Publications by authors named "Abhinandan Reddy Mallepally"

32 Publications

Mid Thoracic intra-spinal facet cyst with lumbar canal stenosis: A rare "double crush".

Int J Neurosci 2021 Jun 1:1-6. Epub 2021 Jun 1.

Department of Spine Services, Indian Spinal Injuries Centre, Vasant kunj, Sector C, 110070 New Delhi.

Introduction: Intraspinal synovial cysts occurrence causing spinal canal occlusion are mostly seen in mobile segments of the spine (lumbar and cervical). An appearance of the cyst in thoracic spine is a relatively rare occurrence. We present an interesting case of "double crush" caused by Lumbar canal stenosis with a mid-dorsal Facet cyst.

Case Presentation: A 67-year-old woman presented with complaints of back pain with neurogenic claudication with significant loss of touch sensation and motor power of MRC grade 3/5 in lower extremities bilaterally. However, patient was hyperreflexic with Babinski sign positive. She was unable to perform tandem walking test and complained of instability. MRI of lumbar spine revealed lumbar canal stenosis. However, in view of the UMN signs, an MRI of the dorsal spine was done. It revealed an extradural, well-delineated lesion along the dorsal aspect of spine at T6-7 level. Thus the patient had a "double crush" due to the FC along with lumbar canal stenosis.Clinical findings correlated with the imaging. Two teams simultaneously operated the 2 pathologies and T6-7 laminectomy along with left sided TLIF at L4-5 level was performed. Presently she is asymptomatic for back pain, claudication distance has improved to 800m.

Conclusion: Our case reiterates the importance of thorough clinical examination to avoid missing a diagnosis. Our case is the first in literature to report a "double crush" due to a proximal dorsal FC and distal LCS. Both the pathologies were tackled in a single setting by two operating teams with a good functional outcome.
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http://dx.doi.org/10.1080/00207454.2021.1938034DOI Listing
June 2021

Management of AO-type C thoracolumbar fractures during COVID-19 pandemic using distractor device: a novel technique.

Br J Neurosurg 2021 May 31:1-8. Epub 2021 May 31.

Department of Spine Services, Indian Spinal Injuries Centre, New Delhi, India.

Study Design: Prospective cohort study.

Introduction: Management of the severe thoracolumbar (TL) spine fracture-dislocation injuries have been further complicated by the COVID-19 pandemic. The need to optimize resources and minimize the personnel in the operating room (OR) led us to develop a novel technique to reduce TL fracture-dislocations (AO type-C) using an orthopedic distractor device (ODD).

Methods: This prospective study was conducted at a tertiary care spine center with a study duration from March 2020 to May 2020 coinciding with the nationwide lockdown and travel restrictions imposed in view of the COVID-19 crisis. Only patients with AO type C fracture-dislocation managed using the ODD operated by a single surgeon were included in the study.

Results: Of 12 cases, the most commonly affected level was D12-L1. Nine patients were American Spinal Injury Association Impairment Scale (AIS) A at presentation, two patients were AIS B, and one AIS C. The mean operative time was 125 min and mean blood loss was 454 ml. Eight patients remained AIS A, one patient improved from AIS B to C. Two patients became independent walkers, one remained AIS B. The post-operative VAS score improved to a mean value of 2.33. The improvement in kyphosis was 26.24° immediate postoperatively and maintained at 25.9°, percentage height loss reduced to 2.75% immediate postoperatively and maintained at 3.16% at 3 months follow-up.

Conclusions: Management of TL fracture-dislocations in COVID times of health care resource scarcity can be challenging. Single surgeon with ODD is a useful technique for achieving good results in these injuries.
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http://dx.doi.org/10.1080/02688697.2021.1929836DOI Listing
May 2021

Radiographic Analysis of the Sagittal Alignment of Spine and Pelvis in Asymptomatic Indian Population.

Asian Spine J 2021 May 10. Epub 2021 May 10.

Department of Spine Services, Indian Spinal Injuries Center, New Delhi, India.

Study Design: This is a descriptive observational study.

Purpose: The objective of this study is to analyze and document the sagittal alignment of the spine and pelvis in normal Indian adult volunteers and compare these parameters with the study population of other races and ethnicities.

Overview Of Literature: Given the importance of the spinopelvic parameters, there is a need to describe the parameters differentially in relation to the ethnicity of the studied individual. Very few reports have defined the normal physiological value. Ethnic differences are a significant factor not only when describing the anthropometric data but also when applying the findings to a different ethnic group. We have compared these values with other races and ethnicities so that we can know whether the principles of spinal fixation can be applied globally.

Methods: In total, 100 participants were studied by using their anteroposterior and lateral radiographic images of whole of pelvic and spinal area. Additionally, various spinal and pelvic parameters were also measured. Subsequently, the outcomes were analyzed with respect to age, sex, and body mass index (BMI). The correlation between different parameters and differences in these parameters between Indians and other races/ethnicities along with population groups were also analyzed.

Results: There was a significant increase in thoracic kyphosis (TK) from T1-T12 and T4-T12 with increasing age. Lumbar lordosis (LL), sacral translation (sagittal vertical axis), and pelvic tilt were significantly higher among females. Additionally, sacral slope (SS), pelvic incidence, C7 sagittal offset, and T9 sagittal offset were also higher in females. TK (T4-T12 and T1-T12), LL, SS, and pelvic incidence showed a significant correlation with BMI. As compared to European population, TK, segmental LL, and sacral translation were found to be significantly lesser in Indian population.

Conclusions: There is a statistically significant difference between Indians and other races/ethnicities and population groups with respect to TK, LL, and sacral translation. The values obtained can be considered as the physiological normal values for Indian population. Importantly, these values can serve as the reference values for future studies.
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http://dx.doi.org/10.31616/asj.2020.0301DOI Listing
May 2021

Hydatid Cyst of the Spine: A Rare Case Report and Review of Literature.

J Orthop Case Rep 2020 May-Jun;10(3):57-59

Department of Spine Services, Indian Spinal Injuries Centre, Delhi, India.

Introduction: Hydatid disease is caused by the parasite Echinococcus granulosus which is also known as the dog tapeworm. This disease is a relatively uncommon cause of spinal cord and dural compression.

Case Report: We came across a peculiar case in a 41-year-old male patient who presented to us with pus discharge from a surgical wound over lower back for 10 days. The patient was a diagnosed as a case of lumbar canal stenosis with recurrent hydatid cyst. The patient had neurological involvement in the form of left-sided foot drop. The patient gave a history of lumbar canal stenosis secondary to hydatid cyst, for which decompression and cyst excision were done 3 years prior. The patient was re-operated in the form of wound debridement with removal of hydatid cyst.

Conclusion: Meticulous surgery avoiding spillage of cyst material, appropriate medication as advised by the infectious disease specialist, will avoid recurrence of the disease.
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http://dx.doi.org/10.13107/jocr.2020.v10.i03.1748DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8051559PMC
May 2021

Iatrogenic postoperative spondylodiscitis attributed to infection in an immunocompetent patient.

Surg Neurol Int 2021 8;12:138. Epub 2021 Apr 8.

Department of Orthopedics, Division of Spine Services, Indian Spinal Injuries Centre, New Delhi, India.

Background: Pyogenic spondylodiscitis (PS) is a rare infection involving the intervertebral disk space, adjacent vertebral endplates, and vertebral bodies. PS occurs in the elderly and immunocompromised patients, and is an uncommon cause of initial and/or postoperative PS. There are only seven cases involving this organism reported in literature.

Case Description: Here, we present a 35-year-old male who following a lumbar discectomy developed a postoperative iatrogenic PS uniquely attributed to . The patient was successfully managed with postoperative surgical debridement and antibiotic therapy.

Conclusion: Rarely, may be the offending organism resulting in a postoperative lumbar PS.
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http://dx.doi.org/10.25259/SNI_518_2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8088530PMC
April 2021

Better late than never: Clinical outcomes of delayed fixation in thoracolumbar spinal trauma.

Eur Spine J 2021 Mar 22. Epub 2021 Mar 22.

Department of Orthopaedics, Indian Spinal Injuries Centre, New Delhi, India.

Purpose: To analyse factors influencing functional outcome and neurological recovery in patients undergoing delayed surgery for traumatic spinal cord injury (SCI) involving thoracolumbar spine.

Methods: Retrospective analysis of 33 patients with thoracolumbar SCI who underwent delayed surgery (≥ 72hrs post-trauma) with a minimum follow-up of 1 year (average:32.55 months) was done. The parameters studied included age, sex, co-morbidities, mode of trauma, associated trauma, level and number of vertebrae involved, fracture morphology, thoracolumbar injury classification and severity score (TLICS), maximal spinal cord compression (MSCC), signal changes in the cord, neurological deficit as per the American Spinal Injury Association (ASIA) scale, lower extremity motor score (LEMS), bowel bladder involvement, time interval between trauma and surgery.

Results: Mean time interval from injury to spine surgery was 24.45 days. At the end of 1-year follow-up, 17(51.5%), 12(36.36%), and 3(9.1%) patients had ≥ 1, ≥ 2, and ≥ 3-grade ASIA improvement, respectively. The mean LEMS rose to 33.86 from 17.09 (P < 0.001). 8 out of 20 patients with bladder involvement showed improvement. 4 patients succumbed, 22 were ambulatory, and 7 remained non-ambulatory. On comparing various parameters, pre-operative LEMS score (P-value: < 0.001), cord signal changes (P-value:0.002), and presence of cord transection (P-value:0.007) differed significantly in the above-mentioned three groups, while age (P-value:0.442), average TLICS (P-value:0.872), time from injury to surgery (P-value:0.386) did not differ significantly.

Conclusion: This study highlights that there is still a significant scope for neurological improvement even after delayed surgery in patients with thoracolumbar SCI. The lower the LEMS score at the time of presentation, signal changes in the cord and presence of cord transection have a significant influence on unfavourable clinical outcomes at the end of 1-year post-surgery.
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http://dx.doi.org/10.1007/s00586-021-06804-5DOI Listing
March 2021

Clinico-Radiological Outcome of Single-Level and Hybrid Total Disc Replacement with Spineart Baguera®-C for Cervical Myeloradiculopathy: Minimum 2-Year Follow-Up Study in Indian Population.

Asian J Neurosurg 2020 Oct-Dec;15(4):856-862. Epub 2020 Dec 21.

Indian Spinal Injuries Center, New Delhi, India.

Context: Cervical radiculopathy and myelopathy is one of the most frequent ailments encountered by spine surgeon. Motion-preserving surgeries in cervical spine is a standard of care due to its certain advantages such as biomechanical anatomical conformity, reduced chances of adjacent segment degeneration, and revision surgeries. While there is abundant data from some centers, data from developing countries are still limited.

Aims: The aim was to study the clinico-radiological outcome of single-level and hybrid total disc replacement (TDR) with Spineart Baguera-C cervical prosthesis for cervical myeloradiculopathy.

Settings And Design: Retrospective study.

Materials And Methods: Retrospective analysis of the 29 consecutive patient undergoing single level TDR and hybrid fixation (i.e., TDR with anterior cervical discectomy and fusion) with Spineart Baguera-C cervical prosthesis for myeloradiculopathy from January 1, 2014 to December 31, 2017, was done. Radiological features and outcome were studied from data collected on Insta-picture archiving and communication system.

Statistical Analysis Used: SAS 9.4 was used for all computations. Results on continuous measurements were presented as mean and standard deviation (min-max) and results on categorical measurements were presented as numbers (n) and percentages.

Results: Twenty-nine patients were included in the study. The mean age was 43.31 ± 9.04 years with 14 males and 15 females. The most common level of TDR was C5-C6 (72.41%). The mean follow-up duration was 3.14 years ± 1.13 years (2-5 years). The mean hospital stay was 4.93 ± 2.12 days. The mean neck disability index (NDI) at admission was 27.24 ± 7.66 which decreased to 6.41 ± 4.29 at final follow-up.

Conclusions: Two-year data on treatment with Spineart Baguera-C cervical prosthesis shows significantly improved NDI, visual analog scale (arm) with maintenance of movement of the prosthesis.
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http://dx.doi.org/10.4103/ajns.AJNS_288_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7869274PMC
December 2020

Dysplasia and anomalies of atlas result in pediatric torticollis: A case report and literature review.

Surg Neurol Int 2020 29;11:471. Epub 2020 Dec 29.

Department of Orthopaedics, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra, India.

Background: Often, the cause of bony torticollis is difficult to determine, especially in cases of multiple craniovertebral junction anomalies.

Case Description: We report a rare case of a dysplastic C1 vertebra (assimilation to the right occiput and C2, a nonseparated left odontoid, and discontinuity in both anterior and posterior arches of the atlas) in a 6-year-old child with progressive torticollis. Notably, the mechanism of torticollis was not a rotatory subluxation of C1-C2, but differential growth between C1-C2. The child underwent a successful C1-C2 Goel and Harms fusion with reduction/correction of the torticollis.

Conclusion: Torticollis caused by differential growth between the C1 and C2 vertebrae resulting in a nonrotatory subluxation/torticollis in a 6-year-old child, was successfully managed with a C1-C2 Goel and Harm's fusion.
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http://dx.doi.org/10.25259/SNI_773_2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7827302PMC
December 2020

Functional Outcomes of Nerve Root Sparing Posterior Corpectomy in Lumbar Vertebral Burst Fractures.

Global Spine J 2021 Jan 25:2192568220984128. Epub 2021 Jan 25.

Department of Spine Services, 76434Indian Spinal Injuries Centre, Vasant kunj, Sector C, New Delhi, India.

Study Design: Retrospective observational.

Objectives: This study aimed to document the safety and efficacy of lumbar corpectomy with reconstruction of anterior column through posterior-only approach in complete burst fractures.

Methods: In this retrospective study, we analyzed complete lumbar burst fractures treated with corpectomy through posterior only approach between 2014 and 2018. Clinical and intraoperative data including pre and post-operative neurology as per the ISNCSCI grade, VAS score, operative time, blood loss and radiological parameters, including pre and post-surgery kyphosis, height loss and canal compromise was assessed.

Results: A total of 45 patients, with a mean age of 38.89 and a TLICS score 5 or more were analyzed. Preoperative VAS was 7-10. Mean operating time was 219.56 ± 30.15 minutes. Mean blood loss was 1280 ± 224.21 ml. 23 patients underwent short segment fixation and 22 underwent long segment fixation. There was no deterioration in post-operative neurological status in any patient. At follow-up, the VAS score was in the range of 1-3. The difference in preoperative kyphosis and immediate post-operative deformity correction, preoperative loss of height in vertebra and immediate post-operative correction in height were significant (p < 0.05).

Conclusion: The posterior-only approach is safe, efficient, and provides rigid posterior stabilization, 360° neural decompression, and anterior reconstruction without the need for the anterior approach and its possible approach-related morbidity. We achieved good results with an all posterior approach in 45 patients of lumbar burst fracture (LBF) which is the largest series of this nature.
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http://dx.doi.org/10.1177/2192568220984128DOI Listing
January 2021

Comparison of TruView and King Vision video laryngoscopes in subaxial cervical spine injury: A randomized controlled trial.

Surg Neurol Int 2020 6;11:375. Epub 2020 Nov 6.

Department of Orthopaedics, Seth GS Medical College and KEM Hospital, Mumbai, Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India.

Background: Airway management with cervical spine immobilization poses a particular challenge for intubation in the absence of neck extension and risks neurological damage in cases of unstable cervical spine injuries. Here, with manual inline stabilization (MILS) in patients with cervical spine injuries, we compared the safety/efficacy of intubation utilizing the TruView versus King Vision video laryngoscopes.

Methods: This prospective, single-blind, comparative study was conducted over a 3-year period. The study population included 60 American Society of Anesthesiologists (ASA) Grade I-III patients, aged 18-65 years, who underwent subaxial cervical spine surgery utilizing two intubation techniques; TruView (TV) versus King Vision (KV). For both groups, relative intubation difficulty scores (IDS), total duration of intubation, hemodynamic changes, and other complications (e.g., soft-tissue injury and neurological deterioration) were recorded.

Results: With MILS, patients in the KV group had statistically significant lower IDS (0.70 ± 1.02) and significantly shorter duration of intubation as compared to the TV group (1.67 ± 1.27) with MILS ( = 0.0010); notably, the glottic exposure was similar in both groups. The complication rate (e.g., soft-tissue injury) was lower for the KV group, but this was not statistically significant. Interestingly, no patient from either group exhibited increased neurological deterioration attributable to the method of intubation.

Conclusion: King Vision has several advantages over TruView for intubating patients who have sustained cervical spine trauma. Nevertheless, both laryngoscopes afford comparable glottic views and safety profiles with similar alterations in hemodynamics.
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http://dx.doi.org/10.25259/SNI_638_2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7771478PMC
November 2020

Role of Invasive Urodynamic Studies in Establishing Cauda Equina Syndrome and Postoperative Recovery.

Global Spine J 2020 Dec 17:2192568220979640. Epub 2020 Dec 17.

Department of Spine Services, Indian Spinal Injuries Centre, Vasant Kunj, New Delhi, India.

Study Design: Retrospective with prospective follow-up.

Objective: Confirming the diagnosis of CES based purely on symptoms and signs is unreliable and usually associated with high false positive rate. A missed diagnosis can permanently disable the patient. Present study aims to determine the relationship between clinical symptoms/ signs (bladder dysfunction) with UDS, subsequently aid in surgical decision making and assessing post-operative recovery.

Methods: A prospective follow-up of patients with disc herniation and bladder symptoms from January 2018 to July 2020 was done. All patients underwent UDS and grouped into acontractile, hypocontractile and normal bladder. Data regarding PAS, VAC, GTP, timing to surgery and onset of radiculopathy and recovery with correlation to UDS was done preoperatively and post operatively.

Results: 107 patients were studied (M-63/F-44). Patients with PAS present still had acontractile (61%) or hypocontractile (39%) detrusor and with VAC present, 57% had acontractile and 43% hypocontractile detrusors. 10 patients with both PAS and VAC present had acontractile detrusor. 82% patients with acute radiculopathy (<2 days) improved when operated <24 hrs while only 47% showed improvement with chronic radiculopathy. The detrusor function recovered in 66.1% when operated <12 hours, 40% in <12-24 hours of presentation.

Conclusion: Adjuvant information from UDS in combination with clinicoradiological findings help in accurate diagnosis even in patients with no objective motor and sensory deficits. Quantitative findings on UDS are consistent with postoperative recovery of patient's urination power, representing improvement and can be used as a prognostic factor.
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http://dx.doi.org/10.1177/2192568220979640DOI Listing
December 2020

Missing Disc Fragment: A Rare Surgical Experience.

Asian J Neurosurg 2020 Jul-Sep;15(3):674-677. Epub 2020 Aug 28.

Department of Spine Services, Indian Spinal Injuries Centre, New Delhi, India.

About 35%-72% of lumbar disc herniations are associated with fragment migration. However, the posterior epidural migration is rare. We present a strange situation encountered during surgical decompression of the posterior migrated fragment. A 72-year-old male presented with a history of pain radiating to the left lower limb and Grade 3 power of the extensor hallucis longus. Magnetic resonance imaging revealed a prolapsed intervertebral disc and a possible posterior epidural migration of disc fragment. Routine surgical steps for microdiscectomy were followed after confirmation of level using fluoroscopy. However, the extruded disc fragment was not seen, and both exiting and traversing roots were free with adequate mobility. After extensively searching for a disc in the spinal canal, suction fluid was filtered through a surgical mop used as a sieve. Material collected was sent for histopathological study. Biopsy report confirmed material filtered was indeed the intervertebral disc. Thus, accidental suction of disc material in case of the posterior epidural migrated disc is a possibility, and we should be vigilant about this scenario to avoid disaster.
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http://dx.doi.org/10.4103/ajns.AJNS_79_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7591192PMC
August 2020

Varicella-Zoster Radiculitis Mimicking Sciatica: A Diagnostic Dilemma.

Asian J Neurosurg 2020 Jul-Sep;15(3):666-669. Epub 2020 Aug 28.

Spinal Services, Indian Spinal Injuries Centre, New Delhi, India.

Varicella-zoster virus (VZV) presenting as a radicular pain in the thoracic region is not uncommon, but the presentation in the lumbar and thigh region is not frequently seen. Characteristic segmental vesicular-bullous rash in a dermatomal distribution associated with pain and allodynia is a prominent feature. The pain appears before rash. It is not uncommon for clinicians to misdiagnose radicular pain caused by VZV due to prolapsed disc. We report two patients who presented to us with complaints of back pain with leg radiculopathy that were initially treated for discogenic radiculopathy and rash was wrongly attributed to hot fomentation. This case report emphasizes the importance of including varicella-zoster radiculitis in the differential diagnosis of radicular pain and clinical examination of every rash. Physical examination is must if the patient complains of rash. Appropriate and timely diagnosis can prevent unnecessary investigations.
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http://dx.doi.org/10.4103/ajns.AJNS_75_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7591216PMC
August 2020

Spinal osteoid osteoma: Surgical resection and review of literature.

Surg Neurol Int 2020 25;11:308. Epub 2020 Sep 25.

Spine Services, Indian Spinal Injuries Centre, New Delhi, India.

Background: Osteoid osteoma (OO) is a rare benign tumor of the spine that involves the posterior elements with 75% tumors involving the neural arch. The common presenting symptoms include back pain, deformity like scoliosis, and rarely radiculopathy.

Methods: From 2011 to 2017, we evaluated cases of OO managed by posterior surgical resection while also reviewing the appropriate literature.

Results: We assessed five patients (three males and two females) averaging 36.60 years of age diagnosed with spinal OOs. Two involved the lumbar posterior elements, two were thoracic, and one was in the C3 lateral mass. All patients underwent histopathological confirmation of OO. They were managed by posterior surgical resection with/without stabilization. No lesions recurred over the minimum follow-up period of 24 months.

Conclusion: Surgical excision is the optimal treatment modality for treating spinal OOs. The five patients in this study demonstrated good functional outcomes without recurrences. Further, the literature confirms that the optimal approach to these tumors is complete surgical excision with/without radiofrequency ablation.
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http://dx.doi.org/10.25259/SNI_510_2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7568094PMC
September 2020

Mini-open thoracoscopic-assisted spinal thoracotomy for traumatic injuries: A technical note.

Surg Neurol Int 2020 29;11:265. Epub 2020 Aug 29.

Spine Services, Indian Spinal Injuries Centre, New Delhi, India.

Background: Mini-open thoracoscopic-assisted thoracotomy (MOTA) has been introduced to mitigate disadvantages of conventional open anterior or conventional posterior only thoracoscopic procedures. Here, we evaluated the results of utilizing the MOTA technique to perform anterior decompression/fusion for 22 traumatic thoracic fractures.

Methods: There were 22 patients with unstable thoracic burst fractures (TBF) who underwent surgery utilizing the MOTA thoracotomy technique. Multiple variables were studied including; the neurological status of the patient preoperatively/postoperatively, the level and type of fracture, associated injuries, operative time, estimated blood loss, chest tube drainage (intercostal drainage), length of hospital stay (LOS), and complication rate.

Results: In 22 patients (averaging 35.5 years of age), T9 and T12 vertebral fractures were most frequently encountered. There were 20 patients who had single level and 2 patients who had two-level fractures warranting corpectomies. Average operating time and blood loss for single-level corpectomy were 91.5 ± 14.5 min and 311 ml and 150 ± 18.6 min and 550 ml for two levels, respectively. Mean hospital stay was 5 days. About 95.45% of cases showed fusion at latest follow-up. Average preoperative kyphotic angle corrected from 34.2 ± 3.5° to 20.5 ± 1.0° postoperatively with an average correction of 41.1% and correction loss of 2.4%.

Conclusion: We concluded that utilization of the MOTA technique was safe and effective for providing decompression/fusion of traumatic TBF.
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http://dx.doi.org/10.25259/SNI_435_2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7533086PMC
August 2020

Posterior Stabilization Without Neural Decompression in Osteoporotic Thoracolumbar Fractures With Dynamic Cord Compression Causing Incomplete Neurological Deficits.

Global Spine J 2020 Oct 6:2192568220956954. Epub 2020 Oct 6.

Indian Spinal Injuries Centre, New Delhi, India.

Study Design: Prospective cohort study.

Objectives: Management of osteoporotic vertebral compression fracture (OVCF) remains an unsolved problem for a spine surgeon. We hypothesize that instability at the fracture site rather than neural compression is the main factor leading to a neurological deficit in patients with OVCF.

Methods: In this study, the prospective data of patients with osteoporotic fractures with incomplete neurological deficits from January 2015 to December 2017 was analyzed in those who underwent posterior instrumented fusion without neural decompression.

Results: A total of 61 patients received posterior indirect decompression via ligamentotaxis and stabilization only. Of these 17 patients had polymethylmethacrylate (PMMA) augmented screws and in 44 patients no PMMA augmentation was done. The mean preoperative kyphosis was 27.12° ± 9.63°, there was an improvement of 13.5° ± 6.87° in the immediate postoperative period and at the final follow-up, kyphosis was 13.7° ± 7.29° with a loss of correction by 2.85° ± 3.7°. The height restoration at the final follow-up was 45.4% ± 18.29%. In all patients, back pain was relieved, and neurological improvement was obtained by at least 1 American Spinal Injury Association Impairment Scale in all except 3 patients.

Conclusion: We propose that neural decompression of the spinal cord is not always necessary for the treatment of neurological impairment in patients with osteoporotic vertebral collapse with dynamic mobility. Dynamic magnetic resonance imaging is a valuable tool to make an accurate diagnosis and determine precise surgical plan and improving the surgical strategy of OVCF.
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http://dx.doi.org/10.1177/2192568220956954DOI Listing
October 2020

Differences in lumbar spine measures as a function of MRI posture in low back pain patients and its clinical implications.

Int J Neurosci 2020 Sep 23:1-10. Epub 2020 Sep 23.

Biodynamics Laboratory, Spine Research Institute, The Ohio State University, Columbus, OH, USA.

Study Design: Observational Study.

Objective: The primary objective was to determine if there were differences in spine structure measures between experimental postures and standard supine posture MRIs.

Methods: Thirty-four low back pain patients were included. MRI was taken in 6 experimental postures. The dependent measures includes sagittal view anterior (ADH), middle and posterior disc heights, thecal sac width, left/right foraminal height (FH). In the axial view: disc width, left and right foraminal height. Measures were done L3/L4, L4/L5 and L5/S1. Each subject served as their own control. Spine measurements in the experimental posture were compared to the same measures in the standard supine posture.

Results: 94% inter-observer reliability was seen. In the sagittal and axial view, 55 of the 108 and 11 of the 18 measures were significantly different. In sagittal view: a) ADH was significantly smaller in the sitting flexed posture by 2.50 mm ± 0.63 compared to the supine posture; b) ADH in sitting neutral posture was significantly smaller than the standard posture by 1.97 mm ± 0.86; c) sitting flexed posture showed that bilateral FH measures were significantly different; d) Bilateral FH was larger in the sitting neutral posture compared to the standard supine posture by 0.87 mm ± 0.17.

Conclusions: This research quantifies the differences in spine structure measures that occur in various experimental postures. The additional information gathered from an upright MRI may correlate with symptoms leading to an accurate diagnosis and assist in future spine research.
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http://dx.doi.org/10.1080/00207454.2020.1825420DOI Listing
September 2020

Anterior Distraction and Reduction with Posterior Stabilization for Basilar Invagination: A Novel Technique.

World Neurosurg 2021 01 3;145:19-24. Epub 2020 Sep 3.

Department of Orthopaedics, Indian Spinal Injuries Centre, New Delhi, India.

Background: Introduction of a posterior spacer for atlantoaxial joint distraction followed by posterior stabilization is a commonly performed procedure for irreducible atlantoaxial dislocation. We present a unique case in which posterior distraction was associated with increased risk of injury to the vertebral artery (VA) owing to its anomalous course, and hence a novel anterior distraction technique was used.

Case Description: A 45-year-old woman presented with severe neck pain for 1 month with gait imbalance and history of occipital headache for 1 year. Clinical examination revealed upper motor neuron-type findings. Hoffmann sign was positive bilaterally. Clinically, the patient had Nurick grade 4 cervical myelopathy. Magnetic resonance imaging showed basilar invagination along with Arnold-Chiari malformation and syrinx formation at C3-C4 vertebral levels. CT angiography revealed anomalous VAs directly overlying the atlanto-occipital joint. Owing to the anomalous route of the VA and unfavorable slope of facet joints, a 2-step anterior reduction followed by posterior stabilization surgery was planned. We achieved complete reduction using a 10-mm titanium cage inserted via a retropharyngeal approach. Following anterior reduction, instrumented in situ occipitocervical fusion was performed using a plate and screw construct. At 2-year follow-up, the patient is ambulating independently without gait imbalance and with successful radiologic fusion.

Conclusions: The craniovertebral junction has a unique pathoanatomy, and the course of the vertebral artery is variable. Appropriate investigations, including computed tomography angiography, with adequate surgical planning will provide a desirable long-term outcome. Our novel technique has the potential to add a new dimension to the management of irreducible atlantoaxial dislocation.
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http://dx.doi.org/10.1016/j.wneu.2020.08.220DOI Listing
January 2021

Degenerative cervical myelopathy: Recent updates and future directions.

J Clin Orthop Trauma 2020 Sep-Oct;11(5):822-829. Epub 2020 Jul 21.

Indian Spinal Injuries Center, Sector C, Vasant Kunj, New Delhi, 110070, India.

Advances in patient selection, surgical techniques, and postoperative care have facilitated spine surgeons to manage complex spine cases with shorter operative times, reduced hospital stay and improved outcomes. We focus this article on a few areas which have shown maximum developments in management of degenerative cervical myelopathy and also throw a glimpse into the future ahead. Imaging modalities, surgical decision making, robotics and neuro-navigation, minimally invasive spinal surgery, motion preservation, use of biologics are few of them. Through this review article, we hope to provide the readers with an insight into the present state of art in cervical myelopathy and what the future has in store for us.
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http://dx.doi.org/10.1016/j.jcot.2020.07.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7452218PMC
July 2020

Evolution of casting techniques in early-onset and congenital scoliosis.

J Clin Orthop Trauma 2020 Sep-Oct;11(5):810-815. Epub 2020 Jul 8.

Department of Spine Services, Indian Spinal Injuries Centre, Sector C, Vasant Kunj, New Delhi, 110070, India.

Casting is being utilized as a therapeutic strategy in some mild to moderate cases obviating surgical intervention for management of early-onset scoliosis (EOS). Bracing, another conservative modality, applies comparable correcting forces on chest wall and axial skeleton. But cast application carries additional advantage of sustained restorative force which bypasses issue of compliance seen with brace wear. There is no specific blanket treatment, conservative or surgical, for the early-onset spinal deformities. Serial cast application provides near total correction of less severe curves (less than 50 to 60) if treatment is initiated before age of 2 yrs. In this review article, we will assess the evolution of plaster cast application in management of EOS and also describe technique of EDF (Elongation- Derotation- Flexion) casting.
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http://dx.doi.org/10.1016/j.jcot.2020.06.034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7452255PMC
July 2020

Clinicoradiological outcomes of Goel and Harms fixation for atlantoaxial instability: An institutional experience.

Surg Neurol Int 2020 11;11:189. Epub 2020 Jul 11.

Department of Spine Service, Indian Spinal Injuries Center, New Delhi, India.

Background: Few studies have reported on the long-term outcomes of Goel and Harms C1-C2 fusions in the Asian population.

Methods: This was a retrospective analysis of 53 patients undergoing Goel and Harms fixation (2010 -2018). Clinical outcomes were assessed utilizing the neck disability index (NDI), Japanese Orthopedic Association (JOA) score, and visual analog scale (VAS). Outcomes were then correlated with fusion rates (using dynamic X-rays), atlanto-dens interval (ADI), and space available for cord (SAC) data.

Results: The study's 53 patients averaged 49.98 years of age and included 42 males and 11 females. The mean preoperative versus postoperative scores on multiple outcome measures showed NDI 31.62 ± 11.05 versus decreased to 8.68 ± 3.76 post, mean JOA score (e.g., in 41 patients with myelopathy) improved from 13.20 ± 3.96 to 15.2 ± 2.17, and the mean VAS decreased from 4.85 ± 1.03 to 1.02 ± 0.87 and showed restoration of the ADI (1.96 ± 0.35 mm) and SAC (20.42 ± 0.35 mm). A 98.13% rate of C1-C2 fusion was achieved at 12 postoperative months.

Conclusion: Goel and Harms technique for C1-C2 fusion resulted in both good clinical and radiological outcomes.
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http://dx.doi.org/10.25259/SNI_350_2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7395524PMC
July 2020

Sexual and Bladder Dysfunction in Cauda Equina Syndrome: Correlation with Clinical and Urodynamic Studies.

Asian Spine J 2020 Dec 21;14(6):782-789. Epub 2020 May 21.

Department of Spine Services, Indian Spinal Injuries Centre, New Delhi, India.

Study Design: Retrospective cohort study.

Purpose: To analyze the clinical and sphincteric outcomes and the extent of sexual dysfunction (SD) in subjects with cauda equina syndrome (CES) and to assess their correlation with patient-reported and clinical/urodynamic parameters.

Overview Of Literature: Despite vast literature present for CES, extent of the problem of SD in CES patients has not received enough attention as reflected by the limited information in literature. Little is known about exact prevalence at presentation or about the recovery. A better understanding of SD and bladder dysfunction in CES secondary to lumbar disc herniation is essential as it commonly occurs in the sexually active age group.

Methods: All cases of cauda equine syndrome secondary to lumbar disc herniation were recruited. Biographical and clinical data, history, examination findings, operative variables, recovery, and SD were noted. Water cystometry and uroflowmetry were done pre- and postoperatively. The International Index of Erectile Function questionnaire and Female Sexual Function Index were used to assess SD among the men and women, respectively.

Results: A total of 43 patients with up to 2.94-year follow-up were included. Urodynamic studies were found to correlate significantly with age, days of bladder involvement, perianal numbness, and motor weakness (p<0.01). In step-wise regression analysis, perianal sensation and overall motor weakness were bladder function determinants. Bladder function recovery was directly related to the number of delay days (t=2.30, p<0.05) and with unilateral leg pain (t=2.15, p<0.05). Significant correlation between SD with age and days of bladder involvement before surgery was found (p<0.01).

Conclusions: Surgery timing is related to patient's functional and sexual outcomes. Patients with unilateral leg pain and hypocontractile bladder have better outcomes. SD is a remarkable problem in CES.
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http://dx.doi.org/10.31616/asj.2019.0305DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7788371PMC
December 2020

Sympathetic Outflow Disturbance After Posterior Deformity Correction: A Rare Complication.

World Neurosurg 2020 08 11;140:89-95. Epub 2020 May 11.

Department of Spine Services, Indian Spinal Injuries Centre, New Delhi, India.

Introduction: Sympathetic system injury is a known but rare complication in scoliosis deformity correction. It is not common following posterior correction. We report a case of diastematomyelia with neuromuscular scoliosis with unusual complication of sympathetic outflow disturbance, after posterior instrumented correction.

Case Description: A 13-year-old girl presented with complaints of deformity in the back first noticed 4 years ago. Roentgenogram revealed a right thoracolumbar kyphoscoliotic deformity of 105° with apex at T8 with non-structural lumbar and cervicothoracic curves with positive sagittal alignment. Magnetic resonance imaging showed split-cord malformation with bony crest near the apex of the curve. Detethering followed by removal of the bony crest and restoration of the dual dural sleeves of the split cord into single neural tube was done in the first stage. In the second stage, pedicle screw fixation with was done from D3 to L3. Deformity correction was achieved using multilevel Smith Peterson osteotomy and concave rib osteotomy. On the second postoperative day, intensive care unit staff noticed persistent sinus tachycardia and profuse sweating in both upper limbs, chest, and upper-back. Twenty-four-hour Holter monitoring did not reveal any abnormality. Patient improved gradually and was discharged on postoperative day 9 when both sinus tachycardia and hyperhidrosis resolved.

Conclusions: Sympathetic chain disturbances after surgery recover with time. The exact time duration needed for recovery is not yet defined, however. Spine surgeons should be aware of this postsurgical complication and identify it so that management can be initiated. The symptoms may be long and drawn out, thus the roles of communication with and counseling of the patient as cannot be underemphasized.
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http://dx.doi.org/10.1016/j.wneu.2020.05.039DOI Listing
August 2020

Use of Topical Tranexamic Acid to Reduce Blood Loss in Single-Level Transforaminal Lumbar Interbody Fusion.

Asian Spine J 2020 Oct 30;14(5):593-600. Epub 2020 Mar 30.

Department of Spine Services, Indian Spinal Injuries Centre, New Delhi, India.

Study Design: Nonrandomized, prospective, and case-controlled study.

Purpose: To evaluate the efficacy and cost-effectiveness of topically applied tranexamic acid (TXA) during different phases of spine surgery.

Overview Of Literature: Perioperative blood loss is the leading cause of postoperative anemia associated with prolonged stays in hospital and long recovery times. The direct and indirect costs involved pose a significant economic challenge in developing countries. There is no consensus for topical use of tranexamic acid in spine surgery.

Methods: Patients requiring a single-level TLIF were divided into two groups. In the TXA group (n=75), the wound surface was soaked with TXA (1 g in 100 mL saline solution) for 3 minutes after exposure, after decompression, and before wound closure, and in the control group (n=175) using only saline. Intraoperative blood loss drain volume was recorded on each of the first 2 days immediately after surgery. An estimated cost analysis was made on the basis of the length of hospital stay and the blood transfusion.

Results: IBL for the control group was 783.33±332.71 mL and for intervention group 410.57±189.72 mL (p<0.001). The operative time for control group was 3.24±0.38 hours and for intervention group 2.99±0.79 hours (p<0.695). Hemovac drainage on days 1 and 2 for control group was 167.10±53.83 mL and 99.33±37.5 mL, respectively, and for intervention group 107.03±44.37 mL and 53.38±21.99 mL, respectively (p<0.001). The length of stay was significantly shorter in the intervention group (4.8±1.1 days) compared to control group (7.0±2.3 days). The cost of treatment in the intervention group was US dollar (USD) 4,552.57±1,222.6 compared with that in the control group USD 6,529.9±1,505.04.

Conclusions: Topical TXA is a viable, cost-effective method of decreasing perioperative blood loss in major spine surgery with fewer overall complications than other methods. Further studies are required to find the ideal dosage and timing.
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http://dx.doi.org/10.31616/asj.2019.0134DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7595815PMC
October 2020

Dysphagia in a Young Adult: Rare Case of Giant Cervical Osteophyte.

Asian J Neurosurg 2020 Jan-Mar;15(1):218-221. Epub 2020 Feb 25.

Department of Spine Services, Indian Spinal Injuries Centre, New Delhi, India.

Cervical osteophytes may be seen in diffuse idiopathic skeletal hyperostosis, ankylosing spondylitis, posttraumatic, postoperative, degenerative causes, cervical spondylosis, and infectious spondylitis. A cervical osteophyte is very rarely considered among the differentials for symptoms of dysphagia. C5-C6 as well as C6-C7 being a site of greater load-bearing and mobility, the propensity to form osteophytes is high, with a small osteophyte leading to local mass effect. A 42-year-old male patient presented with mild dyspnea and significant dysphagia since 8 months, accompanied by dysphonia, weight loss, and intermittent aspiration. Clinical examination including neurological examination was normal. A barium swallow showed that osteophytes were severely protruding and displacing the lower pharynx and the proximal esophagus anterosuperiorly. The patient underwent surgical removal of the osteophyte through Smith-Robinson approach. Complaints of dysphagia were significantly decreased in postoperative period. A thorough evaluation is necessary to rule out other causes of dysphagia. Surgical management of this uncommon condition might be considered after confirmation of the osteophyte to be the offending lesion as it has favorable clinical outcomes.
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http://dx.doi.org/10.4103/ajns.AJNS_181_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7057907PMC
February 2020

Letter to Editor concerning "Diagnostic accuracy of whole spine magnetic resonance imaging in spinal tuberculosis validated through tissue studies" by Kanna RM, et al. (Eur Spine J; 28 [2019]:3003-3010).

Eur Spine J 2020 05 16;29(5):1186-1187. Epub 2020 Mar 16.

Department of Spine Services, Indian Spinal Injuries Centre, Vasant kunj, Sector C, New Delhi, 110070, India.

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http://dx.doi.org/10.1007/s00586-020-06371-1DOI Listing
May 2020

Is VCR necessary to correct very severe deformity? case report and review of literature.

Int J Neurosci 2021 Mar 5;131(3):302-306. Epub 2020 Mar 5.

Department of Spine Services, Indian Spinal Injuries center, Vasant Kunj, New Delhi, India.

Management of severe scoliotic deformities is challenging. Deformity correction may need three column osteotomies that may be associated with significant morbidity. Staged procedure and use of Halo gravity traction is a useful strategy in such cases. A thirty-year-old woman presented with complaint of progressive deformity over the back for the past few years. She was very frail as per the adult spine deformity frailty index (ASD-FI), and her BMI was less than 18. Her Cobb angle measured 180 degrees of main thoracic curve. Her pulmonary function was compromised and had dyspnea on exertion. Management options in these deformities are limited and fraught with risk of major complications. To correct these deformities, a 2-3 level vertebral column resection (VCR) is required using an all-posterior approach. This patient was treated by anterior release followed by halo-gravity traction (HGT) for two weeks, which was then followed by posterior release and correction. The Cobb angle was reduced from 180° to 55° at final follow up of 2 years. Anterior release and traction can help in obviating the vertebral column resection in these severe rigid U-shaped deformities.
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http://dx.doi.org/10.1080/00207454.2020.1737530DOI Listing
March 2021

Computed Tomography-Based Feasibility Study of C1 Posterior Arch Crisscrossing Screw Fixation.

Asian Spine J 2020 Jun 8;14(3):298-304. Epub 2020 Jan 8.

Department of Spine Services, Indian Spinal Injuries Centre, New Delhi, India.

Study Design: Retrospective radiographic analysis.

Purpose: Posterior fixation of C1 using screws is the most popular technique among the various methods for C1 stabilization, but it places the surrounding neurovascular structures at risk. Approximately 20% of the population has an anomalous groove for the vertebral artery; therefore, salvage methods are necessary. Therefore, we analyzed the feasibility of a newer C1 posterior arch crisscrossing screw fixation technique and studied its feasibility in the Indian population on the basis of the anatomy of the C1 posterior arch.

Overview Of Literature: Multiple techniques have been described for C1-C2 fixation, such as wiring techniques, interlaminar clamps, transarticular screws, screw-plate/screw-rod system fixation, and hook-screw system fixation techniques, to provide rigid C1-C2 stability. However, although C1 fixation has evolved with time, it is not complication-free.

Methods: A 100 computed tomography (CT) scans of cervical spines with 1 mm slice thickness in the axial and sagittal sections obtained were randomly selected for the evaluation. Atlantoaxial anomalies due to trauma, deformities, infections, and tumors were excluded. All the images were measured for height of the posterior tubercle, width of the posterior arch, and length of the screw, and the screw projection angle was calculated. Demographic data were collected for all the subjects.

Results: Out of the 88 CT scans analyzed, the mean height of the posterior tubercle was 7.4 mm, wherein 84.09% exceeded 7 mm, and the width of the posterior tubercle was 5.4 mm, wherein 88.6% (n=78) had posterior arch width >3.5 mm. A total of 13.6% (n=12) vertebrae were not suitable for screw placement, whereas 75% (n=66) vertebrae could accommodate 3.5×15 mm or longer screws. The screw projection angles ranged from 11.2° to 35° on the right and from 15.6° to 38.2° on the left.

Conclusions: C1 posterior arch screw fixation is a feasible and safe method because it poses little risk of injury to the surrounding neurovascular structures.
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http://dx.doi.org/10.31616/asj.2019.0199DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7280928PMC
June 2020

Adjacent Level Tuberculous Spondylodiscitis Leading to Proximal Junctional Kyphosis: Rare and Unusual Presentation.

World Neurosurg 2020 Feb 9;134:e808-e814. Epub 2019 Nov 9.

Department of Spine Services, Indian Spinal Injuries Centre, New Delhi, India.

Background: Vertebral osteomyelitis manifesting as a compression fracture misdiagnosed in the setting of steroid-induced or senile osteoporosis is very rare, although such patients are prone to infection or reactivation, as their immune system is exhausted. Spondylodiscitis occurring at adjacent levels following instrumented spinal fusion leading to pathologic fracture and proximal junctional failure, especially caused by tuberculosis, to our knowledge, has not been discussed in the literature.

Methods: In case 1, a 61-year-old woman with osteoporotic T12 collapse was treated with corpectomy, anterior reconstruction, and posterior fixation from T9-L2. Initial biopsy and culture were normal. She presented 4 months later with compression fracture of T8; T8 corpectomy with anterior reconstruction and proximal extension of the construct was performed. In case 2, a 65-year-old woman with multiple comorbidities and osteoporotic L1 compression fracture was treated with L1 corpectomy, anterior reconstruction, and posterior instrumentation from T11-L3. She presented 4 months later with T10 vertebral body acute collapse; 2-stage anterior corpectomy and reconstruction was performed. In both cases, probing the affected vertebral body yielded pus. Pus and bone tissue samples sent for culture and histopathologic examination were positive for tuberculosis suggesting tuberculous spondylitis in both cases.

Results: In both patients, tuberculous spondylodiscitis at the proximal adjacent level was diagnosed <1 year after the initial spinal surgery. Neither patient had a previous history of pulmonary or extrapulmonary tuberculosis. They were successfully treated with antituberculous therapy and proximal extension of the construct with anterior reconstruction.

Conclusions: Adjacent segment spondylodiscitis should be suspected and intraoperative biopsy must be considered for histopathologic and microbiologic examination to rule out subclinical infection in immunosuppressed patients with multiple comorbidities. Management should be individualized, considering the context of infection, causative organism, extent of bone destruction, and neurologic involvement.
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http://dx.doi.org/10.1016/j.wneu.2019.11.007DOI Listing
February 2020

Reversible Central Hypoventilation Syndrome in Basilar Invagination.

World Neurosurg 2019 Nov 7;131:120-125. Epub 2019 Aug 7.

Department of Spine Services, Indian Spinal Injuries Centre, New Delhi, India.

Background: A noninvasive approach for basilar invagination (BI) and moreover, cervical traction to reduce odontoid invagination, has not been thoroughly described in the literature. We report a case of BI with Arnold-Chiari malformation in which preoperative reduction using Gardner well cervical traction was attempted and the patient developed central hypoventilation syndrome.

Case Description: A 15-year-old boy presented with a 6-month history of progressive cervical myelopathy signs and symptoms, modified Japanese orthopedic association score 12 of 18. Radiology showed type A BI with occipitalization of atlas and a posterior arch defect of axis. A preoperative closed cervical traction followed by occipitocervical fusion via a posterior-only approach was planned. The patient developed 3 episodes of apnea on sleeping when on traction. Labeled as central hypoventilation, he was operated by foramen magnum decompression and occipitocervical fusion.

Conclusions: Cervical traction followed by posterior fixation is an effective way to manage basilar invagination with Arnold-Chiari malformation and assimilated C1. However, patients should be monitored closely for respiratory dysfunction.
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http://dx.doi.org/10.1016/j.wneu.2019.07.236DOI Listing
November 2019