Does Elevated Mean-Arterial Pressure Lead to Better Outcomes in Degenerative Cervical Myelopathy?- A Prospective, Pilot Randomized Control Trial.

STUDY DESIGN: Randomized Control Trial. OBJECTIVE: DCM refers to compression of spinal cord either due to static/dynamic causes or commonly, a result of combination of both. Number of variables exist, which determine prognosis post-surgery. Role of intra-operative blood pressure has not been analyzed in depth in current literature. Elevating MAP post SCI is widely practiced and forms a recommendation of AANS/CNS Joint Committee Guidelines. This led us to investigate role played by elevated MAP during surgery for DCM, in order to optimize outcomes. METHODS: This prospective randomized comparative pilot study was conducted at a tertiary care spine centre. 84 patients were randomly divided in two groups. Group 1 had intra-operative MAP in normal range. Group 2, had intra-operative BP 20 mmHg higher than preoperative average MAP with a variation of + 5 mmHg. Outcomes were recorded at 3 months, 6 months and 1 year by mJOA, VAS and ASIA scale. RESULTS: Neurological improvement was documented in 19/30 (63.3%) patients of hypertensive group compared to 16/30 (53.3%) patients of normotensive group. Improvements in mJOA scores were better for hypertensive group during the 1-year follow-up. Improvement in VAS scores were comparable between two groups, but at 1-year follow-up the VAS score of hypertensive groups was significantly lower. CONCLUSION: MAP should be individualized according to preoperative average blood pressure assessment of patient. Keeping intraoperative MAP at higher level (preoperative MAP + 20 mmHg) during surgery for DCM can result in better outcomes.

Preoperative Lumbar Epidural Steroid Injection Increases the Risk of a Dural Tear During Minimally Invasive Lumbar Discectomy.

BACKGROUND: Preoperative lumbar epidural steroid injections (LESI) are known to be a risk factor for intraoperative dural tears in traditional spine surgery. However, whether the same holds true after minimally invasive surgery is debatable. The authors decided to investigate the incidence of complications in patients undergoing minimally invasive lumbar discectomy after a preoperative LESI. METHODS: A retrospective analysis was carried out on patients ages 21 to 65 years who underwent minimally invasive lumbar discectomy over 3 years between November 2017 and October 2020. These were classified into 2 groups based on the administration of an LESI within a year of surgery. Those receiving LESI were further subdivided on the basis of the proximity of the injection to the surgery. The complications encountered during and up to 6 months after the surgery were recorded. Various demographic variables were also noted. RESULTS: A total of 315 patients were included in the study, of which 129 were in the LESI group and 186 were in the non-LESI group. The overall complication rate was 13.65%, with 17.83% in the LESI group and 10.75% in the non-LESI group (P = 0.07). Patients receiving an LESI were 2.49 times more likely to suffer from intraoperative dural tears compared to the other group (95% CI: 1.00-6.20, P = 0.049). This was more prevalent in those who were administered an LESI within 3 months of the surgery (OR: 3.24, 95% CI: 1.12-9.40, P = 0.03). However, the rates of other complications including infections were comparable. CONCLUSIONS: A history of LESI within 3 months of the surgery is a risk factor of intraoperative dural tears. However, other complications, including infections, are not affected by a preoperative LESI. CLINICAL RELEVANCE: A history of an LESI within 3 months of a proposed minimally invasive discectomy should make the surgeon extra-cautious of the risk of a dural tear.

A Mid-term Comparison of the Functional Outcomes of Medial Pivot and Rotating Platform Mobile-Bearing Total Knee Arthroplasty in the Indian Population.

BACKGROUND: Both medial pivot (MP) and rotating platform (RP) mobile-bearing (MB) total knee arthroplasty (TKA) have been developed to better mimic the natural knee kinematics and femoral roll back in flexion. The purpose of this retrospective study was to compare the mid-term functional outcomes and range of motion (ROM) of MP and RP types of total knee arthroplasty. METHODS: 116 patients (mean age of 66.3 years) undergoing TKA (52 Medial pivot design and 64 Rotating Platform design) were evaluated retrospectively with Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) knee score, knee society score (KSS) with its subgroups namely, Knee Score (KSKS) and Functional Score (KSFS) and forgotten joint score (FJS) at a mean follow-up of 7.1 years. Range of motion (ROM) and tibiofemoral anatomic angle on the radiographs were also compared. RESULTS: Mean ROM, WOMAC and KSKS improved significantly from pre-operative to postoperative knees in both the groups. There was, however, no significant difference between the two groups at the final follow-up. In contrast, mean KSFS score improved to 89.5 ± 8.1 in MP group and 86.3 ± 7.1 in RP Group (p = 0.025), while mean FJS was 85.6 ± 4.1 and 80.9 ± 5.4 in the MP and RP groups, respectively (p = < 0.0001). CONCLUSION: Satisfactory clinical and functional outcomes can be obtained using either a MP or RP knee joint in tricompartmental osteoarthritis of knee. The MP design scores better on the KSFS score and FJS than the RP-TKA.

Diabetes Mellitus-A Risk Factor for the Development of Lumbar Disc Degeneration: A Retrospective Study of an Indian Population.

STUDY DESIGN: A retrospective study. OBJECTIVES: To determine the association between type-2 diabetes mellitus (T2DM) and the severity of lumbar disc degeneration disease (LDDD). METHODS: We included 199 patients with low back pain (LBP) who visited our hospital from 2016 to 2018. All patients were divided into 3 groups as per inclusion criteria. Group A, patients without DM (n = 75); group B, patients with controlled DM (n = 72); and group C, patients with uncontrolled DM (n = 52). The patients were further subdivided into group B1, DM duration ≤10 years (n = 38); group B2, DM duration >10 years (n = 34); group C1 DM duration ≤10 years (n = 28); and group C2, DM duration >10 years (n = 24). Sex, age, body mass index, occupation, smoking history, alcohol use, and duration of T2DM were recorded. The severity of LDDD was evaluated using the 5-level Pfirrmann grading system. Operated patients' disc materials were sent for histological examination. RESULTS: Demographic data showed no difference among groups (P > 0.5), except age. Patients with DM showed more severe disc degeneration compared with patients without DM. The average Pfirrmann scores between groups A and B1 had no difference; groups B2, C1, and C2 showed higher average Pfirrmann scores than group A (P < 0.05). Groups B2 and C2 showed higher average Pfirrmann scores than groups B1 and C1 (P < 0.05). Groups C1 and C2 showed higher average Pfirrmann scores than groups B1 and B2 (P < 0.05). The severity of LDDD was significantly related to DM duration in both groups B and C (P < 0.05). DM groups showed increased disc apoptosis and matrix aggrecan fragmentation, disc glycosaminoglycan content and histological analysis were significantly different; the results are similar to Pfirrmann score results. CONCLUSIONS: DM duration >10 years and uncontrolled DM were risk factors for LDDD.

Diabetes Mellitus and the Development of Lumbar Canal Stenosis: Is There Any Relevance?

STUDY DESIGN: Retrospective study. PURPOSE: To assess the relationship between the severity of lumbar canal stenosis (LCS) and type-II diabetes mellitus (DM). OVERVIEW OF LITERATURE: DM is a multiorgan disorder that has an effect on all types of connective tissues. LCS is a narrowing of the spinal canal with nerve root impingement that causes neurological claudication and radiculopathy. Identification of the risk factors of LCS is key in the prevention of its onset or progression. METHODS: LCS patients were divided into three groups as per DM status: group A without DM (n=150); group B patients with well-controlled DM; and group C patients with uncontrolled DM. Groups B and C were subdivided into group B1: patients with DM with a duration of ≤10 years (n=76), group B2: DM with duration of >10 years (n=68), group-C1 DM duration ≤10 years (n=56), and group C2 DM duration >10 years (n=48). The severity of LCS was evaluated using the Swiss Spinal Stenosis Scale (SSSS) and Modified Oswestry Disability score (MODS). Operated patients ligamentum flavum sent for histological staining and quantitative immunofluorescence analysis. RESULTS: The demographic data of groups did not show any difference except in age. There was no difference between the mean SSSS and MODS of groups A and B1. Groups B2, C1, and C2 had higher average SSSS and MODS than group A (p<0.05). Groups B2 and C2 had higher SSSS and MODS than groups B1 and C1. Groups C1 and C2 had higher scores than groups B1 and B2 (p<0.05). The severity of LCS was significantly related to the duration of DM in groups B and C (p<0.05). Uncontrolled and longer duration of DM had significant elastin fibers loss and also higher rate of disk apoptosis, high matrix aggrecan fragmentation, and high disk glycosaminoglycan content. CONCLUSIONS: Longer duration and uncontrolled diabetes were risk factors for LCS and directly correlate with the severity of LCS.

Prospective Randomized Control Pilot Study to Compare the Role of Injection Cerebrolysin in Operated cases of Degenerative Cervical Myelopathy.

STUDY DESIGN: Prospective randomized control trial. OBJECTIVE: The aim of this study was to analyze role of cerebrolysin in patients of degenerative cervical myelopathy (DCM) managed by surgical modalities. SUMMARY OF BACKGROUND DATA: Cerebrolysin has been extensively researched with variable success in neurodegenerative pathologies. There has been only one study in published literature till date that has studied role of cerebrolysin in DCM in conservatively managed patients but none in the patients treated surgically. We present our pilot study which analyzes the role of cerebrolysin in patients of DCM managed by surgical modalities. METHODS: This prospective randomized control trial was conducted at a tertiary care institute in Mumbai. Sixty operated cases of DCM were randomly divided into 2 groups. The first group was given Injection Cerebrolysin 5 mL diluted in 100 mL Normal Saline over 30 minutes once a day for 21 days postoperatively. The second group was given placebo. Modified Japanese Orthopedic Association scores (mJOA) and visual analog scale (VAS) were used to document functional outcomes at 3 weeks, 3 months, 6 months, and 1 year. Recovery of hand function was separately accessed by improvement in hand power and sensations. RESULTS: Preoperative mJOA and VAS scores were comparable between 2 groups. Both groups showed significant improvement in both mJOA and VAS scores at 3weeks, 3 months, 6 months and 1-year follow-up (P < 0.01). In comparing the two groups, there was no difference in improvement of mJOA and VAS scores. However, cerebrolysin group showed significant improvement in hand function at 1 year compared to the placebo. Postoperative neurological recovery was better in the cerebrolysin group with 66.7% patients showing complete neurological recovery compared to 56.7% for placebo, but this was statistically insignificant. Two patients developed headache and one patient complained of dizziness in the cerebrolysin group, but these resolved without any intervention. CONCLUSION: Use of cerebrolysin in postoperative cases of DCM is safe and results in improved hand function.Level of Evidence: 1.

Incidence of Dural Tears in Open versus Minimally Invasive Spine Surgery: A Single-Center Prospective Study.

STUDY DESIGN: A prospective comparative study. PURPOSE: To compare the incidence of unintended durotomy and return to work after open surgery versus minimally invasive spine surgery (MIS) for degenerative lumbar pathologies. OVERVIEW OF LITERATURE: The incidence of accidental durotomy varies between 0.3% and 35%. Most of these are from open surgeries, and only a handful of studies have involved the MIS approach. No single-center studies have compared open surgery with MIS, especially in the context of early return to work and dural tear (DT). METHODS: This study included 420 operated cases of degenerative lumbar pathology with a prospective follow-up of at least 6 months. Patients were divided into the open surgery and MIS groups, and the incidences of DT, early return to work, and various demographic and operative factors were compared. RESULTS: A total of 156 and 264 patients underwent MIS and open surgery, respectively. Incidental durotomy was documented in 52 cases (12.4%); this was significantly less in the MIS group versus the open surgery group (6.4% vs. 15.9%, p <0.05). In the open surgery group, four patients underwent revision for persistent dural leak or pseudomeningocele, but none of the cases in the MIS group had revision surgery due to DT-related complications. The incidence of DT was higher among patients with high body mass index, patients with diabetes mellitus, and patients who underwent revision surgery (p <0.05) regardless of the approach. The MIS group returned to work significantly earlier. CONCLUSIONS: MIS was associated with a significantly lower incidence of DT and earlier return to work compared with open surgery among patients with degenerative lumbar pathology.

The triple technique: A simple and effective outpatient procedure for the dorsal wrist ganglion.

BACKGROUND: Dorsal ganglia are the most common types of wrist ganglia. Though largely asymptomatic, they can cause pain, stiffness and require treatment. The different methods described for the management have high recurrence rates even up to 70%. We describe a new method which combines 3 of these methods thus aiming to achieve the best from each of the techniques. METHODS: A prospective observational study was undertaken to include patients requiring surgery for dorsal ganglion. The method involved a combination of aspiration, steroid instillation and tranfixation with silk suture for 3 weeks. Various demographic parameters, operative variables and functional criteria like QuickDASH Score and Numerical Pain Rating scale (NPRS) were used. The patients were followed up for atleast 24 months. Overall satisfaction rate was also recorded. RESULTS: 83 patients were included with a mean age of 31.7 ± 12.4 years. The mean duration of surgery was 12.0 ± 4.9 min and follow up was 29.8 ± 7.1 months. 15 patients had complex multilobulated ganglia. The most common indication for surgery was cosmesis. 4 complications were encountered of which 2 were superficial infections, 1 whitish discoloration locally and 1 case of persistent pain. We achieved a success rate of 95.2% with only 4 recurrences with a mean reduction in size to be 82.2 ± 5.8%. NPRS and QuickDASH scores improved significantly. Mean satisfaction rate was 89% and 84.3% wished to have the surgery again for a similar complaint. The loss of work was 2.5 ± 1.4 days. CONCLUSIONS: Triple Technique is an effective and safe technique with <5% recurrence at 2 years.

Primary Myoepithelial Carcinoma of the Cervical Spine: A Case Report.

CASE: A 36-year-old man presented with a subacute onset left upper limb weakness. Further investigation revealed a myoepithelial carcinoma arising from the C3-C5 vertebrae. He underwent 2-stage surgery with tumor excision and postoperative radiotherapy. An improvement in power was noted, and no recurrence was observed at the 1-year follow-up. CONCLUSION: Myoepithelial tumors are rare at skeletal locations and require a high degree of suspicion. Immunohistochemistry plays a vital role in establishing the diagnosis. A complete resection is paramount for a favorable outcome.

Does a high BMI affect the outcome of minimally invasive TLIF? A retrospective study of 207 patients.

PURPOSE: We investigated whether a high Body Mass Index (BMI) affects the outcomes following Minimally Invasive TLIF (MI-TLIF) for degenerative lumbar pathologies. METHODS: A retrospective study was undertaken to include patients operated between January 2016 and January 2020 with at least one-year follow-up. Various preoperative and demographic parameters were recorded and the patients were classified into normal, overweight and obese based on the BMI. The operative and outcome measures used for assessment were surgical time, blood loss, number of levels operated upon, skin incision length, day of independent mobilisation, total hospital stay including ICU stay, return to work and Visual Analogue Score (VAS) for back pain (VAS-BP) and leg pain (VAS-LP) and Oswestry Disability Index (ODI). Attainment of Minimal Clinically Important Difference (MCID) for the scores was calculated. Multivariate analyses were done to assess the effect of BMI on different parameters. RESULTS: Blood loss and postoperative ICU stay were found to be higher in the obese patients. However, the other variables were comparable. VAS-BP, VAS-LP and ODI scores were significantly improved in all the patients with no inter-group variability. The MCID attainment was also similar. The satisfaction rating at 1-year and willingness for surgery again for similar disease was also similar. The overall complication rate was 14.9% and was comparable among the groups. Multivariate analyses revealed no significant association between BMI and various parameters. CONCLUSION: In patients treated by MI-TLIF for degenerative lumbar spine pathology, BMI is not a factor that negatively affects the functional and clinical outcomes.

Preoperative T1 magnetic resonance imaging changes carry a poor postoperative prognosis in cervical myelopathy: A retrospective study of 182 patients.

Background: T2 scans are widely used to determine the prognosis for patients undergoing surgery for cervical myelopathy. In this study, we determined whether T1 MR changes in addition to T2 MR changes could have prognostic importance. Methods: This retrospective analysis involved 182 patients undergoing surgery for cervical myelopathy (2017-2020). There were 110 patients in Group 1 (only T2 MR changes) and 72 in Group 2 (both T1 and T2 MR changes). In addition, demographic, visual analog score (VAS), modified Japanese Orthopaedic Association (mJOA) scores, and operative details were recorded at 1 month, 3 months, 6 months, and 1 year postoperatively. Results: Notably, VAS scores were comparable at each point in time and were significantly better than the preoperative scores at 1 year postoperatively. Although mJOA scores were comparable at 1 month in both groups, they were better thereafter for Group 1 patients. Conclusion: The presence of T1 changes on the preoperative magnetic resonance imaging represented a poor prognostic indicator for the postoperative outcome compared to the presence of T2 changes alone.

Osteoporotic burst fracture-clinical, radiological and functional outcome of three-column reconstruction using single posterior approach (Instrumentation, Corpectomy, Arthroscope Assisted Transpedicular Decompression and Mesh Cage).

PURPOSE: To evaluate a novel effective procedure utilizing three-column reconstruction via a posterior approach with a technique that utilizes an arthroscope to visualize the anterior surface of the dura during decompression. METHODS: A Prospective Study. 80 Osteoporotic vertebral burst fracture patients with similar demographic data managed by three-column reconstruction through single posterior approach surgery: Pedicle screw fixation, Corpectomy, Arthroscope Assisted Transpedicular Decompression (AATD) and Fusion (Mesh Cage + Bone grafting). Preoperative and postoperative clinical parameters (Visual Analog Score VAS, swestry Disability Index ODI, neurlogy, radiological parameters and surgical variables were recorded analysed. RESULTS: No significant differences in demographic data. Significant improvement was noted in VAS (pre-operative, 7.90 ±0.60; final follow-up 2.90 ± 0.54) and ODI (preoperative, 77.10 ± 6.96; final follow-up 21.30 ± 6.70). Neurological improvement was noted in 74 patients (Frankel grade E) while six patients remained non-ambulatory (Frankel grade C). Significant improvement was noted in local kyphosis angle (preoperative, 22.14 ± 2.60; postoperative, 10.40 ± 1.40) with a 10% loss of correction (2.5 ± 0.90) at final follow-up. Implant failure in two patients and proximal junctional failure in two patients managed with revision surgery. No iatrogenic dural or nerve injury. CONCLUSIONS: Osteoporotic Burst fracture can be managed with single posterior surgery, three-column reconstruction with mesh cage. It provides a significant improvement in clinical, radiological and functional outcomes. The arthroscope can improve a surgeon's operative field and magnification thereby ensuring complete decompression without injuring the dura or spinal cord.

Hyperglycemia and its influence on development of lumbar degenerative disc disease.

STUDY DESIGN: A Retrospective observational study. OBJECTIVES: To determine the influence of hyperglycemia on severity of lumbar degenerative disc disease (LDDD). METHODS: We retrospectively included 199 patients with low back pain (LBP) who visited our tertiary care hospital from June 2016 to December 2018. All patients divided into three groups as per inclusion and exclusion criteria. Group-A had patients without DM (n = 75). Group B had well-controlled DM patients (n = 72) and Group-C had uncontrolled DM patients (n = 52). Group B and C subdivided according to dutation of DM. Group-B1 DM duration was ≤ 10 years (n = 38), Group-B2 DM duration was >10 years (n = 34), Group-C1 DM duration ≤10 years (n = 28), Group-C2 DM duration >10 years (n = 24). Sex, age, BMI, occupation, smoking history, alcohol use and duration of type-II DM were recorded. The severity of LDDD was evaluated using the five-level Pfirrmann grading system. Operated patient's disc material sent for histological examination. RESULTS: Patients with DM showed more severe disc degeneration compared to patients without DM. The average Pfirrmann scores between Groups A and B1 had no difference; Groups B2, C1, and C2 showed higher average Pfirrmann-scores than Group-A (p > 0.05). Group-B2 and Group-C2 showed higher average Pfirrmann-scores than Group-B1 and Group-C1 (p > 0.05). Group-C1 and Group-C2 showed higher average Pfirrmann-scores than Group-B1 and B2 (p > 0.05). The severity of LDDD was significantly related to DM duration both in groups B & C (p > 0.05). DM groups showed increased disc apoptosis and matrix aggrecan fragmentation, Disc glycosaminoglycan content and histological significantly different, the results are similar to Pfirrmann-score results. CONCLUSIONS: There is a positive relationship between diabetes and LDDD. A longer the duration and poor control of hyperglycemia could aggravate disc degeneration.