Utility of Asymmetric Multilevel Pontes Osteotomy in Ankylosing Spondylitis with Scoliosis using Ultrasonic Bone Scalpel: Case Report.

Introduction: Ankylosing spondylitis is a spondyloarthropathy that commonly involves the axial skeleton with predilection to the sacro-iliac joints and spine. The disease frequently results in a smooth globular kyphotic deformity of the spine; however, a coronal plane scoliotic deformity is extremely rare. We present a unique case of scoliotic deformity in a patient diagnosed with ankylosing spondylitis. To the best of our knowledge, following a review of the literature, this appears to be the first report of this kind. Case Report: A 23-year-old male patient presented with chronic back pain, stiffness, and a truncal shift of the body. He had a rigid left-sided thoracolumbar curve measuring 41° with a coronal imbalance of 3.6 cm. We present a case report on scoliosis deformity correction performed with a four-level asymmetric pontes osteotomy using a bone scalpel with excellent correction of the scoliotic deformity that was well maintained at 2-year follow-up. Conclusion: Scoliosis in ankylosing spondylitis has not been documented in literature. We report the complete correction of the deformity, which is well maintained at the 2-year follow-up.

"Critical pedicle wall" breaches analysis in complex spinal deformity using O-arm navigation.

Background: Free-hand and fluoroscopic-guided pedicle screw placement has been associated with higher rates of pedicle breaches (frequency range 15-40% especially in deformed pedicles). Neurological complications are more "critical" (i.e., frequent and significant) with medial and inferior pedicle-wall breaches due to the proximity of the neural elements. Here, we analyzed the effectiveness of O-arm navigation in minimizing "critical" pedicle wall breaches and their complications in 21 complex spinal deformity cases. Methods: Twenty-one complex spinal deformity cases were prospectively managed with O-arm-navigated posterior-instrumented fusions. Preoperative assessment included; evaluation of the type of scoliosis, the magnitude of the deformity, and the anatomy of the pedicles - (i.e., classified using Watanabe et al.). The O-arm was used to confirm and grade both the intraoperative and postoperative location of screws. Other variables analyzed included; duration of surgery, estimated blood loss, complications, and radiation exposure. Results: In 21 patients, 259 (63.45%) of 384 pedicles were instrumented; we observed 22 of 259 pedicle screw breaches. Significant (>2 mm) breaches were observed in two medial and one inferior wall cases that required revision; the overall biomechanically significant screw breach rate was (3/259) 1.2% with an accuracy rate of 98.8%. Pedicle screw placement resulted in another 14 nonsignificant (<2 mm) breaches; ten were medial and four involved the inferior wall. As anterior, lateral, and "in-out-in" trajectory pedicle screws beaches were nonsignificant, they were not included in our analysis. Conclusion: O-arm navigation decreased the incidence of medial and inferior (i.e., >2 mm "critical") pedicle screw breaches applied in 21 patients with deformed pedicles due to scoliosis. Further, the O-arm minimized the operating time, decreased the estimated blood loss, and reduced the incidence of complications.

O-arm Navigated en bloc Excision of a Solitary Subaxial Cervical Osteochondroma Presenting as Myelo-radiculopathy: A Case Report.

Introduction: Vertebral osteochondroma is a rare entity. It presents with varied complaints ranging from palpable mass to myeloradiculopathy. En bloc excision is the gold standard treatment option for symptomatic patients. Real-time intraoperative navigation has increased the accuracy and safety of tumor excision. We report a case of cervical subaxial osteochondroma with myelo-radiculopathy, treated with excision, and monosegmental fusion under O-arm-based real-time navigation. Case Report: A 32-year-old male presented with complaints of axial neck pain with the right upper limb radiculopathy for 18 months. On examination, signs of myelopathy were identified without sensory-motor deficit. Magnetic resonance imaging and computed tomography scans were suggestive of solitary C6 osteochondroma compressing spinalcord. O-arm navigated en-bloc tumor excision with C5 hemilaminectomy and monosegmental fusion was done. Conclusion: The use of O-arm navigation aids in accurate intraoperative en bloc excision without any residual tumor and with better safety.

Chronic Intramedullary Spinal Cord Abscess Mimicking Intramedullary Spinal Cord Tumor-"Phantom Tumor": A Case Report.

CASE: A 33-year-old woman with back pain and radiculopathy had presented with bilateral ankle weakness. MRI showed an intramedullary conus lesion suggestive of neoplasm, but posterior midline durotomy revealed only pus. Pus samples showed Staphylococcus aureus, which was treated with 6 weeks of antibiotics. Two-year follow-up showed complete neurological recovery with no clinicoradiological signs of recurrence. CONCLUSION: Usually, intramedullary spinal cord abscess (ISCA) has an acute presentation and warrants an emergent line of treatment with a risk of mortality. Very rarely chronic ISCA can mimic intramedullary spinal cord tumor. It is the first case reported in the literature of chronic ISCA mimicking conus IMST.

Standalone cage versus anchored cage for anterior cervical discectomy and fusion: a comparative analysis of clinical and radiological outcomes.

PURPOSE: The use of standalone cages (SAC) and anchored cages (AC) in anterior cervical discectomy and fusion surgery (ACDF) has shown advantage of reduced operative time and lower incidence of dysphagia. However, there is limited literature available comparing the clinical and radiological outcomes of SAC and AC. METHODS: We conducted a prospective study for patients undergoing ACDF for cervical radiculopathy or myelopathy. Patient were classified based on the cage used into SAC group and the AC group. Clinical outcomes were assessed using the modified Japanese Orthopedic Association (mJOA) for myelopathy and Neck Disability Index (NDI) and Visual Analogue Scale (VAS) for radiculopathy. Dysphagia was graded as per Bazaz score. Radiologically, global cervical lordosis, segmental lordosis, cage subsidence, and migration were assessed. RESULTS: We analyzed 31 patients in each group with a minimum two year follow-up. The mean VAS improved from 7.9 to 4.56, mean NDI score improved from 27.6 to 19.8, and mean mJOA improved from 10.8 to 11.7 which were statistically significant (p < 0.05); however, no significant difference was noted between the SAC and AC groups. Mean global lordosis improved from 14.4 to 20.3° and mean segmental lordosis improved from 6 to 10.1° at six months and plateaued to 6.9° at final follow up without any significant difference between the groups. The subsidence was statistically more in 12.9% (4/31) in SAC than 6.4% (2/31) in AC. CONCLUSION: AC showed of lower rates of subsidence while both SAC and AC had comparable clinical outcomes and radiological alignment outcomes.

Emergently Managed Rare Case of Extraosseous Hemorrhagic Spinal Epidural Cavernous Hemangioma: A Case Report.

Introduction: Commonly spinal cavernous hemangioma (CH) is found in vertebral body at thoracic level. Purely extraosseous epidural CH contributes only 4% of all CH. In addition, these patients usually present in their 3rd-6th decade of life. Here, we report emergently treated rare case of hemorrhagic extraosseous epidural thoracic CH in a 26-year-old male. Case Report: A 26-year-old male presented with inability to walk without support with acute onset paraparesis and hypoesthesia below D7 with positive myelopathy signs. Magnetic resonance imaging showed posterior epidural well-defined homogenous mass from D6-8 region. PET scan ruled out other primary lesions in body. Intraoperative after D6-8 laminectomy extradural vascular mass was found which was bleeding on touch. With adequate hemostasis complete mass was excised and sent for sampling which revealed CH. The patient showed gradual clinical recovery with complete neurological recovery after 3 months with no signs of clinical and radiological recurrence on 2 years of follow-up. Conclusion: Extraosseous epidural CH is very rare presentation; hence, the differentials of schwannoma, lymphoma, tubercular/pyogenic epidural abscess, metastasis, and others must always be ruled out. They can present a decade earlier in a case of hemorrhagic CH with rapid progressive neurological deficit which warrants early surgical decompression like in our case and the foraminal or paravertebral extension needs foraminotomy or thoracotomy for complete excision.

Gene Xpert/MTB RIF assay for spinal tuberculosis- sensitivity, specificity and clinical utility.

BACKGROUND: Xpert MTB/RIF assay is a rapid automated molecular test with excellent reported sensitivity, specificity for diagnosis of pulmonary and extrapulmonary Mycobacterium tuberculosis (MTB) infections. However, the clinical utility and accuracy in STB is not well established. A study was conducted to report on the sensitivity, specificity and clinical utility of the Xpert MTB/RIF assay in spinal tuberculosis (STB). METHODS: A retrospective review of medical records was performed for 136 patients that underwent spinal biopsy for suspected spondylodiscitis. Reports for acid fast bacilli (AFB) smear, gram stain, pyogenic culture, MTB culture, histopathology, Xpert MTB/RIF assay, and drug sensitivity testing were reviewed. 'Reference standard for diagnosis of STB' was based on positive histopathology and/or MTB culture evidence and was considered as MTB positive. Any samples returning a positive pyogenic or fungal culture were considered as MTB negative. The sensitivity, specificity for Xpert MTB/RIF was assessed against the reference standard. RESULTS: A total of 125 patients were considered for final analysis, 86 patients met the criteria for 'Reference standard for diagnosis of TB spine' (MTB positive). This includes nine patients that were MGIT culture only positive; 45 that were histopathology only positive and 32 were both culture and histopathology positive. There were 39 culture proven (pyogenic-37 and fungal-2) patients included in MTB negative group. The 86 MTB positive patients, included 53 (61.6%) tissue samples and 33 (38.4%) pus samples. The overall analysis showed a 65.1% sensitivity, 100% specificity, 100% PPV and 56.5% NPV for the Xpert MTB/RIF. CONCLUSIONS: Gene Xpert MTB/RIF showed excellent specificity and was accurate in the identification of drug resistance. The sensitivity was 65% and sampling techniques using pus samples rather than tissue samples could be a possible reason for lower sensitivity.

Clinical and radiological factors associated with postoperative shoulder imbalance and correlation with patient-reported outcomes following scoliosis surgery.

BACKGROUND: Shoulder balance (SB) is an important cosmetic concern and is a determinant to assess outcomes following scoliosis surgery. Shoulder imbalance (SI) has been studied predominantly in idiopathic scoliosis with limited literature on other etiologies. PURPOSE: To assess SB following scoliosis surgery and correlate SRS-30 self-image scores with radiological shoulder imbalance SI. METHODS: A retrospective analysis was performed for 43 patients undergoing scoliosis surgery with a minimum 2-year follow-up. Radiological SI was assessed by the coracoid height difference on whole spine standing radiographs at preoperative, 12-weeks postoperative and 2-year follow-up. The preoperative Cobb angle, postoperative Cobb angle and mean correction were recorded. The upper and lower end vertebrae (UEV/LEV), and instrumented vertebrae (UIV/LIV) were documented. The aetiology of scoliosis and functional outcomes based on the SRS-30 questionnaire were noted. RESULTS: There were 19 males and 24 females with a mean age of 14.5 ± 4.7 years. The 12-week postoperative radiographs showed SI in 15 patients and residual SI in 7 patients at 2-year follow-up. SI was seen in four congenital scoliosis with segmentation or mixed anomalies in the proximal thoracic spine. Two idiopathic scoliosis (Lenke type 1 and type 3) showed SI where the UIV was T3 and T2 respectively. The mean preoperative SRS-30 score for patients with SB (N = 9) was 2.5 ± 0.72 and for SI (N = 34) was 3 ± 0.42 without significant difference (p > 0.5). The final mean SRS-30 self-image score for patients with SB was 3.7 ± 0.54 and for patients with SI was 3.7 ± 0.53 without significant difference (p > 0.05). CONCLUSION: Radiological SI assessed by coracoid height difference was not associated with a significant difference in SRS 30 scores preoperatively and at 2 year follow up. SI was seen with congenital scoliosis associated with segmentation and mixed anomalies of the proximal thoracic spine.

Metastatic small cell neuroendocrine tumor with spinal cord compression - Understanding a rare entity.

Background: Metastatic spinal cord compression with carcinoid tumor as primary is a rare entity with its own diagnostic dilemmas and surgical challenges. Most of these neuroendocrine tumors arise from the gastrointestinal tract or lungs with metastasis to spine in <2% cases. Early diagnosis in an orderly manner is of significance as most of it is delayed due to slowly developing symptoms. Furthermore, prompt management has been an important factor as morbidity and mortality are high in such cases and surgical intervention if needed, which can be a challenge due to disturbed alignment, complex regional anatomy, and careful handling of spinal cord. Case Description: The authors describe a case report on similar lines of a middle aged gentleman presenting with low back pain and weakness in both lower limbs which on further investigations revealed a pathological fracture causing spinal cord compression due to metastasis from small cell carcinoma in the lungs, managed with surgical intervention, and subsequently with radiotherapy. Conclusion: Secondary metastatic deposits in the lumbar vertebrae due to carcinoid tumors in the lungs are a rare entity and can be difficult to diagnose and manage further. However, it should be included in the list of differential diagnosis. The case report emphasizes on using investigative modalities such as PET-CT scan to aid an early diagnosis and plan further treatment plan as early as possible to offer a better quality of life to the patients.

A Case Report: Upper Thoracic Chance Fracture with Monoplegia An Unusual Presentation!

INTRODUCTION: Chance fractures, the horizontal splitting vertebral fractures caused by flexion distraction mechanism, are inherently unstable fractures. These fractures can land up with significant visceral injuries. There are most commonly seen at thoracolumbar junction or in lumbar spine due to their high mobility. These fractures are extremely rare in the thoracic spine due to the rigidity of thoracic spine rendered by attachment of ribs. Furthermore, the level of injury makes neurological complications even graver. CASE REPORT: We present a case of a road traffic accident with right lower limb monoplegia. On careful examination, a thin transverse fracture line was noticed in D5 vertebral body, and magnetic resonance imaging revealed posterior ligamentous disruption extending in line with the transverse fracture line in D5 vertebral body which confirmed the diagnosis of a Chance fracture. Fracture was stabilized by pedicle screw fixation from D4 to D7 level, and decompression was done at D5 level. By the end of 7 months, patient regained Grade 4 power in the right hip and knee joints, with Grade 5 power in the right ankle and great toe. CONCLUSION: Chance fractures in thoracic region are extremely rare. A clinician should have a high index of suspicion as these fractures can be notorious when it comes to presentation on plain X-ray. These being inherently unstable fractures, posterior instrumented stabilization with decompression in patients with neurodeficit gives good results.

Cauda Equina Syndrome in a Lactating Mother - A Safe Treatment Approach.

Cauda equina syndrome is widely considered as a surgical emergency. The cause of cauda equina syndrome usually is a large central lumbar disc herniation, prolapse or sequestration. Decompression at the earliest has been suggested by many authors but the planning of surgical management becomes challenging when the patient is a breastfeeding mother. Fear of harmful effects of the drugs (administered in the mother) on the infant, always confuses clinicians regarding the treatment approach. So the multidisciplinary approach is necessary with involvement of anaesthetist, paediatrician and also a gynaecologist if necessary. Thorough knowledge of the safety of drugs to be used in operative and post operative period becomes a necessity keeping the baby into consideration. We present a case of one month postpartum female with cauda equina syndrome and present a stepwise multidisciplinary approach, which involves active contributions from surgeon, for safety of the mother and the infant.

Mobile Schwannomas of lumbar spine: A diagnostic dilemma.

Mobile Schwannoma is a very rare entity and is reported sparsely in literature, with most of them occurring in lumbar spine region. We present a case of seventy-year-old male patient who had pain in lower back radiating to ipsilateral thigh. A diagnosis of migratory tumour was made based on findings of plain and contrast MRI preoperatively. We did a two level laminectomy and tumour excision. In this report, we intend to discuss various likely causes of tumour migration and various diagnostic methods to tackle this surgical dilemma, we have also attempted to review the sparse literature available till date on migratory lumber schwannoma.

Demographics of Thoracolumbar Fracture in Indian Population Presenting to a Tertiary Level Trauma Centre.

STUDY DESIGN: Prospective, cross-sectional, observational study. PURPOSE: Spine traumata are devastating injuries, which may result in serious disabilities and dire consequences. The current study involves a detailed analysis and description of patients, who were operated at a tertiary care, urban level 1 Spine Centre in India. OVERVIEW OF LITERATURE: Various studies in literature have discussed the epidemiology and patterns of these injuries in trauma patients. However, literature describing the demographic profile and distribution of these traumata in the Indian population is scarce. METHODS: The current study was conducted as a prospective trial involving patients, who were treated at our Spine Centre in India between July 2009 to December 2012. We studied 92 patients with thoraco-lumbar spine fracture, who were operated with short or long segment posterior stabilization. Epidemiological details, pre- and post-hospitalisation care received and other injury pattern factors were studied. RESULTS: Fall from height (46 patients, 50%) was the most common mechanism observed in the patients. Sixty-three percent injuries belonged to AO type A fractures, while 16.2% and 19.4% of the patients had suffered from AO types B and C injuries, respectively. CONCLUSIONS: We identified interesting epidemiological data and prevailing inadequacies in Emergency Spine care management in the study patients. These observations could facilitate implementation of the changes required to improve current standards of patient care.