Anthropometric evaluation for surgical feasibility of C1-C2 transarticular screw stabilization in Indian population.

STUDY DESIGN: This study was a radiographic observational study for C1-C2 anthropometry. PURPOSE: The purpose of the study was to understand the anatomic relationship of C1-C2 in view of transarticular screw (TAS) fixation, to overcome the difficulties related with TAS placement, and to minimize the technique-related complications. MATERIALS AND METHODS: It was an anthropometric observational study with retrospectively obtained anatomical data of randomly selected 116 patients from a single center. The anatomical measurements such as pars width, pars height, screw trajectory, and length were evaluated on the axial, sagittal, and three-dimensional reconstructed cervical CT scan using the radiant DICOM viewer software by the two fellowship trained spine surgeons which were blind to the study group details. The intra- and interobserver reliability with regard to the measured parameters was statistically analyzed. RESULTS: The mean age of male and female was 28 and 29 years. The average BMI was calculated to be 23.5 and 25 for males and females, respectively. The mean right pars width in males was 5.78 ± 0.93 (range: 3.1-6.5 mm), while in female, it was 5.84 ± 0.95 (range: 3.1-6.5). The mean left pars width in males was 5.95 ± 1.13 (range: 3.8-8.1 mm), while in females, it was 5.70 ± 1.18 (range: 3.7-8.1 mm). Right side mean pars height in males was 5.90 ± 1.2 (range: 3.7-9.4 mm), and in females, it was 6.11 ± 1.04 (range: 3.8-9.3 mm). Left-sided mean pars height in males was 6.0 ± 1.1 (range: 3.2-9.4 mm) as compared to females, in which it was 5.77 ± 1.23 (range: 4.1-9.3 mm). The mean lateral angulation angle in males was 9.99° ± 1.70° (8.1°-15°), while in females, it was 10.15° ± 1.73° (8.1°-15°). The mean sagittal angulation in males was 26.33° ± 3.32° (21.0°-32.80°), while in females, it was 27.18 ± 3.05 (21.0°-32.10°). The average screw length in males was 41.74 ± 5.63 (34-54.8 mm), whereas in females, it was 41.35 ± 4.77 (34-54.8 mm). CONCLUSION: This study provides a morphometric database which is characteristic of the C1-C2 vertebrae in the normal Indian population with regard to the anatomic feasibility of the TAS fixation for various C1-C2 pathologies. The C2 pars width and height measured in the current study can guide the selection of TAS screws in the Indian population. This study could serve in providing the baseline anatomic parameters assessed in the healthy individuals to design and develop customized screws and related implant assembly which might provide wider clinical applicability.

Surgical outcomes of single stage surgery for Tandem spinal stenosis (TSS) in elderly and younger patients: A comparative study.

STUDY DESIGN: Retrospective study. OBJECTIVE: To evaluate and compare the outcomes of single stage surgery for Tandem Spinal Stenosis (TSS) in elderly (Age ≥65 years) and younger patients (Age <65 years). SUMMARY OF BACKGROUND DATA: Tandem spinal stenosis among elderly is common and often missed diagnosed with delayed presentation. Literature evaluating efficacy and safety of single staged surgery for TSS in elderly patients is scanty. METHODS: Analysis of 74 patients with TSS managed with single stage posterior surgery from 2007 to 2016 was done. A total of 62 patients who satisfied our inclusion criteria were evaluated and subdivided into two groups based on age; Study group (age ≥65years)] (n = 32) and control group (age <65years) (n = 30). Perioperative, clinical/radiological parameters and postoperative complications and recovery rate were noted. RESULTS: The Mean ODI and mJOA showed significant improvement post-operatively in both groups however there was no significant difference between the two groups at final follow-up. There was no statistical difference in operative time, blood loss and hospital stay between the groups. As per Odom's criteria, 78.1% had excellent to good results in study group, while 83.3% had excellent to good results in control group. Postoperative complications were more in elderly group however, there was no significant difference among neurological or cardiopulmonary complications between both groups. CONCLUSIONS: Single stage surgery is safe & efficacious modality with less morbidity and optimal results in elderly patients with proper preoperative risk assessment. Our study showed that increased age does not proved to be deterrent in the outcome of single staged surgery in tandem spinal stenosis.

Surgical outcomes of posterior trans-facetal decompression and stabilisation in tuberculous spondylodiscitis with neuro-deficit.

STUDY DESIGN: Retrospective study. PURPOSE: To evaluate the functional, neurological and radiological outcomes of posterior trans-facetal decompression and stabilisation in tuberculous spondylodiscitis patients with neuro-deficit. OVERVIEW OF LITERATURE: Spinal tuberculosis mainly involves anterior column and for that anterior approach has been the most frequently used surgical technique in the past as it allows direct access to the infected tissue providing a good decompression. However, anterior surgery is associated with higher morbidity which can be reduced by posterior trans-facetal approach. MATERIALS AND METHODS: The study included 100 Tuberculous Spondylodiscitis patients with neuro-deficit who underwent posterior trans-facetal decompression and stabilisation from 2009 to 2014. Demographic data, clinical parameters (back pain score-VAS, ODI), neurological status (Frankel's grade), radiological parameters (Kyphosis angle) and complications were evaluated. RESULTS: Out of the total 100 patients there were 58 males and 42 females. 84 patients had thoracic and 16 had thoracolumbar region involvement. The mean age of the patients was 34.7 years. The extent of fixation was 2 segments in 52 patients and >2 segments in 48 patients. Postoperatively significant improvement in VAS (pre-op 6.5 ± 0.65 to post-op 1.73 ± 0.64) and ODI (pre-op 76.54 ± 6.96 to post-op 30.5 ± 6.56) were noted. The mean kyphosis angle was corrected from 22.33° ± 5.59° to 5.14° ± 1.32°. 86 patients showed at least 1 grade of improvement in neurology (Frankel's grading) and there was no deterioration in any patient. 3 patients developed superficial infection and 2 had an intra-operative dural tear. 94 patients showed bony fusion at 2 years follow-up. CONCLUSION: Posterior trans-facetal decompression and stabilisation is an effective procedure in the management of thoracic & thoracolumbar tuberculous spondylodiscitis patients with neuro-deficit. It offers circumferential decompression with stabilisation and also maintains kyphosis correction.

Is Older Age a Contraindication for Single-Level Transforaminal Lumbar Interbody Fusion?

STUDY DESIGN: Retrospective cohort. PURPOSE: This study's primary objective was to compare the clinico-radiological outcomes and incidence of perioperative complications of transforaminal lumbar interbody fusion (TLIF) at lower lumbar levels for elderly and younger patients. The secondary objective was to evaluate the effect of age on clinical outcomes and patient satisfaction in the two groups. OVERVIEW OF LITERATURE: The lumbar interbody fusion surgery in elder age has been reported to produce a higher complication rate and suboptimal results. Literature evaluating efficacy and safety of TLIF in elderly population is scanty. The effect of age on clinical outcome and the overall patient satisfaction after TLIF has been understudied. METHODS: This retrospective study was conducted from 2011 to 2017 with 121 patients, who underwent TLIF and were divided into two cohorts based on age (group A, >65 years and group B, <65 years). Perioperative clinical/radiological parameters, postoperative complications, and satisfactory outcomes were evaluated in both groups. A statistical analysis between two matched groups was performed with logistic regression analysis and Student t-test. RESULTS: The mean age was 73.8±4.5 years in group A and 47.3±12.7 years in group B. There was no statistical difference in surgical time (p=0.15), mobilization, or hospital stay (p=0.15) between the two groups. There were no statistically significant differences noted in the Oswestry Disability Index, Visual Analog Scale, or Wang's outcome score between the two groups at final follow-up. Postoperative complications not affecting outcome were common in the elderly group, but there was no statistically significant difference noted among neurological or cardiopulmonary events between the two groups. CONCLUSIONS: In judiciously selected patients with proper preoperative risk assessment and optimized medical co-morbidities, TLIF surgery can have successful results, in terms of clinical outcome and satisfaction, in the elderly. Older age should not be a contraindication for TLIF in patients with degenerative lumbar disease.

Superior Facet Joint Violations in Single Level Minimally Invasive and Open Transforaminal Lumbar Interbody Fusion: A Comparative Study.

STUDY DESIGN: Prospective comparative study. PURPOSE: To compare the incidence of iatrogenic superior facet joint violation (SFV) in minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and open TLIF (OPEN-TLIF) at a single lower lumbar fusion level and to evaluate the patient and surgical factors influencing the outcome. OVERVIEW OF LITERATURE: Iatrogenic SFV is a significant risk factor for adjacent segment disease (ASD). Blind screw placement technique in MIS-TLIF contributes to the increasing incidence of iatrogenic SFV which can be influenced by several other potential factors. There are only limited studies comparing the incidence of iatrogenic SFV in MIS-TLIF and OPEN-TLIF. METHODS: In total, 225 cases (450 top screws; MIS-TIFL, 120; OPEN-TILF, 105) undergoing single-level lower lumbar fusion were included in the study. Postoperative computed tomography grading system was used to evaluate iatrogenic SFV. Patient and surgical factors such as age, body mass index, top-screw level, side of the top screw, depth of the spine, and superior facet joint angle (SFA) were analyzed in iatrogenic SFV and non-violation groups to determine their influence on iatrogenic SFV. The clinical outcomes in both groups were assessed preoperatively and postoperatively. RESULTS: The overall incidence of iatrogenic SFV and high-grade violations was higher in MIS-TLIF (41.25%) than in OPEN-TLIF (30.4%). In both groups, bivariate analysis showed a significantly greater incidence of the iatrogenic SFV in patients aged <60 years and those with obesity, top pedicle screws at L4, right-sided top screws, SFA >35°, and depth of the spine >50 mm. CONCLUSIONS: This study demonstrated that the incidence of iatrogenic SFV is greater in MIS-TLIF than in OPEN-TLIF at a single lower lumbar level. MIS-TLIF is effective for lumbar degenerative disease; however, the incidence of iatrogenic SFV was higher. Patient and surgical factors must be considered to protect the facet joints in both TLIF methods to avoid ASD.

Unstable Hangman's fracture: Anterior or posterior surgery?

CONTEXT: Literature evaluating the efficacy and long-term clinico-radiological outcomes of anterior cervical discectomy and fusion (ACDF) and posterior fixation at C2-C3 for the treatment of unstable hangman's fractures is scanty. AIMS: The aim of this study is to compare the efficacy, clinical-radiological outcomes, and complications of ACDF and posterior fixation techniques performed for unstable hangman's fractures. SETTINGS AND DESIGN: The study design involves retrospective comparative study. SUBJECTS AND METHODS: This study conducted from 2012 to 2018 included 21 patients with unstable hangman's fracture (Levine and Edwards Type II, IIa and III). All patients were divided into two groups based on the approach taken for fracture fixation (Group A-anterior approach and Group B-posterior approach). Peri-operative clinical, radiological parameters, postoperative complications, and outcomes were evaluated and compared in both the groups. STATISTICAL ANALYSIS USED: Chi-square test and Student's t-test were used. RESULTS: The mean age was 39.8 ± 4.5 years in-group A and 41.3 ± 6.7 years in-group B. The male patients outnumbered the female patients and road traffic accident was the most common cause of unstable fractures. There were statistical significant differences in surgical time (P = 0.15), operative blood loss, pain-free status postsurgery, and hospital stay (P = 0.15) between two groups. No statistically significant differences noted in clinic-radiological outcomes in the form of visual analog scale and fusion rate at final follow-up between two groups at final follow-up. CONCLUSIONS: The unstable hangman's fractures can be effectively managed with both anterior and posterior approaches with comparable clinico-radiological outcome. A minimally invasive nature, earlier pain-free status, early mobilization with reduced hospitalization make the ACDF efficacious, particularly in cases with no medullary canal in C2 pedicles and traumatic C2-3 disc herniation with listhesis compressing the spinal cord.