HRCT chest in COVID-19 patients: An initial experience from a private imaging center in western India.

The COVID-19 pandemic began in late December in 2019 and has now reached to 216 countries with 1,08,42,028 confirmed cases and 5,21,277 deaths according to the WHO reports and 6,49,666 confirmed cases in india alone with 18,679 deaths (as on 04th july 2020). RT-PCR has been considered the standard test for diagnosis of COVID 19. However, there has been reported a high false negative rate. This high false negative rate increases the risk of further transmission as well as delays the timely management of suspected cases. We have conducted HRCT chest of various (200 patient case study) proven and suspected cases of COVID-19 infection in the months of April, May and June 2020. Out of 200 scanned patients with clinical complains and suspicion, positive HRCT chest findings were seen in 196 patients, showing clinical-radiological correlation and an accuracy of 98%. The sensitivity of chest CT in suggesting COVID-19 was 98.6% (146/148patients) based on positive RT-PCR results. In patients with negative RT-PCR results and high clinical suspicion, 90% (18/20) had positive chest CT findings. HRCT chest is very sensitive and accurate in picking up lung parenchymal abnormalities in laboratory negative RT-PCR cases with high clinical suspicion of COVID-19 infection and also in all symptomatic patients where RT-PCR was not done. HRCT can also be very sensitive, cost effective and time effective in screening patients with high clinical suspicion. HRCT scores over RT-PCR in giving immediate results, assessing severity of disease and prediction of prognosis. We suggest HRCT chest for detection of early parenchymal abnormalities, assessing severity of disease in all patients with clinical symptoms and suspicion of COVID infection irrespective of laboratory RT-PCR status.

Multilevel en bloc spondylectomy for tumors of the thoracic and lumbar spine is challenging but rewarding.

BACKGROUND: Over the years, en bloc spondylectomy has proven its efficacy in controlling spinal tumors and improving survival rates. However, there are few reports of large series that critically evaluate the results of multilevel en bloc spondylectomies for spinal neoplasms. QUESTIONS/PURPOSES: Using data from a large spine tumor center, we answered the following questions: (1) Does multilevel total en bloc spondylectomy result in acceptable function, survival rates, and local control in spinal neoplasms? (2) Is reconstruction after this procedure feasible? (3) What complications are associated with this procedure? (4) is it possible to achieve adequate surgical margins with this procedure? METHODS: We retrospectively investigated 38 patients undergoing multilevel total en bloc spondylectomy by a single surgeon (AL) from 1994 to 2011. Indications for this procedure were primary spinal sarcomas, solitary metastases, and aggressive primary benign tumors involving multiple segments of the thoracic or lumbar spine. Patients had to be medically fit and have no visceral metastases. Analysis was by chart and radiographic review. Margin quality was classified into intralesional, marginal, and wide. Radiographs, MR images, and CT scans were studied for local recurrence. Graft healing and instrumentation failures at subsequent followup were assessed. Complications were divided into major or minor and further classified as intraoperative and early and late postoperative. We evaluated the oncologic status using cumulative disease-specific and metastases-free survival analysis. Minimum followup was 24 months (mean, 39 months; range, 24-124 months). RESULTS: Of the 38 patients, 34 (89%) were alive and walking without support at final followup. Thirty-one (81%) had no evidence of disease. Two patients died postoperatively and another two died of systemic disease (without local recurrence). Only three patients (8%) had a local recurrence. There were 14 major complications and 22 minor complications in 25 patients (65%). Only one patient required revision of implants secondary to mechanical failure. Two cases of cage subsidence were noted but had no clinical significance. Wide margins were achieved in nine patients (23%), marginal in 25 (66%), and intralesional in four (11%). CONCLUSIONS: In patients with multisegmental spinal tumors, oncologic resections were achieved by multilevel en bloc spondylectomy and led to an acceptable survival rate with reasonable local control. Multilevel en bloc surgery was associated with a high complication rate; however, most patients recovered from their complications. Although the surgical procedure is challenging, our encouraging mid-term results clearly favor and validate this technique. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Four- and five- level en bloc spondylectomy for malignant spinal tumors.

STUDY DESIGN: Retrospective study. OBJECTIVE: To report results of 4- and 5-level en bloc spondylectomy (EBS) in the treatment of malignant spinal tumors. SUMMARY OF BACKGROUND DATA: EBS is widely used to avoid local recurrence in the treatment of spinal malignant tumors. Four- and 5-level EBS are aggressive procedures associated with complications and morbidity. METHODS: We conducted a retrospective study of all patients treated with minimum 4-level EBS. Patient and surgical data were noted. Radiographs, magnetic resonance images, and computed tomographic scans were studied for local recurrence, graft, and instrumentation failures at subsequent follow-up. Type of excision was classified into intralesional, marginal, and wide margins. Complications were divided into major or minor and were further classified as intraoperative, early, and late postoperative. At the last follow-up, the patients were classified as alive with no evidence of local or systemic disease, alive with evidence of local or systemic disease or both, dead with evidence of local disease, or systemic disease or both, and dead without evidence of local and systemic disease. RESULTS: Nine patients were identified who required a minimum 4-level en bloc resection. Five males and 4 females. Average age was 41.66 years (11-66). There were 8 primary malignant tumors: 3 chordomas, 3 osteosarcomas, 1 chondrosarcoma, 1 primary lung tumor and 1 metastatic alveolar soft part sarcoma. Six were operated with 4-level en bloc and 3 with 5 levels. The mean surgical time was 713 minutes and estimated blood loss was 4.5 L. Mean follow-up was 27.7 months (8-84). At the last follow-up, 6 patients were alive with no evidence of local or systemic disease, 1 alive with evidence of systemic disease, 1 dead with evidence of local disease, or systemic disease or both, and 1 DNLS. Only 1 (11%) patient had a local recurrence. Three patients with Frankel D had full neurological recovery. Histopathological assessment showed marginal margins in 7 patients and wide in 2. There were 9 major and 9 minor complications in 7 patients. Five of 7 patients (71%) with complications, had fully recovered from their complications at the last follow-up. CONCLUSION: Multilevel EBS, can be offered to a patient to prevent local recurrence of disease. Even in experienced hands, the risks of intra- and postoperative complications are high (78%). However, most of the patients with complications, recovered completely (71%). Although the surgery itself may prove beneficial, patients should be well informed regarding the morbidity associated with it. LEVEL OF EVIDENCE: 4.

Epidural and intradural cement leakage following percutaneous vertebroplasty: a case report.

A 48-year-old woman presented with severe bilateral leg pain, urinary incontinence, and paraparesis following vertebroplasty in another hospital 15 days earlier. Computed tomography and magnetic resonance imaging showed blocks of epidural and intradural cement from T12 to L1 with neurological compression. She underwent corpectomy of L1 and removal of extradural cement, followed by anterior reconstruction with an expandable cage and dual rodscrew construct (Kaneda system). Postoperatively, the patient had minimal improvement in leg pain and neurological deficit. Computed tomographic myelography was therefore performed and revealed complete blockage, which is suspected to be due to intradural cement leakage. The patient underwent posterior durotomy and removal of the cement. Postoperatively, the patient reported immediate pain relief. Her neurological status gradually improved over months. At the 2-year follow-up, the patient was able to walk with support and to perform activities of daily living and had regained her urinary function.

Cervical epidural haematoma causing Brown-Sequard syndrome: a case report.

Brown-Sequard syndrome secondary to compression of the spinal cord by an epidural haematoma following minor trauma is rare. A 65-year-old woman presented with neck pain and sudden onset hemiplegia with contralateral anaesthesia. Magnetic resonance imaging showed a haematoma in the epidural space in the C3 to C5 levels. She underwent open-door laminoplasty for evacuation of the haematoma. At the 2-year follow-up, she had regained normal sensations and a neurological grade of 5/5.

Intraoperative skull-femoral (skeletal) traction in surgical correction of severe scoliosis (>80°) in adult neglected scoliosis.

STUDY DESIGN: Retrospective review. OBJECTIVE: To evaluate the effectiveness, safety, and reliability of intraoperative skeletal traction in the surgical correction of severe adult neglected scoliosis. SUMMARY OF BACKGROUND DATA: Literature shows that curves more than 80° that do not reduce to 50° to 55° on bending radiographs require an anterior release. A combined anterior and posterior approach is often used for treating severe rigid scoliosis. However, anterior approach has its own complications in the form of increased morbidity, increased blood loss, operative time, and pulmonary complications. Corrective surgery gets even more challenging if the patients are adults. METHODS: Ten patients with severe scoliosis (>80°) and low flexibility index (<0.5) treated with intraoperative skeletal traction were part of this study. The patients were operated between April 2008 and May 2010. Eight patients with neglected adolescent idiopathic scoliosis and 2 with neuromuscular scoliosis were included. The mean age was 27.4 years (19-36). Corrective surgery and fusion was performed using intraoperative skeletal traction. RESULTS: The Cobb angle improved from a mean of 89.35° preoperatively to 40.25° postoperatively giving a mean correction of 55.29%. Apical vertebral rotation (Nash and Moe) improved from a mean of grade 3(2-4) to a mean of grade 2(1-3). Apical vertebral translation improved from a mean of 2.19 cm preoperatively to 0.98 cm postoperatively (55.41% correction). There were no intraoperative adverse events or postoperative complications. All patients had good shoulder balance and were satisfied with the correction achieved. CONCLUSION: Intraoperative skull-femoral traction can be a safe and effective method to assist correction of severe and rigid scoliosis. It facilitates surgical exposure and pedicle screw insertion. It obviates the need of an anterior release surgery and associated morbidity, thus reducing the hospital stay and costs. It provides a much simpler way to correct the sagittal and coronal imbalance, as well as the pelvic obliquity.

S1 tuberculosis treated with segmental lumbopelvic fixation: a case report.

STUDY DESIGN: A case report. OBJECTIVE: To describe an effective surgical option for sacral tuberculosis (TB). SUMMARY OF BACKGROUND DATA: Sacral TB is a rare cause of low back pain. A differential diagnosis of TB should always be made, especially in India where TB cases are on a rampant rise with increasing drug resistance and immunosuppressed population. METHODS: A retrospective review. RESULTS.: We report on a 24-year-old woman with low back pain and radiculopathy. Magnetic Resonance Imaging (MRI) showed a destructive lesion in S1 body. Empirical antitubercular treatment was started elsewhere with no relief but worsening of the lesion. She underwent a Computed Tomography (CT)-guided biopsy and drug sensitivity test, which did not reveal anything. The patient was bedridden for almost a year. A lumbopelvic instrumented fixation and S1 body reconstruction with structural allograft was performed. Culture sensitivity revealed multidrug resistance. After surgery, the patient responded rapidly, and at 2-year follow-up, she is symptom-free. CONCLUSION: TB should always be considered as a differential diagnosis of sacral lesions, and identifying multidrug resistance is equally important in its treatment. Lumbopelvic fixation is a safe and reliable option as it unloads the S1 segment by achieving fixation in the lumbosacral spine and iliac wings.

Adjuvant combined ozone therapy for extensive wound over tibia.

Disinfectant and antibacterial properties of ozone are utilized in the treatment of nonhealing or ischemic wounds. We present here a case of 59 years old woman with compartment syndrome following surgical treatment of stress fracture of proximal tibia with extensively infected wound and exposed tibia to about 4/5 of its extent. The knee joint was also infected with active pus draining from a medial wound. At presentation the patient had already taken treatment for 15 days in the form of repeated wound debridements and parenteral antibiotics, which failed to heal the wound and she was advised amputation. Topical ozone therapy twice daily and ozone autohemotherapy once daily were given to the patient along with daily dressings and parenteral antibiotics. Within 5 days, the wound was healthy enough for spilt thickness skin graft to provide biological dressing to the exposed tibia bone. Topical ozone therapy was continued for further 5 days till the knee wound healed. On the 15(th) day, implant removal, intramedullary nailing, and latissimus dorsi pedicle flap were performed. Both the bone and the soft tissue healed without further complications and at 20 months follow-up, the patient was walking independently with minimal disability.