Invasive, gangrenous mucormycosis of arm: A fatal opportunistic infection in a highly immunocompromised host.

Opportunistic fungal infections occur predominantly in immunocompromised (IC) patients. Mucormycosis has the highest mortality among fungal infections. The organism is ubiquitous in its presence. The infection is commonly acquired by inhalation of fungal spores or by inoculation by direct trauma. Rhinocerebral and pulmonary mucormycosis present commonly with high mortality rates. Cutaneous mucormycosis (CM) is rarely reported and usually presents in two forms, superficial and disseminated. The superficial infection occurs commonly in immunocompetent hosts, and it can sometimes turn angioinvasive and become a fatal and very aggressive disseminated disease, especially in IC hosts. Coexistant risk factors increase the mortality rate. We report a case of posttraumatic, highly lethal, angioinvasive, and gangrenous type of CM of the arm in an IC patient. Diabetic ketoacidosis and cirrhosis due to chronic alcoholic liver disease were the risk factors.

Reliability of Allen Ferguson classification versus subaxial injury classification and severity scale for subaxial cervical spine injuries: a psychometrics study.

STUDY DESIGN: A psychometrics study. OBJECTIVES: To determine intra and inter-observer reliability of Allen Ferguson system (AF) and sub-axial injury classification and severity scale (SLIC), two sub axial cervical spine injury (SACI) classification systems. SETTING: Online multi-national study METHODS: Clinico-radiological data of 34 random patients with traumatic SACI were distributed as power point presentations to 13 spine surgeons of the Spine Trauma Study Group of ISCoS from seven different institutions. They were advised to classify patients using AF and SLIC systems. A reference guide of the two systems had been mailed to them earlier. After 6 weeks, the same cases were re-presented to them in a different order for classification using both systems. Intra and inter-observer reliability scores were calculated and analysed with Fleiss Kappa coefficient (k value) for both the systems and Intraclass correlation coefficient(ICC) for the SLIC. RESULTS: Allen Ferguson system displayed a uniformly moderate inter and intra-observer reliability. SLIC showed slight to fair inter-observer reliability and fair to substantial intra-observer reliability. AF mechanistic types showed better inter-observer reliability than the SLIC morphological types. Within SLIC, the total SLIC had the least inter-observer agreement and the SLIC neurology had the highest intra-observer agreement. CONCLUSION: This first external reliability study shows a better reliability for AF as compared to SLIC system. Among the SLIC variables, the DLC status and the total SLIC had least agreement. Low-reliability highlights the need for improving the existing classification systems or coming out with newer ones that consider limitations of the existing ones.

A case of severe and rigid congenital thoracolumbar lordoscoliosis with diastematomyelia presenting with type 2 respiratory failure: managed by staged correction with controlled axial traction.

INTRODUCTION: Congenital lordoscoliosis is an uncommon pathology and its management poses formidable challenge especially in the presence of type 2 respiratory failure and intraspinal anomalies. In such patients standard management protocols are not applicable and may require multistage procedure to minimize risk and optimize results. CASE DESCRIPTION: A 15-year-old girl presented in our hospital emergency services with severe breathing difficulty. She had a severe and rapidly progressing deformity in her back, noted since 6 years of age, associated with severe respiratory distress requiring oxygen and BiPAP support. She was diagnosed to have a severe and rigid congenital right thoracolumbar lordoscoliosis (coronal Cobb's angle: 105° and thoracic lordosis -10°) with type 1 split cord malformation with bony septum extending from T11 to L3. This leads to presentation of restrictive lung disease with type 2 respiratory failure. As her lung condition did not allow for any major procedure, we did a staged procedure rather than executing in a single stage. Controlled axial traction by halogravity was applied initially followed by halo-femoral traction. Four weeks later, this was replaced by halo-pelvic distraction device after a posterior release procedure with asymmetric pedicle substraction osteotomies at T7 and T10. Halo-pelvic distraction continued for 4 more weeks to optimize and correct the deformity. Subsequently definitive posterior stabilization and fusion was done. The detrimental effect of diastematomyelia resection in such cases is clearly evident from literature, so it was left unresected. A good scoliotic correction with improved respiratory function was achieved. Three years follow-up showed no loss of deformity correction, no evidence of pseudarthrosis and a good clinical outcome with reasonably balanced spine. CONCLUSION: The management of severe and rigid congenital lordoscoliotic deformities with intraspinal anomalies is challenging. Progressive reduction in respiratory volume in untreated cases can lead to acute respiratory failure. Such patients have a high rate of intraoperative and postoperative morbidity and mortality. Hence a staged procedure is recommended. Initially a less invasive procedure like halo traction helps to improve their respiratory function with simultaneous correction of the deformity, while allowing for monitoring of neurological deficit. Subsequently spinal osteotomies and combined halo traction helps further improve the correction, following which definitive instrumented fusion can be done.

An inflammatory pseudotumor in the thoracic epidural space presenting with progressive paraplegia: a histopathological diagnosis with clinical and radiological uncertainty. Case report with literature review.

INTRODUCTION: Inflammatory pseudotumors (IPTs) are benign lesions with unknown etiology, probably an immunological reaction to a traumatic or an infective insult or sometimes considered as an IgG4-related autoimmune disorder. It can occur as an isolated or multi-centric lesion and are reported to involve almost all parts of the human body. Although lung and orbital IPTs are reported commonly, central nervous system involvement is a rare occurrence. Only seven cases of spinal epidural IPTs have been reported to date. These are clinically and radiologically a diagnosis of exclusion. It is an exclusive histopathological diagnosis. CASE REPORT: We present here a 49-year-old female with 2 months history of progressive weakness in lower limbs, with no history suggestive of any traumatic, infective, inflammatory, or neoplastic pathology. Both clinical and radiological investigations were inconclusive. There was a mass lesion in the epidural space (predominantly in the posterior and right lateral space) at T1-T3 vertebral levels compressing the thoracic spinal cord. Considering the progressive nature of her neurological deficit, an emergency decompressive laminectomies of T1-T3 vertebrae were done with excision of the compressive mass lesion. Histopathological examination showed a rich lympho-plasmacytic cell infiltrates with storiform spindle cells and dense fibrosis, which was diagnostic of IPT. Post-operatively there was a rapid recovery in neurology and she became ambulatory at the end of 2 weeks. The purpose of this case report is to discuss the clinical, histopathological and radiological features, differential diagnosis, management, and prognosis of spinal IPT on the background of relevant literature review.

Antepartum surgical management of Pott's paraplegia along with maintenance of pregnancy during second trimester.

INTRODUCTION: The existing literature is limited and inconclusive regarding management of spinal tuberculosis with neurological deficit during advanced pregnancy. None of the previously published case series concerning this problem during the second trimester of pregnancy have explored the option of simultaneous surgical intervention for it along with maintenance of pregnancy. CASE REPORT: A 22-year-old woman with 26 weeks of pregnancy (2nd trimester) presented with upper back pain for the past 2 months, inability to move both lower limbs for the last 1 week, bladder and bowel dysfunction for the past 5 days (Frankel Grade B). Patient subsequently underwent MRI scan dorsal spine and the image findings were suggestive of spinal tuberculosis T2 level. After obstetric evaluation and opinion of the expectant mother, in view of extensive neurological deficit which progressed rapidly, decision was taken for surgical intervention along with maintenance of pregnancy. Patient was positioned in right lateral position after giving general anesthesia using double lumen endotracheal tube with lung isolation technique. Exposure was done using transthoracic third rib excision approach. Decompression was achieved by radical debridement at T2 vertebrae level followed by multiple rib strut grafts and stabilization with screw and rod construct between T1 and T3 vertebrae. Intra-operative measures including type of anesthesia, prevention of maternal hypotension, hypoxemia and hypothermia, and fetal monitoring by attending obstetrician were undertaken to maintain feto-maternal safety. Postoperative ultrasonography evaluation of the fetus revealed a normal study. Post-surgery histopathological evaluation of the surgical specimen confirmed tuberculosis infection and the patient continued anti-tubercular drug therapy for 9 months. She delivered a healthy girl child at 36 weeks of gestation by cesarean section. After about 14 months of postoperative follow-up, patient has completely recovered motor power with mild persistent sensory symptoms. She is self-voiding with mild constipation requiring occasional intermittent laxative use. Radiological improvements in comparison to the previous reports were also seen at the last follow-up. CONCLUSION: Although this is only a single case but being the first to our knowledge, the good results highlight the point that both surgical management and maintenance of pregnancy during second trimester complicated by Pott's paraplegia are possible, involving a multi-disciplinary team approach for optimal maternal and fetal outcome.

A novel technique for reduction of unreducible lumbar fractures in ankylosing spondylitis.

STUDY DESIGN: Retrospective case series study. PURPOSE OF STUDY: Fractures in ankylosed lumbar spine are difficult to reduce and it is like attempting to reduce the ends of a long bone fracture of an extremity. Simple compression from the posterior results in the anterior column opening in lumbar spine because of the inherent lordosis present there, which usually requires combined approach, if the gap is extensive. Purpose of our study is to describe a new technique for reduction of lumbar fracture not reducing through conventional technique in ankylosing spondylitis. There are no techniques described for reduction of these complex fractures in the literature to the best of our knowledge. METHODS: Four patients were operated by a new modified staged posterior approach. Two patients had AIS D neurology, one patient had AIS A neurology and one patient had normal neurology (AIS E). Patients were operated in a staged procedure in a single sitting, as single posterior procedure did not allow for complete reduction of lumbar fracture. The patients were first positioned prone and instrumentation was done. To close the anterior gap, patients were then positioned lateral and reduction and stabilization of fracture was done. RESULTS: Mean age of the patients was 50 years. Average time of surgery was 3 h 40 min. All four patients operated with this modified posterior approach had fusion 6 months after surgery. There were no significant complications. CONCLUSION: We recommend this technique to be used in fractures in lumbar ankylosed spine as they have tendency to open anteriorly after trauma. It helps in closure of anterior column in a single surgery and obviates the need for anterior surgery in these patients.