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Coverpage
Sep-Oct 2022
Volume 70 | Issue 8 (Supplement)
Page Nos. 103-342

Online since Friday, November 11, 2022

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NI FEATURE: THE FIRST IMPRESSION  

Spine Surgery with Robotic Assistance Highly accessed article p. 103
Sandeep Kandregula, Bharat Guthikonda
DOI:10.4103/0028-3886.360944  
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EDITORIAL Top

The Future of Minimally Invasive Spine Surgery Highly accessed article p. 104
Dong Hwa Heo, Yoon Ha, Seung Yi, Hungtae Chung
DOI:10.4103/0028-3886.360930  
Minimally invasive spine surgery (MISS) is an important option for spinal operations, with advantages including rapid recovery and preservation of normal structures. As the number of geriatric patients is increasing, the role of MISS might expand in the future. MISS techniques and approaches continue to be developed, and recent trends in MISS development include the refinement of surgical approaches and techniques, as well as systems related to newly developed techniques, rather than spinal implants. Among the various techniques for MISS, endoscopic spine surgery, including uniportal and biportal endoscopic approaches, is the focus of vigorous research efforts that may lead to further expansion of the indications of endoscopic spine surgery. Endoscopic spine surgery will be an important part of spine surgery. Lateral lumbar interbody fusion and endoscopic lumbar interbody fusion may play meaningful roles in the MISS fusion area. Robotics and augmented reality are also likely to be important technological modalities in spine surgery in the future.
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SYMPOSIUM - OPERATIVE NUANCES - STEP BAY STEP (VIDEO SECTION) Top

Robotic-Assisted Navigation Guided Kyphotic Deformity Correction Surgery p. 108
Harvinder S Chhabra, Jitesh Manghwani
DOI:10.4103/0028-3886.360927  
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ORIGINAL ARTICLES Top

Laminectomy with Rib Shears: A Technical Note p. 113
Survendra Kumar R Rai, Saswat K Dandapat, Dikpal Jadhav, Neha Jadhav, Abhidha Shah, Ranjit D Rangnekar
DOI:10.4103/0028-3886.360943  
Introduction: Laminectomy/laminoplasty either free or vascularized pedicle flap is currently performed with a variety of expensive instruments. Use of Tudor Edwards rib shears to perform above procedure is described. Materials and Methods: Tudor Edwards rib shear was used to cut lamina in 18 cases for a variety of spinal lesions. Depending upon the size of lesion, laminectomy/laminoplasty was required for 2 to 8 levels. Vascularized pedicle laminoplasty or free flap laminoplasty was done with Tudor Edwards rib shears. Ligamentum flavum and interspinous and supraspinous ligaments were preserved in cases of vascularized pedicled laminoplasty, which was carried out in 12 cases. Free flap laminoplasty was carried out in 6 cases. Results: In all our cases, laminectomy was successfully achieved with rib shears without any injury to the dura or its underlying structures. It was possible to perform vascularized pedicle laminoplasty or free flap laminoplasty in all cases. Laminectomy was easier to perform in the cervical region and dorsal region, while it was difficult in the lumbar region due to the wider, thick lamina and its angulation, especially in adults. Conclusion: Laminectomy/laminoplasty with Tudor Edwards rib shears is quick, safe, and easy. Beveled cut edges with minimal bony loss prevents sinking of laminoplasty, thereby facilitates lamina fixation. This is an alternative method of performing laminectomy/laminoplasty, especially for those not having accessibility to expensive equipment.
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A New Surface Technique for Phrenic Nerve Conduction Study p. 117
Sunil Pradhan, Sucharita Anand
DOI:10.4103/0028-3886.360904  
Objective: To report a new patient friendly and convenient technique for phrenic nerve conduction with alternative sites of stimulation and recording. Methods: Phrenic nerve conduction was performed in forty volunteers and ten patients of peripheral neuropathy. Active recording electrode was placed in tenth intercostal space 2.5 cm away from para-spinal muscles (mid-scapular line), reference electrode in eighth intercostal space just medial to subcostal margin with ground between stimulating and recording electrode. Stimulation was done at the level of crico-thyroid space near or under the posterior margin of sternocleidomastoid muscle. This new method was compared with existing ones. Analysis: Data was analysed using SPSS 23 version. Correlation between height, weight, body mass index, age, and chest expansion was done using bi-variate correlation. Mean latency and amplitude of the study method were compared with other methods using MANNOVA test. Results: Total of forty subjects were studied. Thirty-seven were male subjects. Mean age was 28.03 ± 9.63 years, height 168.0 ± 9.60 cm and chest expansion 3.53 ± 0.64 cm. Right sided phrenic nerve mean latency was 5.99 ± 0.629 ms and amplitude 1.088 ± 0.178 mV. Left sided phrenic nerve conductions showed mean latency of 6.02 ± 1.82 ms, amplitude of 1.092 ± 0.2912 mV. These standard deviations were smaller than what were observed with other methods suggesting increased consistency of our results. There was no correlation between phrenic nerve conduction with age, height, gender or chest expansion. Conclusion: This study method gave a better as well as consistent morphology, higher amplitude and required lower amount of current strength. It was superior to previously reported methods in consistency of normative data.
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Double Anchoring Technique of Occipito-Cervical Fixation Using Innovative Occipital Plate: A Preliminary Study p. 123
Deepak K Singh, Vipul V Pathak, Neha Singh, Mohammad Kaif, Kuldeep Yadav, Rakesh Kumar
DOI:10.4103/0028-3886.360909  
Background: Occipito-cervical fixation (OCF) provides immediate rigid fixation to cranio-vertebral junction (CVJ); however, in current practice, the optimal occipito-cervical fixation method is arguable. Aim: The aim of this study was to test the safety and efficacy of a newly designed inside-outside occipital (OC) plate system for the treatment of cranio-vertebral junction instability. Material and Methods: Thirty-two patients of CVJ instability were treated using this new OC plate system. Safety and efficacy of this new OC plate was evaluated radiologically and clinically. Results: Follow-up period ranged from 9 to 23 months. During the follow-up, no implant failure, recurrent subluxation, or newly developed instability at adjacent levels occurred, except in one patient in whom C2 screw pullout occurred due to trauma. All patients showed a satisfactory fusion at three months follow-up examination. Conclusions: These preliminary results suggest that this OC plate system is a simple, safe, and effective method for providing immediate internal rigid fixation of the CV junction. Long-term results are needed to determine the superiority of this OC plate over other methods of occipital fixation.
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Single-Stage Posterior Only Approach for Unilateral Atlantoaxial Spondyloptosis with type-II odontoid Fracture in Pediatric Patients p. 129
Gaurav Varshney, Amandeep Kumar, Ramesh S Doddamani, Rajesh Meena, Dattaraj P Sawarkar, Satish Verma, Pankaj Kumar Singh, Deepak Gupta, Gurudutta Satyarthee, P Sarat Chandra, Shashank Sharad Kale
DOI:10.4103/0028-3886.360918  
Objective: When there is a complete slippage of facet joints of C1 over C2 such that there is no contact between the articulating surfaces of C1 and C2, the condition is known as atlantoaxial spondyloptosis (AAS). AAS represents an extremely rare manifestation of atlantoaxial instability. This study was performed to highlight the presentation, radiological features, and management of unilateral AAS in pediatric patients. Material and Methods: We retrospectively identified four pediatric patients with AAS from our hospital records in the last 6 years (2014–2019). Results: Among the four patients with unilateral AAS, three were posttraumic and one was diagnosed with craniovertebral junction tuberculosis (CVJ TB). All the patients had a varying degree of spastic quadriparesis on presentation. One patient with CVJ TB presented with neck tilt. All patients with traumatic unilateral AAS were associated with an odontoid fracture. These patients underwent C1-C2 fixation with complete reduction of spondyloptosis using the techniques of joint manipulation and joint remodeling with a posterior only approach. Complete reduction of AAS in patients with trauma was also associated with the realignment of the odontoid fracture. All patients improved neurologically after surgery and achieved excellent correction of the deformity on a follow-up imaging. Conclusion: Pediatric unilateral AAS is an extremely rare phenomenon. A single-stage posterior approach with C1-C2 fixation is a feasible technique for the treatment of this seemingly difficult to correct deformity in pediatric patients and the clinical outcomes are excellent.
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O-Arm Assisted Anterior Odontoid Screw Fixation in Type II and Rostral Type III Odontoid Fractures: Single Center Surgical Series of 50 Patients p. 135
Dattaraj Paramanand Sawarkar, Pankaj Kumar Singh, Deepak Agrawal, Guru Dutta Satyarthee, Deepak Kumar Gupta, Vivek Tandon, Hitesh Kumar Gurjar, Sachin Borkar, Amandeep Jagdevan, Shashwat Mishra, Shweta Kedia, Rajeev Sharma, Ramesh Doddamani, Satish Verma, Rajesh Meena, Rajinder Kumar, P Sarat Chandra, Shashank S Kale
DOI:10.4103/0028-3886.360924  
Background: Accuracy of screw placement is one of the important factors necessary for adequate union in odontoid fractures with malposition rates as high as 27.2% with standard techniques. Objective: To evaluate efficacy of intraoperative O-arm assistance in improving accuracy of anterior odontoid screw placement and clinco-radiological outcome in type II and III odontoid fractures. Material and Methods: In this retrospective study, surgery consisted of anterior odontoid screw fixation under intraoperative O-arm assistance over 5 years. Demographical, clinical, radiological, operative details and postoperative events were retrieved from hospital database and evaluated for fusion and surgical outcome. Results: 50 patients (Mean age 34.6 years, SD 14.10, range: 7–70 years; 44 males and 6 females) with Type II and Type III odontoid fracture underwent O-arm assisted anterior screw placement. The mean interval between injury and surgery was 12 days (range 1–65 days). Mean operating time was 132.2 min ± SD 33.56 with average blood loss of 93 ml. ±SD 61.46. With our technique, accurate screw placement was achieved in 100% patients. At the mean follow-up of 26.4 month (SD13.75), overall acceptable fusion rate was 97.8% with non-union in 2.2% patients. Morbidity occurred in two patients; one patient developed fixation failure while other patient had nonunion which was managed with posterior C1-C2 arthrodesis. We had surgical mortality in one patient due to SAH. So overall our procedure was successful in 94% patients and among patients whose follow-up was available, acceptable fusion rates of 97.8% were achieved. Conclusion: We conclude that use of intraoperative three-dimensional imaging using O-arm for anterior odontoid screw fixation improves accuracy and leads to improved radiological and clinical outcomes. It further enables us to extend the indications of odontoid screw fixation to selected complex Type II and rostral Type III odontoid fractures.
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Vision Loss Following Vertebral Artery Injury during Surgery for Atlantoaxial Instability p. 144
Atul Goel, Sagar Bhambere, Abhidha Shah, Hardik Darji, Chandrima Biswas, Akshay Hawaldar
DOI:10.4103/0028-3886.360938  
Background: A number of complications following surgery aimed at atlantoaxial fixation have been reported. However, there is no report in the literature describing visual loss following vertebral artery injury. Objective: Vision loss as a complication of vertebral artery injury during surgery for atlantoaxial fixation is reported. Material and Methods: This is a report of two patients who were operated for atlantoaxial instability by the Goel technique of atlantoaxial fixation. During surgery, there was an injury to the vertebral artery and the artery had to be sacrificed. Results: Both patients suffered severe visual loss following surgery. One patient had a partial visual recovery that started within few days of surgery while the other patient remained completely blind. Conclusions: Although rare, visual loss can be a complication of vertebral artery sacrifice during surgery for atlantoaxial stabilization.
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Craniovertebral Junction Anomalies: An Overlooked Cause of 'Posterior Circulation Stroke' p. 149
Kanwaljeet Garg, Vivek Tandon, Rajinder Kumar, P Sarat Chandra, Shashank S Kale, Bhawani Shankar Sharma, Ashok K Mahapatra
DOI:10.4103/0028-3886.360916  
Background: Vertebral artery dissection (VAD) is a treatable cause of vertebrobasilar ischemic stroke and can be spontaneous or more commonly traumatic. Craniovertebral junction (CVJ) anomalies are a rare and often overlooked cause of VAD. Objective: The objective of this study was to study cases where CVJ anomaly presented as posterior circulation infarct and to conduct a relevant literature review. Materials and Methods: The medical records of seven patients who were managed for posterior circulation infarct associated with CVJ anomaly at our center from January 2009 through August 2013 were reviewed. PubMed and MEDLINE databases were also searched for similar cases, and the published case reports/series were reviewed. Results: Seven patients met our inclusion criteria and were included in the study. The mean age was 17.4 years (range: 10–35 years). All the patients were males. The most common symptoms were headache, vomiting, and gait ataxia. Slurring of speech was seen in one patient. One patient had repeated episodes of gait ataxia with left-sided weakness with complete recovery in between the episodes. One patient presented in unconscious state. Four patients complained of vertigo. The median duration of symptoms was 7 days (range: 3 days–12 months). Conclusions: CVJ anomalies can present as posterior circulation infarct. One must evaluate all patients with posterior circulation stroke, especially young patients, for possible CVJ anomalies. Dynamic lateral cervical spine X-ray is an important tool to diagnose AAD. CVJ anomalies represent a treatable cause of VAD.
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Evaluation of Dural Parameters at C1 Level in Patients with Chiari 1 Malformation Following Foramen Magnum and C1 Posterior Arch Removal: Introduction of a Novel Concept to Decompress without Affecting Stability p. 160
Mukesh Bisht, Amandeep Kumar, Pankaj K Singh, Ajay Garg, Dattaraj Sawarkar, Satish Verma, Ramesh Doddamani, Rajesh Meena, Joseph Devarajan Leve, Sarat P Chandra, Shashank Sharad Kale
DOI:10.4103/0028-3886.360922  
Background: Chiari 1 malformation has crowding at craniovertebral junction (CVJ), treated by Foramen magnum decompression (FMD) but is associated with high failure rates, which is explained by recently introduced concept of central instability. So, we propose a new concept of relieving this crowding without affecting stability. Objective: To derive a threshold for coring out of internal surface of C1 posterior arch instead of complete laminectomy accompanying FMD. Methods and Material: We prospectively included nine patients with a mean age of 25.33 ± 7.97 years, diagnosed with ACM-1 without AAD, who were operated with FMD and lax duraplasty and C1 laminectomy. The preoperative dural diameter and area covered under the dura at the level of C1 were measured and compared with the postoperative state. Results were analyzed to derive a cut-off threshold which could be drilled from the inner aspect of C1 arch. Results: The postoperative AP diameter of the dura increased statistically significantly from pre-op; however, the AP extension was less than the preoperative diameter with posterior arch included. Likewise, the area spanned by the dura increased statistically significantly from pre-op but was less than the cumulative area of dura with C1 arch included in pre-op. Analyzing all, a mean cut-off of 50.58% was achieved. Conclusion: The authors suggest FMD with partial coring (~50%) of the inner part of arch of C1, instead of full-thickness laminectomy with a wider length of coring as the target, and this will serve the purpose intended, without increasing mobility.
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AIIMS Cervical Myelopathy Score – A New Comprehensive and Objective Patient-Reported Modification of mJOA: Results of an Internal Validation Study p. 166
Kanwaljeet Garg, Vaibhav Vij, Shashwat Mishra, Deepti Vibha, Manmohan Singh, P Sarat Chandra, Shashank S Kale
DOI:10.4103/0028-3886.360920  
Background: Several scoring systems have been developed for assessment of patients with compressive cervical myelopathy. However, all of these have some shortcomings. We proposed a new modification of the modified Japanese Orthopedic Association (mJOA) score—the AIIMS cervical myelopathy score (ACMS). Objective: The aim of this study was to compare the ACMS with mJOA score and Nurick score. Methods: We prospectively studied patients with cervical compressive myelopathy. The new ACMS, mJOA, Nurick proposed by Benzel, and Nurick scores were recorded preoperatively and at three months postoperatively in patients. Results: Sixty-two patients completed the 3-month follow-up and were included in the final analysis. The mean preoperative and postoperative Nurick, mJOA, and ACMS scores were 3.3 and 3.0, 12.3 and 13.8, and 15.1 and 17.7, respectively. High correlation (Pearson's r > 0.8, 95% CI: 0.94 to 0.97, P < 0.005) was observed between ACMS and mJOA scores for all the individual components of both scales, both in pre- and postoperative assessments. A negative correlation was observed between the occupational ability scores ACMS and the Nurick scale (r = −0.76, 95% CI: −0.83 to − 0.68). No correlation was found with cord/canal ratio on magnetic resonance imaging (MRI) with any of the three scoring systems (preoperative, postoperative, or recovery rates). Conclusions: The ACMS score showed a good correlation with the mJOA score for evaluation of functional disability in the setting of cervical myelopathy. The patients could themselves report the scores using the ACMS scoring chart. The occupational component of the ACMS also correlated well with the Nurick score.
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Factors Predicting Poor Surgical Outcome in Patients with Thoracic Ossified Ligamentum Flavum – Analysis Of 106 Patients in a Tertiary Care Hospital in South India p. 175
Venkata Vemula Ramesh Chandra, Bodapati C M Prasad, Paradesi Rajesh, Sudharsan Agarwal, Mohana Murali Krishna
DOI:10.4103/0028-3886.360929  
Background: Ossified ligamentum flavum (OLF) is the major cause of thoracic myelopathy in our locality. Surgical outcomes and their related factors for patients with thoracic OLF (T-OLF) remain unclear because of the few studies on this condition. Objectives: The present study aimed to examine the factors predicting poor surgical outcomes and the effectiveness of decompressive laminectomy and OLF resection in patients with T-OLF. Material and Methods: A total of 106 patients with T-OLF operated at our institute from 2007 to 2018 were included. The mJOA score was used in neurological assessment preoperatively and during the follow-up. Multiple regression analysis was conducted to know the best correlation between factors and surgical outcomes. Results: The mean mJOA score was 5.67 ± 2.13 preoperatively and 7.50 ± 2.60 postoperatively at the end of follow-up. The recovery rate was 43.29 ± 30.55%. After decompressive laminectomy, the mean mJOA score, modified Nurick score, and Ashworth's grade showed significant improvement (P < 0.001). Multiple regression analysis showed that the age of the patient, associated trauma, OLF level, tuberous type OLF, intramedullary signal change on T2WI, preoperative severity of myelopathy, pre-op mJOA score, and pre-op Nurick grade were significantly correlated with the surgical outcome (P < 0.001). No correlation was identified with the duration of symptoms, dural ossification, dural tear, and CSF leak (P > 0.05). Conclusion: It is important to identify preventable risk factors for poor surgical outcomes for T-OLF. Age of the patient, associated trauma, OLF level, tuberous type OLF, intramedullary signal change on T2WI, preoperative severity of myelopathy, preoperative mJOA score, and Nurick grade were important predictors of surgical outcome in our study series.
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Management of Pediatric and Adolescent Traumatic Thoracolumbar Spondyloptosis p. 182
Mayank Garg, Amandeep Kumar, Dattaraj Paramanand Sawarkar, Mohit Agrawal, Pankaj Kumar Singh, Ramesh Doddamani, Deepak Agrawal, Deepak Gupta, Gurudutta Satyarthee, P Sarat Chandra, Shashank Sharad Kale
DOI:10.4103/0028-3886.360921  
Background: Complete subluxation of >100% of one vertebral body with respect to the adjacent vertebra is defined as spondyloptosis. It is the severest form of injury caused by high-energy trauma. Pediatric patients with a traumatic spine injury, particularly spondyloptosis are surgically demanding as reduction and achieving realignment of the spinal column requires diligent planning and execution. Objective: To enlighten readers about this rare but severest form of thoracolumbar spine injury and its management. Methods: Retrospective analysis of patients treated here with spondyloptosis between 2008 and 2016 was done. Results: Seven children, ranging from 9 to 18 years (mean years) age were included in the study. Five patients had spondyloptosis at thoracolumbar junction and one each in the lumbar and thoracic spine. All patients underwent single-stage posterior surgical reduction and fixation except one patient who refused surgery. Intraoperatively, cord transection was seen in five patients while dura was intact in one patient. The mean follow-up period was 17 months (1–36 months) during which one patient expired due to complications arising from bedsores. All patients remained American Spinal Injury Association (ASIA) A neurologically. Conclusions: Traumatic spondyloptosis is a challenging proposition to treat and the aim of surgery is to stabilize the spine. Rehabilitation remains the most crucial but the neglected part and dearth of proper rehabilitation centers inflict high mortality and morbidity in developing countries.
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Efficacy of Non-Fusion Surgeries in the Management of AO Type C Injuries of the Thoracic and Thoracolumbar Spine: A Retrospective Study p. 189
Chandhan Murugan, Ajoy P Shetty, Rohit Kavishwar, Vibhu Krishnan, Rishi M Kanna, Shanmuganathan Rajasekaran
DOI:10.4103/0028-3886.360910  
Background: The initial descriptions of successful management of non-fusion surgeries in the management of unstable burst injuries of the thoracic and thoracolumbar spine (TTLS) were published by Osti in 1987 and Sanderson in 1999. These were further supported by prospective studies and meta-analyses establishing comparable results between fusion and non-fusion surgeries. However, there is a paucity of literature regarding the efficacy of non-fusion surgeries in the management of AO type C injuries. Objective, Materials and Methods: The study aims to determine the efficacy of open posterior instrumented stabilization without fusion in AO type C injuries of the TTLS. Patients with AO type C injuries of the TTLS (T4-L2 levels) with normal neurology who underwent open, posterior, long segment instrumented stabilization without fusion between January 2015 and June 2018 were included. The regional kyphotic angle, local kyphotic angle, AP (anterior and posterior wall) ratio, and cumulative loss of disc space angle were assessed on radiographs. Functional outcome was assessed using Oswestry Disability Index (ODI) and the AO Spine patient-reported outcome spine trauma (PROST) instrument. Results and Conclusion: The study included 35 patients with AO type C injury of the TTLS and a normal neurology who underwent open posterior instrumented stabilization and had a mean follow-up of 43.2 months (range 24–60 months). The mean preoperative regional kyphotic angle decreased from 19.8 ± 13.7° to 6.6 ± 11.3° after surgery but showed an increase to 9.21 ± 10.5° at final follow-up (P = 0.003). The cumulative loss of disc space angle was significant at final follow-up (2.4 ± 5° [P = 0.002]). Twenty-eight out of 35 patients had minimal while seven had moderate disability on the ODI score. The AO Spine PROST revealed that patients regained 95.7 ± 4.2% of their pre-injury functional status at final follow-up. Posterior instrumented stabilization without fusion in the management of AO type C injuries of the TTLS gives satisfactory results with acceptable functional and radiological outcomes.
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iCT Navigation for Transpedicular Screw Fixation in the Thoracolumbar Spine: Experience in 100 Consecutive Cases p. 195
Michael Payer, Markus Wiesli, Christoph Woernle
DOI:10.4103/0028-3886.360699  
Background: Various guidance techniques have been developed for optimal pedicle screw placement. We present our initial experience with intraoperative CT (iCT) navigation for transpedicular screw fixation in the thoracolumbar spine. Objective: This study aimed to describe the accuracy and reliability of iCT navigation for transpedicular screw fixation. Material and Methods: One hundred consecutive patients underwent thoracolumbar pedicle screw fixation under iCT navigation. After iCT registration of the local bony anatomy with a firmly attached spinous process tracker, pedicle screw placement was performed under navigation with an infrared camera and infrared reflectors on insertion instruments. Screw trajectories of the intraoperative verification CT were matched against the navigation paths. Radiological and clinical follow-up was prospectively documented and retrospectively analyzed. The study included 47 women and 53 men with a mean age of 66 years. Indications for thoracolumbar pedicle fixation were degenerative instability with stenosis, cyst or disc herniation (82), spondylolytic instability (9), scoliosis with stenosis (6), and traumatic fractures (3). A total of 443 pedicle screws were inserted: 22 in the thoracic spine, 371 in the lumbar spine, and 50 in S1. Results and Conclusions: Four hundred thirty-five out of 443 screws (98%) were correctly placed. Misplacement was explained by loosened infrared reflectors on pedicle awl or probe, or by the displacement of the spinous process tracker; misplaced screws were re-inserted intraoperatively and showed correct placement on the second verification CT. Based on our first 100 cases, iCT navigation for transpedicular screw fixation in the thoracolumbar spine seems to be very accurate and reliable.
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A Comparative Study of Diagnosis and Treatment of Pott's Spine Amongst Specialists and Super Specialists in India p. 200
Siddharth Warrier, Sarvesh K Chaudhary, Jayantee Kalita, Abhilasha Tripathi, Usha K Misra
DOI:10.4103/0028-3886.360937  
Background and Objective: There is a paucity of guidelines about the diagnosis and management of Pott's spine. In this study, we report the pattern of practice of diagnosis and treatment of Pott's spine among the specialists and super-specialists in India. Subject and Methods: Response to a 22-item questionnaire regarding the diagnosis and treatment of Pott's spine has been reported. The responses were compared between medical and surgical specialists, residents and consultants, and specialists and super-specialists. There were 84 responders: 42 physicians and 42 surgeons; 48 residents and 36 faculty or consultants; 53 specialists and 31 super-specialists. Results: Thirty-eight responders rarely recommended biopsy whereas others recommended biopsy more frequently, especially the surgeons (P < 0.007). Twenty-five responders recommended immobilization even in an asymptomatic patient whereas 38 would immobilize those with neurological involvement only. All but 4 responders would repeat imaging at different time points. The response of medical treatment was judged at 1 month by 53, and 3 months by 26 responders. Surgery was recommended in a minority of patients—in those with neurological involvement or abscess. Surgeons more frequently biopsied, immobilized the patients, and recommended surgery compared to the physicians. The residents also recommended biopsy and recommended immobilization more frequently compared to consultants or faculty members. Super-specialists more frequently recommended biopsy compared to specialists. Conclusion: There is marked variation in investigations and treatment of Pott's spine patients, suggesting the need for consensus or evidence-based guidelines.
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Adult Intramedullary Pilocytic Astrocytomas: Clinical Features, Management, and Outcomes p. 206
Tao Yang, HaiBo Wu, ChengYu Xia
DOI:10.4103/0028-3886.360936  
Purpose: Adult intramedullary pilocytic astrocytomas (PAs) are exceedingly rare. The aim of this study was to summarize our experiences in treating adult intramedullary PAs. Materials and Methods: We retrospectively reviewed the records of seven adult patients who underwent microsurgery for intramedullary PAs between 2010 and 2017. Magnetic resonance imaging was the standard radiological investigation. The diagnosis of PAs was based on pathology. All the follow-up data were obtained during office visits. Results: There were three males and four females with the mean age of 40.9 years. The tumors generally exhibited hypointensity on T1-weighted images (WI) and hyperintensity on T2WI. Contrast-enhanced T1WI showed heterogeneous enhancement. Gross total resection (GTR) of the tumor was achieved in four cases and subtotal resection (STR) was achieved in three cases. Two cases of STR received postoperative radiotherapy. One STR case had mildly residual tumor regrowth. At the last follow-up, neurological status was improved in six patients. Conclusion: The accurate diagnosis of adult intramedullary PAs depends on pathology. GTR is the best treatment and the outcome is favorable. STR increases the risk of tumor recurrence, and regular follow-up is necessary. Due to uncertain therapeutic efficacy, radiotherapy should be considered carefully for cases of STR.
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Spinal Morphometry As A Novel Predictor For Recurrent Lumbar Disc Herniation Requiring Revision Surgery: Results of A Case Control Study p. 211
Sumit Thakar, Vivek Raj, Sankar Neelakantan, Pavan Vasoya, Saritha Aryan, Dilip Mohan, Alangar S Hegde
DOI:10.4103/0028-3886.360932  
Introduction: There is conflicting data on the risk factors for recurrent lumbar disc herniation (rLDH). Most of the predictors for rLDH identified so far are acquired risk factors or radiological factors at the level of the herniation. Whole lumbar spine (WLS) morphometry has not been evaluated as a possible predictor of rLDH. Objectives: We aimed to evaluate if preoperative spinal morphometry can predict the occurrence of rLDH requiring revision surgery. Methods: This retrospective case-control study on 250 patients included 45 patients operated for rLDH, 180 controls without rLDH who had previously undergone microdiscectomy for a single level lumbar disc prolapse, and a holdout validation set of 25 patients. Morphometric variables related to the WLS were recorded in addition to previously identified predictors of rLDH. Logistic regression (LR) analysis was performed to identify independent predictors of rLDH. Results: LR yielded four predictors of which two were WLS morphometric variables. While increasing age and smoking positively predicted rLDH, increasing WLS interfacet distance and WLS dural-sac circumference negatively predicted rLDH. The LR model was statistically significant, χ2 (4) =15.98, P = 0.003, and correctly classified 80.3% of cases. On validation, the model demonstrated a fair accuracy in predicting rLDH (accuracy: 0.80, AUC: 0.70). Conclusions: Larger mean lumbar bony canals and dural sacs protect from the occurrence of symptomatic rLDH. These WLS morphometric variables should be included in future risk stratification algorithms for lumbar disc disease. In addition to the previously recognized risk factors, our study points to an underlying developmental predisposition for rLDH.
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Correlation Between Obliquity of Exiting Nerve Root on Lateral Sagittal MRI Images and Degenerative Spondylolisthesis p. 218
Dattaprasanna B Katikar
DOI:10.4103/0028-3886.360925  
Background: MRI has become the investigation of choice for patients of low back pain with radiculopathy. However, MRI does not consistently detect spondylolisthesis. In far lateral sagittalT2 MRI images, exiting nerve roots are seen descending vertically. We observed that the obliquity of these descending nerve roots may be related to spondylolisthesis. Objective: Aim of this study is to evaluate the correlation between obliquity of exiting nerve root on MRI and lumbar instability on dynamic radiographs. Methods and Material: We retrospectively studied 248 patients who underwent discectomy or laminectomy and stabilization for degenerative lumbar disease at our institute from January 2017 to February 2020. For objectively measuring the obliquity of the exiting nerve root, we described an angle between the vertebra and exiting nerve root on far lateral T2 MRI images. We measured the exiting root angle and studied its correlation with degenerative spondylolisthesis on dynamic X-rays. Results: Out of 108 patients having spondylolisthesis, 106 (98.15%) had an angle of obliquity of the exiting nerve root as >105° and only two (1.85%) had an angleof <105°. Among 140 patients without spondylolisthesis, 137 (97. 86%) had an angle of obliquity of <105°and only three (2.14%) had an angle of >105°. Statistical parameters for our test of “angle of obliquity for the exiting nerve root in spondylolisthesis”are as follows: sensitivity of the test- 98.14%, specificity of the test- 97.85%. Conclusion: Obliquity of the exiting nerve root is a very easy to detect. It has avery high sensitivity and very high specificity for detecting spondylolisthesis on supine MRI.
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Lumbar Facet Effusions and Other Degeneration Parameters and Its Association with Instability p. 224
Damián Bendersky, Martín Asem, Oscar Navarrete
DOI:10.4103/0028-3886.360912  
Background: Controversy exists in the literature about whether facet effusions and other degeneration parameters are associated with instability. Objective: To assess the association between facet effusions and other lumbar degeneration parameters and segmental instability. Material and Methods: In this study, 207 L4–L5 and L5–S1 levels in 104 patients were assessed. We divided the spinal levels into two groups: the small facet effusions (SFE) group in whom facet effusions were <1.5 mm or non-effusions were found, and the large facet effusions (LFE) group in whom they were ≥1.5 mm. The association between other degeneration parameters and instability was also assessed, such as disc degeneration, Modic changes (MC), spondylolisthesis, facet orientation and tropism, facet subchondral sclerosis, and facet cartilage degeneration. Furthermore, we subdivided the levels into subgroups to evaluate the association of LFE and instability within each one. Results: The main analysis comparing the presence of instability in SFE and LFE groups showed a non-statistically significant association between LFE and instability. The presence of MC type 1 and the existence of L4–L5 spondylolisthesis had a statistically significant association with instability. In the subset of 43 levels with L4–L5 degenerative spondylolisthesis, the presence of LFE and the existence of MC type 1 reached a significant association with instability. Conclusion: The presence of LFE and/or MC type 1 may act as red flags in patients with L4–L5 degenerative spondylolisthesis to suspect segmental instability.
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Analysis of Nanohydroxyapatite/Polyamide-66 Cage, Titanium Mesh, and Iliac Crest in Spinal Reconstruction of the Patients with Thoracic and Lumbar Tuberculosis p. 230
Dian Zhong, Lu Lin, Yang Liu, Zhen-Yong Ke, Yang Wang
DOI:10.4103/0028-3886.360908  
Background: The standard recommended and common reconstruction method for spinal tuberculosis is titanium mesh bone graft and autogenous iliac crest. However, these methods have their own disadvantages. Objective: To evaluate the clinical efficacy of one-stage posterior debridement with iliac bone graft, titanium mesh bone graft, or nanohydroxyapatite/polyamide-66 cage in thoracic and lumbar tuberculosis. Materials and Methods: Between January 2013 and December 2018, 57 patients with thoracic or lumbar tuberculosis were treated by interbody bone graft combined with posterior internal fixation after debridement. Thirteen patients were treated with iliac bone graft to construct the stability of the vertebral body, 26 patients were treated with titanium mesh bone graft, and 18 patients were treated with nanohydroxyapatite/polyamide-66 cage bone graft. The main clinical results were evaluated by intervertebral height, cage subsidence, operation time, operative blood loss, postoperative hospitalization, postoperative complications, visual analog scale (VAS) score, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), American Spinal Injury Association (ASIA) grade, and bone graft fusion time. All the outcomes were recorded and analyzed by statistical methods. Results: The mean follow-up time was 24.5 months. Neurologic function was improved in most patients at the last follow-up. There were significant differences in ESR, CRP, and VAS score between preoperative and postoperative values; however, there were no significant differences in ESR, CRP, and VAS score among the three groups. There were no significant differences in operation time, blood loss, postoperative hospitalization, and postoperative complications among the three groups at discharge. There was no significant difference in ASIA grade among the three groups at the last follow-up. Nanohydroxyapatite/polyamide-66 cage group had a lower cage subsidence (P = 0.013). The bone graft fusion time of the nanohydroxyapatite/polyamide-66 cage group was significantly shorter than the iliac bone graft group and the titanium mesh bone graft (P < 0.05). Conclusions: The follow-up outcomes showed that the method involving one-stage posterior debridement and internal fixation, interbody graft, and fusion is an effective and safe surgical method for patients with thoracic and lumbar tuberculosis. The incidence rate of cage subsidence was less and the bone graft fusion time was shorter with nanohydroxyap atite/polyamide 66 cage when compared with iliac bone graft and titanium mesh bone graft in the surgical treatment of thoracic and lumbar tuberculosis. Nanohydroxyapatite/polyamide-66 cage has a promising application prospect to be a new bone graft material.
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Investigation of Sexual Function in Men with Spinal Cord Injury in a Rehabilitation Hospital in Turkey p. 239
Engin Koyuncu, Özlem Taşoğlu, Neşe Özgirgin
DOI:10.4103/0028-3886.360933  
Background: Sexual function is one of the most important functions for males with spinal cord (SC) injuries, and there are wide ranges and conflicting results about sexual dysfunction and the frequency of education of these patients. Objectives: The aim of our retrospective study is to evaluate sexual function and to determine the level of sexual education provided by medical professionals in males with SC injury. Patients and Methods: Eighty-one inpatient males with SC injury were included in the study. “International Index of Erectile Function” and “International Spinal Cord Injury Male Sexual Function Basic Data Set” were used to evaluate sexual function. Results: The median age of the patients was 31 years old (range 20–63), and the median disease duration was 190 days (range 30–5475). Of 81 patients, 55.6% had C1-T10, 33.3% had T11-L2, and 11.1% had L3 and lower injury. Of the patients, 90.1% were never informed about the impact of SC injury on sexual function. The rates of normal psychogenic and reflex erection were 16 and 18.5%, respectively. Erectile dysfunction was severe in 66.7% and moderate in 16% of patients. Only 4.9% of patients had normal ejaculation and 7.4% had normal orgasmic function. Sexual desire was very high or high in 49.4% and moderate in 32.1%. Overall, sexual satisfaction was high or moderate in only 6.2% of patients. Conclusion: Sexual education rates of male SC injured persons are very low. Although most of the patients have normal sexual desire, erection, ejaculation, orgasmic function, and sexual satisfaction are severely damaged.
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Combined Effect of Virtual Reality Training (VRT) and Conventional Therapy on Sitting Balance in Patients with Spinal Cord Injury (SCI): Randomized Control Trial p. 245
Manasa S Nair, Vivek N Kulkarni, Ashok K Shyam
DOI:10.4103/0028-3886.360934  
Background: Post spinal cord injury (SCI), sitting balance is considered a prerequisite for the effective performance of activities of daily living. Virtual Reality Training (VRT) may provide an interactive medium of rehabilitation, preventing a reduction in active participation of the patients while allowing for the training of sitting balance. Aim: The aim of this study was to evaluate the effect of the addition of VRT to conventional therapy in improving sitting balance in persons with SCI. Subjects and Methods: This was a single blinded randomized control trial conducted on 21 subjects with SCI (level of injury: D10 or below). They were randomly allocated into two groups; both groups received their routine exercise program. In addition, the intervention group, that is, Group B (n = 11) received 30 min of VRT in the seated position using Xbox-Kinect, while the conventional therapy group, that is, Group A (n = 10) received 30 min of additional conventional therapy to equalize the duration of the intervention (3 days/week, 4 weeks). The modified functional reach test and T-shirt test were measured at the beginning and at the end of 4 weeks. Results: MFRT changes for forward (Group A: 1.7 ± 1.09 cm; Group B: 4.83 ± 2.95 cm), right lateral (Group A: 2.43 ± 2.81 cm, Group B: 5.08 ± 1.85 cm), left lateral (Group A: 3.05 ± 4.65 cm, Group B: 6.19 ± 1.51 cm) were statistically significant for Group B (P < 0.05). No significant difference was observed between the two groups for T-shirt test (P > 0.05). Conclusion: VRT can be used as a part of a comprehensive rehabilitation program to improve sitting balance post-SCI.
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Transplantation of NEP1-40 and NT-3 Gene-Co-Transduced Neural Stem Cells Improves Function and Neurogenesis after Spinal Cord Injury in a Rat Model p. 251
Feng Chen, Zhuang Zhang, Lin-nan Wang, Xi Yang, Chun-Guang Zhou, Ce Zhu, Lei Wang, Li-min Liu, Yue-ming Song
DOI:10.4103/0028-3886.360942  
Background: Spinal cord injury (SCI) generally results in necrosis, scarring, cavitation, and a release of inhibitory molecules of the nervous system, which lead to disruption of neurotransmission and impede nerve fiber regeneration. This study was intended to evaluate the therapeutic efficacy rates of the transplantation of NEP1–40- and NT-3 gene-co-transduced neural stem cells (NSCs) in a rat model of SCI. Methods: Ninety Sprague–Dawley rats were subdivided randomly into six groups: sham-operated, SCI model, SCI + NSCs-NC, SCI + NEP1-40-NSCs, SCI + NT-3-NSCs, and SCI + NEP1-40/NT-3-NSCs. Motor function at different time points was evaluated using the Basso, Beattie, and Bresnahan locomotor activity scoring system (BBB). At 8 weeks post-transplantation, histological analysis, a terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) assay, immunofluorescent assay, immunocytochemical staining, and cholera toxin subunit B (CTB) retrograde tracing were performed. Results: BBB scores of the co-transduction group significantly surpassed those of other transplantation groups and of the SCI-model group after 2 weeks post-transplantation. The apoptotic rate of neurocytes was significantly lower in the co-transduction group than in other experimental groups. Expression of NF-200, MBP, and ChAT was significantly higher in the SCI + NEP1-40/NT-3-NSCs group than in other transplantation groups, whereas the expression of GFAP and GAD67 was the second lowest after the sham-operated group. CTB retrograde tracing showed that CTB-positive neural fibers on the caudal side of the hemisected site were more numerous in the SCI + NEP1-40/NT-3-NSCs group than in other experimental groups. Conclusion: Transplantation of NEP1–40- and NT-3-gene-co-transduced NSCs can modify the protein expression following acute SCI and promote neuron formation and axonal regeneration, thus having a neuroprotective effect. Furthermore, this effect surpasses that of transplantation of single-gene-transduced NSCs. Transplantation of NEP1–40- and NT-3-gene-co-transduced NSCs is effective at the neural recovery of the rat model of SCI and may be a novel strategy for clinical treatment of SCI.
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Quantifying Neurological Examination in 21st Century: Yilmaz- Ilbay Plantar Flexion Test, A Novel and Reliable Test for Evaluation of Plantar Flexion in L5-S1 Disc Herniation p. 259
Murat Yilmaz, Gul Ilbay, Huriye E Yilmaz, Onder Ertem, Serhat Erbayraktar, Konuralp M Ilbay
DOI:10.4103/0028-3886.360913  
Background: Current methods used to measure the muscle strength required to achieve plantar flexion may yield highly variable results depending on the perception of the physician conducting the examination because these tests involve subjective and qualitative evaluation. Objective: To describe and evaluate the efficacy of a novel examination technique that can quantitatively measure plantar flexion in L5–S1 disc herniation. Materials and Methods: A total of 32 patients (average age: 49.4 years, range: 23–78) with L5–S1 disc herniations were included. The patient to be tested stood next to a table on which they could lean with their hands. The leg closer to the table was fully flexed at the knee, and the other foot was brought to maximum plantar flexion on the toes. At this point, a stopwatch was started to measure the time that passed until the muscles fatigued and the heel fell. The differences between the right and left plantar flexion times were noted. In addition, three different physicians graded muscle strength by using the classical “The Medical Research Council of the United Kingdom” method. Results: The time until fatigue in right and left plantar flexion was measured using the proposed method, and each test underwent a video recording. The Yilmaz–Ilbay plantar flexion test yielded the correct classification for all cases. Conclusion: We suggest that the proposed method “Yilmaz–Ilbay plantar flexion test” can serve as a useful, practical, and effective test to detect quantitative evaluation of plantar flexion in L5–S1 herniation.
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Value of Evoked Potential Changes Associated with Neck Extension Prior to Cervical Spine Surgery p. 263
Min Zhao, Jionglin Wu, Fengtao Ji, Deng Li, Jichao Ye, Zheyu Wang, Yanni Fu, Lin Huang, Liangbin Gao
DOI:10.4103/0028-3886.360905  
Background: Multimodal intraoperative monitoring (MIOM) is a useful tool to warn surgeons to intervene for intraoperative spinal cord injury in cervical spine surgery. However, the value of MIOM remains controversial before cervical spine surgery. Objective: To explore the value of MIOM in early detecting spinal cord injury associated with neck extension before cervical spine surgery. Methods and Materials: Data of 191 patients receiving cervical spine surgery with the MIOM were enrolled from June 2014 to June 2020. The subjects were divided into a group of evoked potentials (EP) changes and a group of no EP changes for analysis according to the monitoring alerts or not. Results: Five (2.62%) patients showed EP changes associated with neck extension during intubation or positioning. After early different interventions, such as repositioning and timely surgical decompression, none or transient postoperative neurological deficits were observed in four cases, and only one case was with permanent neurological deficits. The average preoperative Japanese Orthopaedic Association (JOA) scores of the group with EP changes were lower than those of the group with no EP changes (P = 0.037 < 0.05). There was no statistical significance in gender, average age, mean Pavlov ratio, and the minimum Palov ratio between the two groups (P > 0.05). Conclusions: The MIOM could identify spinal cord injury associated with neck extension before cervical spine surgery. Active and effective interventions could prevent or reduce permanent postoperative neurological deficits. Severe spinal cord compression might be a risk factor for EP changes.
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Preoperative Heart Rate Variability Predicts Postinduction Hypotension in Patients with Cervical Myelopathy: A Prospective Observational Study p. 269
Sarah L Boyle, Alastair Moodley, Emad Al Azazi, Michael Dinsmore, Eric M Massicotte, Lashmi Venkatraghavan
DOI:10.4103/0028-3886.360911  
Background: Autonomic dysfunction, commonly seen in patients with cervical myelopathy, may lead to a decrease in blood pressure intraoperatively. Objective: The aim of our study is to determine if changes in Heart rate variability (HRV) could predict hypotension after induction of anesthesia in patients with cervical myelopathy undergoing spine surgery. Methods and Material: In this prospective observational study, 47 patients with cervical myelopathy were included. Five-minute resting ECG (5 lead) was recorded preoperatively and HRV of very low frequency (VLF), low frequency (LF), and high frequency (HF) spectra were calculated using frequency domain analysis. Incidence of hypotension (MAP <80 mmHg, lasting >5 min) and the number of interventions (40 mcg of phenylephrine or 5 mg of ephedrine) required to treat the hypotension during the period from induction to surgical incision were recorded. HRV indices were compared between the hypotension group and the stable group. Results: The incidence of hypotension after induction was 74.4% (35/47) and the median (IQR) interventions needed to treat hypotension was 2 (0.5–6). Patients who experienced hypotension had lower HF power and higher LF–HF ratios. A LF/HF >2.5 indicated postinduction hypotension likely. There was a correlation between increasing LF–HF ratio and the number of interventions that needs to maintain the MAP above 80 mmHg. Conclusion: HF power was lower and LF-HF ratio was higher in patients with cervical myelopathy who developed postinduction hypotension. Hence, preoperative HRV analysis can be useful to identify patients with cervical myelopathy who are at risk of post-induction hypotension.
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Use of Assessment Tools in Cervical Spondylotic Myelopathy—Results of An Anonymized Survey Among Indian Spine Surgeons p. 276
Kanwaljeet Garg, Roshan Sahu, Mohit Agrawal, Shashwat Mishra, Sachin Borkar, PS Chandra, Shashank S Kale
DOI:10.4103/0028-3886.360923  
Background: Cervical spondylotic myelopathy (CSM) is the commonest cause of cervical myelopathy. It contributes to high morbidity and consequent economic burden for society. Many measurement tools have been devised to quantify the disease severity, assist in decision-making, and to evaluate the outcome of surgical intervention. Objective: Most of the assessment scales are used for research purposes only and rarely in clinical practice. The purpose of this survey was to check the awareness of spine surgeons about these assessment scales and their role in the management of patients with CSM. Methods: An online questionnaire using the application “Google Forms” made consisting of 10 questions regarding the experience of treating the CSM patients and their preference for various parameters in assessing these patients. Statistical analysis was done using the statistical programming language R. Results: One-hundred and sixty-three responses were analyzed. About 90% of the respondents were aware of the assessment tools and only 57% of them used any in management. Nurick's grade was the most well known among all groups. The commonest reason for surgeons not using any of these assessment scales despite being aware of these scales was their perception that it is very time-consuming to complete these assessment scales. Conclusion: Assessment scales have a role in the management and follow-up of CSM patients. While awareness regarding these tools is well spread, time constraint plays a major role in limiting its usage.
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Comparison of Different Tidal Volumes for Ventilation in Patients with an Acute Traumatic Cervical Spine Injury p. 282
Deep Sengupta, Ashish Bindra, Indu Kapoor, Purva Mathur, Deepak Gupta, Maroof A Khan
DOI:10.4103/0028-3886.360926  
Background: There is scant literature comparing high tidal volume ventilation (HTV) over low tidal volume (LTV) ventilation in acute traumatic cervical spinal cord injury (CSCI). Objective: The aim of this prospective randomized controlled parallel-group, single-blinded study was to compare the effect of two different tidal volumes (12–15 mL/kg and 6–8 mL/kg) in CSCI on days to achieve ventilator-free breathing (VFB), PaO2/FIO2 ratio, the incidence of complications, requirement of vasopressor drugs, total duration of hospital stay, and mortality. Materials and Methods: We enrolled patients with acute high traumatic CSCI admitted to the neurotrauma intensive care unit within 24 h of injury, requiring mechanical ventilation. Participants were randomized to receive either HTV, 12–15 mL/kg (group H) or LTV, 6–8 mL/kg (group L) tidal volume ventilation. Results and Conclusions: A total of 56 patients, 28 in each group were analyzed. Patient demographics and injury severity were comparable between the groups. VFB was achieved in 23 and 19 patients in groups H and L, respectively. The median number of days required to achieve VFB was 3 (2, 56) and 8 (2, 50) days, P = 0.33; PaO2: FIO2 ratio was 364.0 ± 64 and 321.0 ± 67.0, P = 0.01; the incidence of atelectasis was 25% and 46%, P = 0.16, respectively, in group H and group L. The hemodynamic parameters and the vasopressor requirement were comparable in both groups. There was no barotrauma. The duration of hospital stay (P = 0.2) and mortality (P = 0.2) was comparable in both groups. There was no significant difference in days to achieve ventilator-free breathing with HTV (12–15 mL/kg) ventilation compared to LTV (6–8 mL/kg) ventilation in acute CSCI. The PaO2:FiO2 ratio was higher with the use of 12–15 mL/kg. No difference in mortality and duration of hospital stay was seen in either group.
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Silver Needle Thermal Therapy Relieves Pain, Repairs the Damaged Myofascial Fiber, and Reduces the Expression of 5-HT3 Receptors in the Spinal Cord of Rats with Myofascial Pain Syndrome p. 288
Xianglong Lv, Chunxin Wo, Jing Yao, Wei Lu, Zilong Yu, Yue Qin, Yue Wang, Zhongjie Zhang, Yu Wu, Yuanxin Huang, Lin Wang
DOI:10.4103/0028-3886.360917  
Background: There is an urgent clinical need to provide a theoretical basis for silver needle thermal therapy to Myofacial pain syndrome (MPS). Objective: This study was conducted to explore the effect of silver needle thermal therapy on myofascial pain syndrome in rats. Methods: MPS rat models were duplicated, and the rats were subsequently divided into model and treatment groups. A normal control group was synchronously set up. No treatment was given to the model group, whereas silver needle thermal therapy was administered to the treatment group. The thermal and mechanical pain threshold, the morphological structure as well as the expression of 5-HT3 receptors in the spinal cord were observed. Results: Rats from the treatment group presented with a significantly higher pain threshold compared to the untreated model group. The myofascial arrangement of the affected part of the model group was disordered, and some muscle fibers were atrophied and deformed. Meanwhile, the myofascial arrangement of the treatment group became more regular than that of the model group. The expression levels of 5-HT3 receptor in the spinal cord of the untreated model group were significantly increased, while being markedly decreased in the treatment group. Conclusions: Silver needle thermal therapy can augment the pain threshold of rats with MPS, repair the damaged myofascial membrane in the rats, and further reduce the expression of 5-HT3 receptors in the spinal cord of the MPS rats.
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CASE REPORTS Top

Cervical Spine Fracture with Extreme Dislocation in a Patient with Ankylosing Spondylitis: A Case Report and Systematic Review of the Literature p. 296
Kanwaljeet Garg, Rahil Rafiq, Shashwat Mishra, Pankaj Singh, Deepak Agrawal, P Sarat Chandra
DOI:10.4103/0028-3886.360906  
Background: Ankylosing spondylitis (AS) is a seronegative arthropathy which results in pathological ossification of the ligaments, disc, endplates and apophyseal structures. Cervical spinal fractures are more common in patients with ankylosing spondylitis than in patients without ankylosing spondylitis due to coexistent osteoporosis and kyphotic alignment of the spine. The risk of fracture–dislocation and associated spinal cord injury is also more in these patients. Management of cervical spine fractures in patients with ankylosing spondylitis is more challenging. Case Description: We report a 56-year-old male patient who presented to our emergency department following a road traffic accident. He had ASIA B spinal cord injury at C7 level. CT scan revealed a C6–7 fracture–dislocation with features suggestive of AS. The fracture involved all the three columns and extended through C7 body anteriorly and through the C6–7 disc posteriorly. The treating team was not aware that he had AS, and thus, precautions related to his head position were not taken. He underwent reduction of the fracture–dislocation and 360° fixation. Conclusions: The management of cervical spine fractures in patients with ankylosing spondylitis is challenging. They need long segment fixation in their preoperative spinal alignment. Proper preoperative planning can result in good outcome.
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Non Dysraphic Intramedullary Spinal Cord Lipoma p. 302
D Balachandar, P Bhaskar Naidu, Sangeetha , K Selvakumar
DOI:10.4103/0028-3886.360941  
Among all intramedullary spinal cord lesions, intramedullary spinal cord lipomas account less than 1%. Non-dysraphic intramedullary lipoma is very rare. It is most commonly seen in cervicodorsal region followed by cervico bulbar, lumbar and sometimes multiple. Here we present a 17-year-old female who underwent MRI due to upper dorsal pain followed by progressive bilateral lower limb weakness which showed intramedullary lesion extending from T1-T9, involving eight vertebral segments with distal syrinx and features suggestive of lipoma. Patient underwent surgical decompression of lipoma. Patient had an uneventful post-operative period. Diagnosis confirmed by histopathology.
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‘White Cord Syndrome’: A Rare Catastrophic Complication Following Anterior Cervical Discectomy and Fusion p. 306
Nishant Goyal, Jitender Chaturvedi, Pankaj Kandwal, Priyanka Gupta, Ashutosh Kaushal, Mritunjai Kumar
DOI:10.4103/0028-3886.360940  
Background: 'White-cord syndrome' is an extremely rare entity following decompression of cervical cord in which post-operative reperfusion injury results in worsening of patient's neurology and MRI reveals signal changes in spinal cord in absence of cord compression. We wish to report a case of 'white-cord syndrome' following a 'routine' ACDF. Case Description: A 39-year-old woman with paresthesias and spastic quadriparesis was found to have C5-C6 PIVD on MRI. ACDF was performed at C5-C6, after which worsening of quadriparesis was noted, for which intravenous high-dose steroids were started. An urgent MRI was done, which revealed findings of white-cord syndrome, without compression on underlying cord. With conservative management, her ASIA grade improved from C to D and the features of white-cord syndrome disappeared on follow-up imaging. Conclusion: It is important for surgeons and patients to be aware of this rare but potentially catastrophic entity as this needs to be discussed while taking consent for surgery.
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Reporting a Case of Cervical Vertebral Body Primary Malignant Melanoma—A Rare Entity p. 310
G Krishna Kumar, Chandrasekhar Chigurupalli, Anandh Balasubramaniam, BJ Rajesh, Pooja Chavali
DOI:10.4103/0028-3886.360928  
Melanomas of vertebral body are usually metastatic lesions. Isolated vertebral body melanomas are rare may be due to unknown primary. Only threesuch cases havebeen reported in literature. We are reporting a 30-year-old female presented with progressive quadriparesis and bladder involvement. On evaluation, an extradural lesion at the C4-5 level with the destruction of C4 vertebral body and anterior in the prevertebral space seen with areas of blooming. The patient underwent surgery and biopsy was suggestive of melanoma. On further evaluation, we could find any other lesion in the body. The lesion can be either metastatic with unknown primary or primarily arising from vertebrae. Primary vertebral body melanomas are rare, surgical decompressions followed by immunotherapy may prolong the survival in this patients.
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Intraoperative Neuromonitoring for Spinal Surgery in a Pregnant Patient: Case Report and Literature Review p. 314
Mayank Tyagi, Megha Bir, Akanksha Sharma, Pankaj K Singh, Ashish Bindra, P Sarat Chandra
DOI:10.4103/0028-3886.360931  
We report the strategy of anesthesia and intraoperative neurophysiological monitoring (IONM) in a 29-year-old, 22 weeks pregnant patient posted for surgery for aggressive vertebral body hemangioma. We used propofol and fentanyl-based anesthesia for IONM. Motor-evoked potentials (MEP) and somatosensory-evoked potentials (SSEP) were used to monitor the neural tracts during surgery. Fetal heart rate monitoring was done preoperatively and postoperatively. Train of 8, 75 μs duration pulse, 250–500 Hz stimulus was used for MEP and 30 mA, 200–400 μs, 3–5 Hz was used for SSEP. No new motor or somatosensory deficits appeared. Our findings suggest that IONM can be safely done in pregnant women.
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Meningeal Melanomatosis with a Spinal Meningeal Melanocytoma Trigger by an in vitro Fertilization p. 322
Aida Antuña Ramos, Paula Ferrara, Vanesa Martin Fernández, Carmen Rodriguez Sanchez, Marco A Alvarez Vega
DOI:10.4103/0028-3886.360914  
Meningeal melanomatosis is an infrequent tumor originating from the melanocytes in the leptomeninges and one of the recognized primary melanocytic tumors of the central nervous system. The average survival has known to be about 5 months. It can be associated with solid tumors, such as meningeal melanocytomas. The patient we present was diagnosed of a meningeal melanomatosis that developed two solid tumors related to an in vitro fertilization. The clinical course was rapidly fatal. Although the use of comprehensive diagnostic procedures, usually the final diagnosis of primary diffuse meningeal melanomatosis is postmortem, it would be advisable for the appropriate management of the patient to make a differential diagnosis and to be aware of the behavior of the tumor.
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Distinct Spinal Dysraphisms Arising from Each Hemicord of Type I Split Cord Malformation - A Rare Coexistence p. 326
Lavlesh Rathore, Debabrata Sahana, Sanjeev Kumar, Rajiv Sahu
DOI:10.4103/0028-3886.360939  
In this report, we describe a 6-month-old child having Type I split cord malformation (SCM), associated with meningomyelocele of one hemicord and lipomeningomyelocele of other hemicord at the same level along with Type II Chiari malformation. The classical embryological theories on split cord malformation and neurulation defect do not clearly explain such a complex entity at one level. The new research on the genetic association of posterior neuropore defect opens a new horizon of research on such genesis.
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Spinal Dural Arteriovenous Fistula in a Young Male Associated with Craniospinal Leptomeningeal Spread of a Treated High-Grade Glioma p. 330
Chinmay P Nagesh, Parthasarthy Satischandra, KN Krishna, Girish Joshi, Rashmi Devaraj, Ajay Herur
DOI:10.4103/0028-3886.360935  
Spinal dural arteriovenous fistulae (SDAVF) are most commonly idiopathic in origin but may occasionally be seen secondary to surgery, trauma, or inflammation. We report a case of 27-year-old male who came with features of a myelopathy. He was found to have an SDAVF associated with leptomeningeal spread (LMS) of a previously treated high-grade cerebral glioma. Hemorrhagic presentation of gliomas, as in this case, is due to upregulation of vascular endothelial growth factor, which has also been postulated to play a role in the development of SDAVFs. This may suggest a possible mechanism of induction of secondary SDAVFs associated with such tumors. While the coexistence of intracranial neoplasms with vascular malformations has been reported previously, this is the first case report of LMS of a high-grade glioma associated with an SDAVF.
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Transoral Vertebroplasty of C2 Aggressive Hemangioma: A Clinical Case p. 335
Kosimshoev Murodzhon, Kubetskiy Yuliy, Rzaev Jamil
DOI:10.4103/0028-3886.360907  
The article describes a clinical case of surgical treatment of a patient with aggressive C2 vertebral hemangioma by vertebroplasty with a transoral approach.
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Symptomatic Spinal Intramedullary Metastasis (SIM) in a Postoperative Case of Low-Grade Intracranial Oligodendroglioma after Nine Years p. 340
Gagandeep Attri, Suyash Singh, G Krishna Kumar, Jeena Joseph, Kamlesh S Bhaisora, Arun K Srivastava, Sushila Jaiswal, Sanjay Behari
DOI:10.4103/0028-3886.360919  
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Online since 20th March '04
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