Effect on functional outcome of robotic assisted rehabilitation versus conventional rehabilitation in patients with complete spinal cord injury: a prospective comparative study.

STUDY DESIGN: Prospective Comparative Study. OBJECTIVE: This study aims to compare the functional outcomes of Robotic-assisted rehabilitation by Lokomat system Vs. Conventional rehabilitation in participants with Dorsolumbar complete spinal cord injury (SCI). SETTING: University level teaching hospital in a hilly state of northern India. METHODS: 15 participants with Dorsolumbar SCI with ASIA A neurology were allocated to robotic rehabilitation and 15 participants to conventional rehabilitation after an operative procedure. Pre-and Post-rehabilitation parameters were noted in terms of ASIA Neurology, Motor and sensory function scores, WISCI II score (Walking Index in SCI score), LEMS (Lower Extremity Motor Score), SCI M III score (Spinal Cord Independence Measure III score), AO Spine PROST (AO Patient Reported Outcome Spine Trauma), McGill QOL score (Mc Gill Quality of Life score), VAS score (Visual Analogue Scale) for pain and Modified Ashworth scale for spasticity in lower limbs. RESULTS: On comparing robotic group with conventional group there was a statistically significant improvement in Robotic-assisted rehabilitation group in terms of Motor score (p = 0.034), WISCI II score (p = 0.0001), SCIM III score (p = 0.0001), AO PROST score (p = 0.0001), Mc GILL QOL score (p = 0.0001), Max velocity (p = 0.0001) and Step length (p = 0.0001). Whereas LEMS score (p = 0.052), ASIA neurology (p = 0.264 (ASIA A); 1.000 (ASIA B); 0.053 (ASIA C)), VAS score (p = 0.099), Sensory score (p = 0.422) and Modified Ashworth scale for spasticity (p = 0.136) were not statically significant when comparing between two groups. CONCLUSION: Robot-assisted rehabilitation is superior than conventional rehabilitation in people living with SCI with AIS A neurology. Differences in the patient group, type of a lesion its and severity, duration from onset to initiation of rehabilitation, devices employed, administration of the therapies and regulation of interventions are likely the cause of variations in the findings seen in the literature for robotic assisted training. LEVEL OF EVIDENCE: III.

Healing Assessment of Spinal Tuberculosis: A Systematic Review.

OBJECTIVE: Deciding the healing end point in spinal tuberculosis (STB) remains a controversial topic. The current systematic review aims to address the controversy existing in the literature to find a comprehensive method to assess healing in STB. METHODS: A thorough literature search was carried out for studies with the assessment of healing parameters in STB. Data extraction was carried out manually, which included study characteristics and healing criteria evaluated in each study. RESULTS: Qualitative analysis of 8 included studies showed that healing parameters were described in 3 domains: clinical, hematologic, and radiologic response of the patient to antitubercular chemotherapy. Each domain included various individual parameters, with clinical and radiologic assessment criteria being used in most of the studies. Improvement in terms of pain, constitutional symptoms, weight gain, neurology; variation in erythrocyte sedimentation rate and C-reactive protein; and changes in radiography, magnetic resonance imaging, and positron emission tomography/computed tomography were found to be promising predictors in the assessment of healing. CONCLUSIONS: Radiologic response parameters emerged as the maximally used criteria to assess healing in STB. However, in the absence of any statistical analysis and an observed lag in radiologic response, the cumulative effect of all the parameters in 3 domains (clinical, hematologic, and radiologic) can be used to declare a spinal tubercular lesion nonhealing, healing, or healed.

Is Final Fusion Necessary for Growing-Rod Graduates: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVES: The need for definitive fusion for growing rod graduates is a controversial topic in the management of Early-onset scoliosis (EOS) patients. The authors performed a systematic review and meta-analysis on the available literature to evaluate the outcomes of growing rod graduates undergoing final fusion or observation with implants in-situ. METHODS: An extensive literature search was carried out aimed at identifying articles reporting outcomes in growing rod graduates. Apart from the study characteristics and demographic details, the extracted data included Cobb's correction, trunk height parameters, and revision rate. The extracted data was analyzed and forest plots were generated to draw comparisons between the observation and fusion groups. RESULTS: Of the 11 included studies, 6 were case-control and 5 were case series. The authors did not find any significant difference between the 2 groups with respect to the pre-index and final Cobb's correction, T1-T12 or T1-S1 height gain in either over-all, or sub-analysis with case-control studies. The meta-analysis showed a significantly higher revision rate in patients undergoing a definitive fusion procedure. CONCLUSION: The current analysis revealed comparable outcomes in terms of correction rate and gain in the trunk height but a lesser need of revisions in observation sub-group. The lack of good quality evidence and the need for prospective and randomized trials was also propounded by this review.

Endovascular management of iatrogenic vertebro-vertebral fistula: Black Swan event in C2 pedicle screw.

Background: Vertebro-vertebral fistulas (VVF) are rare. Anatomically, they consist of an arteriovenous fistula, a direct pathological communication between vertebral veins (including the epidural vertebral venous plexus) and extradural vertebral artery. The various etiologies include trauma, iatrogenic, or spontaneous (e.g., NF-1 or Ehlers Danlos Syndrome). The clinical presentation may include acute/delayed onset of radiculopathy and/or myelopathy. They may further be characterized by the delayed onset hearing loss to tinnitus and/or the sensation of water in the ear. Case Description: We report successful endovascular management for iatrogenic VVF in a 37-year-old female who was diagnosed with an odontoid fracture (Anderson type IIC). She underwent a posterior C1 lateral masses to C2 pedicle/laminar screw fixation. An intraoperative vertebro-vertebral fistulas (VVF) was recognized during the procedure and it was managed successfully with percutaneous transarterial endovascular coiling. Conclusion: Iatrogenic VVF should immediately be suspected when the implant trajectory goes slightly off track during a C1-2 fixation. Immediate postoperative DSA and MRI are advisable, irrespective of whether the patient is symptomatic. These lesions are best managed with endovascular coiling with or without detachable balloons.

Management of Andersson lesions of spine: A systematic review of the existing literature.

Introduction: Andersson lesions also termed as aseptic spondylodiscitis, spinal pseudoarthrosis are known to occur in patients with ankylosing spondylitis. Trauma as well as inflammation has been cited as factors responsible for the causation of these lesions. A variety of surgical approaches have been described in the literature such as anterior, posterior, combined anterior and posterior, with or without reconstruction of the anterior column defect. Controversy still exists regarding the optimal management these lesions. Objective: To address the optimal method of management, levels of instrumentation, requirement of fusion and anterior instrumentation and general epidemiological profile of the patients with Andersson lesions. Materials and methods: An electronic search for studies on the surgical management of Andersson lesions of spine was performed. Quality assessment of the included articles was done by two independent authors according to the criteria used by researchers previously in systematic reviews. Results: Males were found to have an increased incidence with the thoracolumbar junction being the most common level. Posterior approach was the most favoured with reconstruction of the gap in the anterior column. Posterior osteotomy with correction of deformity was done commonly for an optimal healing environment. Instrumenting 2-3 levels above and below the lesion is favoured by most. Conclusion: Conservative management for Andersson lesions can be employed in the setting of acute trauma and stable fractures involving a single column. Surgical management of these lesions with a posterior long segment fixation and anterior column reconstruction is the favoured treatment in majority of the cases.

Is detethering necessary before deformity correction in congenital scoliosis associated with tethered cord syndrome: a meta-analysis of current evidence.

PURPOSE: To compare the clinical and radiological outcomes in patients with congenital scoliosis (CS) and tethered cord syndrome (TCS) undergoing deformity correction with (NI group) versus without (NNI group) prior neurosurgical intervention aimed at detethering the cord. METHODS: A systematic review and meta-analysis were performed. The databases PubMed, Embase and Google Scholar were searched until March 2020. Inclusion criteria was studied describing performance of deformity correction and fusion surgery for congenital scoliosis with tethered cord syndrome with or without prior detethering procedure. Studies describing growth sparing procedures or congenital scoliosis associated with non-tethering pathologies such as syrinx were excluded. Case reports and series with less than 10 subjects were also excluded. NIH quality assessment tool was used for assessing quality of individual study. RESULTS: Sixteen studies were included for analysis of which eight were found to be retrospective case series (level IV evidence) and retrospective case-control studies (level III evidence) each. Overall proportional meta-analysis found no significant difference in correction rate, operative duration, blood loss or complication rate between the NI and NNI groups. However, subgroup analysis performed after inclusion of only level III evidence studies revealed significantly lesser operative duration and blood loss with comparable correction and complication rate in NNI group. CONCLUSION: Deformity correction and fusion surgery may be performed safely and effectively in CS with TCS patients without the need of a prior detethering procedure.

Pyogenic Vertebral Body Osteomyelitis in a Child: A Case Report.

INTRODUCTION: Pyogenic vertebral body osteomyelitis is rarer in children in comparison to adults. A rare case of pyogenic vertebral body osteomyelitis in a 10-year-old male is presented which was managed conservatively with antibiotics on the basis of antibiogram of blood culture. With 6 weeks of antibiotic therapy and at 12-month follow-up, the patient has no symptoms with no affection of any activity. This should be considered as a differential diagnosis in pediatric patients presenting with atypical symptoms related to spine and hip. CASE REPORT: A 10-year-old child presented with a 7-day history of progressively increasing insidious onset pain in the lower back radiating to the right hip, with an associated limp and restriction of floor level activities and activities of daily living. On examination, the child had tenderness at L3, L4, and L5 vertebral level and normal neurology in both lower limbs. A pseudoflexion deformity 20° was also noted in the right hip with normal range of motion in other planes. Keeping a differential of infective etiology of either hip or spine, routine blood investigations, blood culture, and radiological evaluation were done which included X-rays of lumbosacral spine and hip, ultrasound of bilateral hips and abdomen, and magnetic resonance imaging (MRI) of lumbosacral spine. The blood investigations showed an increase in white blood cell count, erythrocyte sedimentation rate, and high-sensitivity C-reactive protein, with the isolation of methicillin-sensitive Staphylococcus aureus in blood culture. Ultrasonography of hip showed mild effusion in the right hip and collections in the psoas; MRI confirmed the findings with an enhancement of L4 vertebral body. CONCLUSION: Pyogenic vertebral body osteomyelitis is a rare diagnosis in children that should be considered in patients with atypical symptoms. MRI is the investigation of choice with prompt antibiotic therapy instituted on time which leads to healing without any sequelae.

Pig Bite Injury Mimicking as Battered Baby Syndrome Leading to Bilateral Foot Amputation in a Toddler: A Diagnostic Dilemma and a Rare Case Report.

INTRODUCTION: Animal bites are a less common cause of pediatric injury. They are rarely associated with fractures in toddlers. Child abuse is the most closely related differential diagnosis in a child presenting with animal bite and it is a serious threat to both mental health and physical well-being of pediatric population. In all such cases with diagnostic dilemma, battered child syndrome (BCS) needs to be ruled out and reported. To the best of our knowledge, there has been no case report of bilateral femur fracture after a pig bite injury in a toddler with gangrene of bilateral foot. Hence, we report this case to highlight the importance of differentiating animal bite injuries to BCS. CASE REPORT: We report a rare case of pig bite injury with bilateral femur fracture and bilateral foot gangrene in a case of an 11-month-old female child suffering from BCS. CONCLUSION: Apart from the medical and surgical management of pediatric injuries, it is essential to determine the cause of pediatric fractures and differentiate between abuse and accidental trauma. Identification of the etiology is significant to make sure that proper multidisciplinary intervention is initiated for the safety of the child.