/rod stabilization and human leukocyte antigens (HLAs) matched allograft (i.e. from her father). Postoperatively, she was treated with "off-label" teriparatide injections, bisphosphonates, and sirolimus. Four years later, while continuing the bisphosphonate therapy, she remained stable. Conclusion: Surgical multirod stabilization from T5 to S2, supplemented with HLA compatible allograft, and multiple medical "off-label" therapies (i.e., teriparatide, sirolimus, and bisphosphonates) led to a good 4-year outcome in a 12-year-old female with GSD.

RCC (reinforced criss-cross construct): an easy and effective multi-rod thoraco-lumbar posterior reconstruction technique.

STUDY DESIGN: Surgical technical note and literature review. OBJECTIVES: To describe a technique that uses 4 rod constructs in cases of complex thoracolumbar spinal deformity correction or revision surgeries based on the hybrid use of two different types of purchase points by a staggered pedicle screw fixation. It utilizes two rods on either side of the spine using a lateral and medial entry point of pedicle screws in the vertebral body. METHODS: Pedicle screws using extra-pedicular technique are more converging screws and are inserted alternately in the vertebral body and connected by rods. The left-out alternate vertebral bodies are fixed by a relatively straighter pedicle entry screw and connected to each other by a separate rod. So, two trajectories are independently used for a four-rod construct. This reconstruction has been named RCC (reinforced criss-cross construct). The screws in the index case were placed by free hand method, but we have increasingly utilized navigation guidance for placement of screws in recent times. RESULTS: We present a surgical technical note in a patient with human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV-AIDS). He was diagnosed to have multi-drug-resistant (MDR) tuberculous spondylodiscitis, complicated with Immune reconstitution inflammatory syndrome (IRIS) and implant failure resulting in kyphosis and thoracic myelopathy. RCC with pharmacological management achieved healing and union, which was maintained at 4 years follow-up. Our method of four-rod construct provides a strong and lasting construct in the management of spinal deformities and three-column osteotomies. It provides good structural support to the spine till bony union is achieved. CONCLUSION: Hybrid multi-rod construct like RCC provides a rigid mechanical support to the instrumentation and reduces the chances of rod failure especially in complex thoraco-lumbar spinal deformity correction surgeries.

The Effect of Head Loading on Cervical Spine in Manual Laborers.

STUDY DESIGN: A prospective case-control study. PURPOSE: To determine the effect of axial loading on the cervical spine when weights are carried on the head. OVERVIEW OF LITERATURE: Traditionally, carrying weights on the head has been a common practice in developing countries. The laborers working in agriculture, construction, and other industries, as well as porters at railway platforms, are required to lift heavy weights. Since controversy exists regarding carrying weights on the head, we decided to evaluate its effect on the cervical spine. METHODS: The study comprised 62 subjects. Of this number, 32 subjects (group A) were unskilled laborers from the construction industry; the other 30 subjects (group B) were in the control group and had never previously carried heavy weights on their heads. Cervical spine radiographs were taken for all the 62 subjects. Subjects in group A were asked to carry a load (approximately 35 kg) on their heads and walk for about 65 m, with their cervical spine radiographs taken afterward. RESULTS: The mean ages of patients in groups A and B were 27.17 and 25.75 years, respectively. The mean cervical lordosis observed in group A (18.96°) was dramatically less compared with group B (25.40°), showing a further decrease in head loading (3.35°). Five subjects had a reversal of lordosis (-5.61°). A statistically significant reduction in disc height and listhesis was observed when the load was carried on the head with a further decrease after walking with the load. Accelerated degenerative changes, particularly affecting the upper cervical spine, were observed in head loaders. CONCLUSIONS: Carrying a load on the head leads to accelerated degenerative changes, which involve the upper cervical spine more than the lower cervical spine and predisposes it to injury at a lower threshold. Thus, alternative methods of carrying loads should be proposed.

The Effectiveness and Safety of Ultrasonic Bone Scalpel Versus Conventional Method in Cervical Laminectomy: A Retrospective Study of 311 Patients.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The aim of this study was to compare the results of cervical laminectomy (CL) performed with ultrasonic bone scalpel (UBS) or conventional method (CM). METHOD: This study comprised 311 CL performed by a single surgeon between January 2004 and December 2017. Group A (GpA) comprised 124 cases of CL performed using UBS, while Group B (GpB) comprised 187 cases of CL performed using CM. These 2 groups were compared in terms of demographic characteristics of patients, duration of surgery, estimated blood loss, and surgical complications. RESULTS: GpA included 112 males and 12 females, mean age being 61.18 years. GpB comprised 166 males and 21 females, mean age being 62.04 years. Mean duration of surgery, estimated blood loss, and length of hospital stay was 65.52/70.87 minutes, 90.24/98.40 mL, and 4.80/4.87 days in GpA and GpB, respectively. Six patients were reported to have dural injuries in each group. In GpA, 2 cases of C5 palsy and 1 nerve root injury was observed, while in GpB, 3 cases of C5 palsy and no nerve root injury was reported. One patient had developed transient neurological deterioration postsurgery in GpA as against 11 patients in GpB. CONCLUSION: Neurological complications observed in CM leads to intensive care unit admission, additional morbidity, and additional expenditure, whereas UBS provides a safe, rapid, and effective means of performing CL, thereby decreasing the rate of surgical complications and postoperative morbidity.

Transforaminal Thoracic Interbody Fusion for Thoracic Disc Prolapse: Surgicoradiological Analysis of 18 Cases.

STUDY DESIGN: Retrospective observational study. OBJECTIVES: Thoracic disc prolapse (TDP) surgeries have reported complications ranging from paraplegia to approach related complications. This study is to present a series of TDP patients surgically treated with transforaminal thoracic interbody fusion (TTIF). Emphasis on surgical technique and strategies to avoid complications are analyzed. METHODS: Eighteen patients with TDP were included. Imagings were analyzed for end-plate changes and calcification. Type of disc prolapse (central/para-central) and percentage of canal occupancy were noted. Objective outcome was quantified with Visual Analogue Scale (VAS), modified Nurick's grade, and ASIA (American Spinal Injury Association) score. All complications were noted. RESULTS: Eighteen patients (average age 43.65 years) having total 22 levels operated, that included double level (n = 2) and missed level (n = 2) are reported. All patients had myelopathy. Calcification of disc (n = 13), central disc prolapses (n = 9), para-central (n = 11) and more than 50% canal occupancy (n = 8) were noted. VAS back pain, modified Nurick's grade and ASIA grade improved significantly in all patients. One patient had postoperative transient deficit. The functional score achieved its maximum at 1 year follow-up and remained static at final follow-up of 65.05 months. Union was achieved in all patients. CONCLUSIONS: The most important factor for outcome in TDP is the technical aspect of avoiding cord manhandling and avoiding wrong level surgeries. TTIF is not devoid of complications but can give good results to posterior approach trained surgeons.

Risk Factors and Surgical Treatment for Recurrent Lumbar Disc Prolapse: A Review of the Literature.

We aim to present the current evidence on various risk factors and surgical treatment modalities for recurrent lumbar disc herniation (rLDH). Using PubMed, a literature search was performed using the Mesh terms "recurrent disc prolapse," "herniated lumbar disc," "risk factors," and "treatment." Articles that were published between January 2010 and May 2017 were selected for further screening. A search conducted through PubMed identified 213 articles that met the initial screening criteria. Detailed analyses showed that 34 articles were eligible for inclusion in this review. Sixteen articles reported the risk factors associated with rLDH. Decompression alone as a treatment option was studied in seven articles, while 11 articles focused on different types of fusion surgery (anterior lumbar interbody fusion, posterior lumbar interbody fusion, open transforaminal lumbar interbody fusion [TLIF], and minimally invasive surgery-TLIF). Management of the rLDH requires consideration of the possible risk factors present in individual patients before primary and at the time of second surgery. Both, minimally invasive and conventional open procedures are comparably effective in relieving leg pain, and minimally invasive techniques offer advantage over the other technique in terms of tissue sparing. Non-fusion surgeries involve the risk of lumbar disc herniation re-recurrence, and the patient may require a third (fusion) surgery.

Age- and sex-related changes in facet orientation and tropism in lower lumbar spine: an MRI study of 600 patients.

PURPOSE: We aimed to determine the age- and sex-related changes in facet orientation and facet tropism in lower lumbar spine. METHODS: Between June 2015 and December 2017, magnetic resonance imaging scans of the consecutive 600 patients performed in the outpatient department for low back pain were analyzed. The data were divided according to age into four groups: group A (< 30 years), group B (31-45 years), group C (46-60 years) and group D (> 60 years). The orientation of the facet angles at L3-4, L4-5 and L5-S1 was measured using the method described by Noren et al. Sagittal angles and tropism were determined at each level. RESULTS: Average facet angle is noted to increase from L3-4 to L5-S1 level in all groups irrespective of age and sex. A positive correlation is noted between age and sagittal facet orientation at all levels across all groups. Tropism was noted to be statistically significant (p < 0.05) at L5-S1 level. L3-4 and L4-5 levels did not show a positive correlation with respect to age. Facet angle sagittalization was significantly associated in males at L5-S1 level (p < 0.05) and in females at L4-5 level (p < 0.05). CONCLUSIONS: Predominant morphological changes in superior articular process are responsible for remodeling of facets that occur with increasing age, resulting in sagittalization. Even though the facet orientation changes over a period of time, differential changes within the facets at the same level might not be seen. These slides can be retrieved under Electronic Supplementary Material.

Ultrasonic bone scalpel: utility in cervical corpectomy. A technical note.

PURPOSE: Anterior cervical corpectomy and fusion (ACCF) is a technically challenging surgery. Use of conventional instruments like high-speed burr and kerrison rongeurs is associated with high complication rates such as increased blood loss and incidental durotomy. Use of ultrasonic bone scalpel (UBS) in cervical corpectomy helps to minimize such adverse events. METHODS: We performed a retrospective study based on the data of 101 consecutive patients who underwent cervical corpectomies with UBS for different cervical spine pathologies from December 2014 to December 2016. Total duration of surgery, time taken for corpectomy, estimated blood loss, and incidental durotomies were noted. RESULTS: Total surgical time was 30-80 min (59.36 ± 13.21 min) for single-level ACCF and 60-120 min (92.74 ± 21.04 min) for double-level ACCF. Time taken for single-level corpectomy was 2 min 11  ± 10 s and 3 min 41  ± 20 s for double-level corpectomy. Estimated blood loss ranged from 20-150 ml (52.07 ± 29.86 ml) in single level and 40-200 ml (73.22 ± 41.64 ml) in double level. Four (3.96%) inadvertent dural tears were noted, two during single-level corpectomy and other two during double-level corpectomy. CONCLUSIONS: Use of UBS is likely to provide a safe, rapid, and effective surgery when compared to conventional rongeurs and high-speed burr. The advantages such as lower blood loss and lower intra-operative incidental dural tears were noted with the use of UBS.

Does the Surgical Timing and Decompression Alone or Fusion Surgery in Lumbar Stenosis Influence Outcome in Cauda Equina Syndrome?

STUDY DESIGN: A retrospective comparative analysis of 64 patients with cauda equina syndrome (CES), who underwent either decompression alone (NF) or fusion (F) surgery. PURPOSE: We compared the outcomes and timing effects. OVERVIEW OF LITERATURE: CES can cause loss of autonomic control of vesicular function and lower limb neurological deficits. Prompt diagnosis and emergency surgery markedly improve outcome. Although decompression only is a mainstream technique, there is guarded recovery of vesicular dysfunction. Decompression ventrally in a narrow window requires manipulation of neural tissue in an already jeopardised critical canal and may accentuate irreversible damages. In F surgery, the adequate exposure leads to a lower neural manipulation. METHODS: Until January 2008, we treated CES with decompression (laminectomy and/or discectomy). However, from that month forward, all our single-level CES patients have received a fusion operation. In this study, characteristic categorical variables and outcomes were analysed. RESULTS: In a retrospective analysis of 64 patients, NF (n=37) and F (n=27) who received treatment, we found that both groups improved significantly on follow-up in all objective parameters. Although, the comparison of clinical and functional outcome data between the two groups was statistically insignificant, the average value of objective outcome such as vesicular function, low back pain (LBP), and complications was better for patients in F group compared with NF group. However, the patient satisfaction for the F group was also lower, in view of their residual symptoms and disabilities. Contrary to common perceptions, we found that the timing of surgery does not influence the recovery rate for either approach. CONCLUSIONS: Although both the techniques appear to be equally effective, the fusion approach overall showed a definite edge over non-fusion, with respect to reduced incidence of iatrogenic dural tears, LBP, and overall outcome, even despite the lower patient satisfaction.

The Relationship of Facet Joint Orientation and Tropism with Lumbar Disc Herniation and Degenerative Spondylolisthesis in the Lower Lumbar Spine.

STUDY DESIGN: Retrospective study. PURPOSE: This study aimed to clarify the relationship of both facet tropism (FT) and the sagittally aligned facet (SAF) joint with lumbar disc herniation (LDH) and degenerative spondylolisthesis (DS). OVERVIEW OF LITERATURE: Despite several studies conducted, there is no consensus on the association of the SAF joint and FT with DH and DS. METHODS: Between June 2015 and December 2017, magnetic resonance imaging scans of 250 consecutive patients who underwent surgery for LDH and DS were analyzed. The facet angles at all the lower lumbar levels were calculated, and SAF and FT were noted. The relationship between the side of disc herniation and that of the SAF joint were also determined. Statistical analysis was performed, and the relation of SAF and FT to LDH and DS was noted. RESULTS: We observed a positive relationship between SAF and LDH at L4-5 and L5-S1 with a p-value of 0.02 (<0.05). FT demonstrated a positive association with LDH at L4-5 (p=0.047) but not at L3-4 or L5-S1. SAF demonstrated a positive relationship with DS at L3-4 (p<0.001) but not at L3-4 or L5-S1. FT demonstrated a significant relation with DS at L4-5 (p<0.001), whereas no positive association was observed at L3-4 and L5-S1. CONCLUSIONS: The L4-5 level demonstrated a significant association with SAF and FT in LDH and DS. Moreover, SAF at L5-S1 demonstrated a positive association with LDH. These findings provide useful information for future longitudinal studies to elucidate the possible causes for such phenomena.

Two-stage surgical management of multilevel symptomatic thoracic haemangioma using ethanol and iliac crest bone graft.

This article presents a 56-year-old obese female who presented with back pain and progressive weakness in her lower limbs for three months. She was bed-ridden for one week before reporting to our hospital. Plain radiographs showed vertical striations in multiple vertebrae classical of haemangioma. Magnetic resonance imaging (MRI) spine revealed multiple thoracic and lumbar vertebral haemangiomas. Extra osseous extension of haemangioma at T12 was causing spinal cord compression. Two-stage surgery was performed with absolute alcohol (ethanol) injection followed by pedicle screw fixation and decompression with tricortical iliac crest bone graft into the vertebral body. Postoperatively rapid neurological improvement was seen. After three weeks, she could walk independently. One year later, computed tomography showed complete incorporation of bone graft and maintained vertebral body height. MRI showed complete resolution of the cord edema at T12. These findings indicated diminished vascularity of the tumor.