Publications by authors named "Harvinder Singh Chhabra"

69 Publications

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

An extremely rare presentation of AV fistula: Massive destruction of multiple vertebral bodies with paraparesis.

Surg Neurol Int 2021 30;12:123. Epub 2021 Mar 30.

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

Background: Spinal ventral epidural arteriovenous fistulas (EDAVFs) are rare and underdiagnosed entities and usually present with benign symptoms such as radiculopathy. To the best of our knowledge, EDAVFs presenting with massive vertebral body destruction have not been reported in the literature.

Case Description: A young male presented with mid back pain for 1 year and weakness of both lower limbs for 3 months. He was clinicoradiologically diagnosed with spinal tuberculosis and started on antitubercular treatment elsewhere. Radiological investigations suggested destruction and collapse of T12 and L1 vertebrae. Prominent flow voids were seen in T9-L2 epidural space, likely prominent epidural vessels. The primary differential diagnoses were spinal tuberculosis and neoplastic etiologies. T9 to L3 surgical stabilization and anterior decompression by pediculectomy of left T12 and L was done. The surgeon encountered massive bleeding at the time of anterior decompression and a vascular etiology was suspected. Biopsy revealed negative results for infection or malignancy. DSA revealed ventral EDAVFs, and hence, transcatheter embolization was performed. He had excellent outcome on assessment at 21 months postoperative follow-up.

Conclusion: Spinal epidural AVFs can rarely present with gross vertebral body destruction and paraparesis. Preoperative radiological assessment with suspicion of spinal epidural AVFs can help to avoid intraoperative difficulties and complications. Timely, management of spinal epidural AVFs can result in excellent outcomes.
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http://dx.doi.org/10.25259/SNI_875_2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8053452PMC
March 2021

Severe Form of Bacterial Meningitis After Spine Surgery: A Case Report and Review of the Literature.

Cureus 2021 Mar 14;13(3):e13877. Epub 2021 Mar 14.

Orthopaedics, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, IND.

Meningitis after spine surgery is a rare complication. In this report, we aim to discuss the case of a male patient who developed this rare condition after undergoing cervical spine surgery with devastating outcomes. We also engage in a review of the relevant literature. A 17-year-old boy presented with post-traumatic cervical kyphotic deformity with signs of cord compression. He was operated in three stages, all conducted in a single sitting. There was an incidental cerebrospinal fluid (CSF) leak, which was primarily repaired. On the fourth postoperative day, the patient developed altered sensorium and seizures. Evaluations for clinical signs of meningitis such as neck rigidity and Kernig's sign were inconclusive. CSF analysis confirmed the diagnosis of meningitis. Thereafter, the patient developed hydrocephalus and intractable infection, for which multiple procedures were done. Finally, we succeeded in controlling the infection, but the patient developed a neurological deficit, which did not resolve even after 2.5 years of follow-up. The clinical signs and symptoms of meningitis after cervical spine surgery are not very clear or suggestive. A strong index of suspicion should be maintained for the early detection of this condition to prevent devastating complications that result from it.
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http://dx.doi.org/10.7759/cureus.13877DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8043217PMC
March 2021

Effect of Meditation on Psychological and Functional Outcomes in Spinal Cord Injury Patients.

Int J Yoga 2021 Jan-Apr;14(1):36-42. Epub 2021 Feb 5.

Indian Spinal Injuries Centre, New Delhi, India.

Background: Spinal cord injury (SCI) is a debilitating disorder with dysfunction in daily activities and psychological consequences like anxiety as well as depression impacting the quality of life substantially. Existing treatments focus mainly on rehabilitation, symptom reduction, and secondary complications. However, psychological, social, and existential issues are least addressed in the prevailing models.

Aims: To study the role of meditation in addressing psychological impairment and any resultant improvement in functional outcomes in SCI patients.

Methods: Nonrandomized controlled study was conducted in a tertiary care center for SCI patients. Hospital inpatients were recruited into either experimental intervention group (add on easy with conventional rehabilitation-ER = 50) or control intervention group (conventional rehabilitation alone-CR = 50). Patients in the ER group received easy for 1 month, along with conventional rehabilitation and the CR group patients received only conventional rehabilitation. All the subjects were assessed for psychological (perceived stress scale [PSS], Hospital Anxiety and Depression Scale [HADS]) and functional impairment (spinal cord independence measure (SCIM), numeric pain rating (NPR) and WHO quality of life-BRIEF (WHOQOLBREF)] at baseline and after 1 month.

Results: After 1 month of add-on easy , there was significant decrease in the scores of HADS (F[1,88] = 272.92, < 0.001), PSS (F[1,88] = 274.41, < 0.001) and NPR (F[1,88] = 60.60, < 0.001) and significant increase in the scores of WHOQOLBREF (F[1,88] = 349.94, < 0.001) and SCIM (F[1,88] = 29.09, < 0.001) in the ER group compared to CR group in analysis of covariance.

Conclusion: One-month add-on easy improves psychological and functional outcomes (HADS, PSS, NPR, WHOQOLBREF and SCIM) in patients with SCI. Future studies with robust designs are needed to validate the results.
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http://dx.doi.org/10.4103/ijoy.IJOY_68_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8023440PMC
February 2021

New Onset Sacroiliac Joint Pain After Transforaminal Interbody Fusion: What Are the Culprits?

Global Spine J 2021 Apr 12:21925682211003852. Epub 2021 Apr 12.

Department of Spine Service, 76434Indian Spinal Injuries Center, Vasant Kunj, New Delhi, India.

Study Design: A retrospective case-control study.

Objective: Only a few studies have studied the incidence of new-onset SI joint pain following lumbar spine fusion surgery. We aimed to explore the association between new-onset SI joint pain following Transforaminal Lumbar Interbody Fusion (TLIF) for degenerative spine disorders and changes in spinopelvic parameters.

Methods: A retrospective review of hospital records and imaging database of a tertiary care institute was done for patients who underwent TLIF from October 2018 to October 2019. The 354 patients who satisfied the eligibility criteria were divided into 2 groups(Group A, new-onset SI joint pain group, n = 34 and Group B, normal controls, n = 320). Symptomatic relief (>70% reduction in the VAS [Visual Analogue Scale] score) after 15 minutes of SI joint injection was considered diagnostic of SI joint pain. Clinical and radiological spinopelvic parameters were compared between the 2 groups.

Results: Patients with postoperative SI joint pain (Group A) had significantly less preoperative and postoperative lumbar lordosis (p < 0.001) compared to the other group. Most of the patients in Group A had a cephalad migration of the apex postoperatively (30/34 patients) whereas majority of patients in group B had either predominant caudal migration (44/320 patients) or no migration of the lumbar apex (272/320 patients).

Conclusions: The preoperative and postoperative lumbar lordosis are significantly less and the postoperative pelvic tilt is significantly high in patients with new-onset SI joint pain compared to the control group. The cephalad migration of the lumbar apex is significantly associated with new-onset SI joint pain.
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http://dx.doi.org/10.1177/21925682211003852DOI Listing
April 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

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

Incidence and Risk Factors for Neurological Deterioration in Posterior Corrective Surgeries for Severe Angular Kyphotic Deformities: A 10-Year Institutional Retrospective Study.

Global Spine J 2020 Dec 30:2192568220979122. Epub 2020 Dec 30.

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

Study Design: Retrospective case-control study.

Objective: Neurological deficit is one of the dreaded complications of kyphotic deformity correction procedures. There is inconsistency in the reports of neurological outcomes following such procedures and only a few studies have analyzed the risk factors for neurological deficits. We aimed to analyze the factors associated with neurological deterioration in severe kyphotic deformity correction surgeries.

Methods: We performed a retrospective study of 121 consecutive surgically treated severe kyphotic deformity cases (49 males, 56 females) at a single institute (May 1st 2008 to May 31st 2018) and analyzed the risk factors for neurological deterioration. The demographic, surgical and clinical details of the patients were obtained by reviewing the medical records.

Results: 105 included patients were divided into 2 groups: Group A (without neurological deficit) with 92 patients (42 males, 50 females) and Group B (with neurological deficit) with 13 patients (7 males, 6 females) (12.4%). Statistically significant difference between the 2 groups was observed in the preoperative sagittal Cobbs angle (p < 0.0001), operative time (p = 0.003) and the presence of myelopathic signs on neurological examination (p = 0.048) and location of the apex of deformity (p = 0.010) but not in other factors.

Conclusions: Preoperative Sagittal Cobbs angle, presence of signs of myelopathy, operative time and location of apex in the distal thoracic region were significantly higher in patients with neurological deterioration as compared to those without neurological deterioration during kyphotic deformity correction surgery. Distal thoracic curve was found to have 4 times more risk of neurological deterioration compared to others.
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http://dx.doi.org/10.1177/2192568220979122DOI Listing
December 2020

Long-Term Functional Outcomes of Endoscopic Decompression with Destandau Technique for Lumbar Canal Stenosis.

Asian Spine J 2020 Nov 16. Epub 2020 Nov 16.

Department of Neurosurgery, Bel Air Clinic, Bordeaux, France.

Study Design: Retrospective study of patients with lumbar canal stenosis (LCS) operated using endoscopic unilateral laminotomy with bilateral decompression (ULBD).

Purpose: This study aimed to provide a detailed description of the technique of endoscopic decompression in LCS along with a description of the surgical anatomy and its advantages. We also discuss the clinical outcomes in patients operated using this technique.

Overview Of Literature: In 1999, the results with the use of microscopic ULBD were published. Microscopic/microendoscopic decompression using tubular retractor system showed good to excellent results in studies that compared such techniques with midline decompression. The first description of the use of endoscope in spine surgery was in 1988 when it was used for discectomy. With advancements and familiarity with the techniques, full endoscopic surgery has found application in LCS treatment.

Methods: The clinical records of 953 patients who were operated between 1998 and 2008 were analyzed in 2018. Along with patient characteristics, information about return to daily activities, complication rates, and functional outcomes using Prolo score was assessed.

Results: L4-L5 was the most common level for which surgery was performed. Two-level decompression was performed in 116 patients; 89.5% patients were able to return to their daily activities after 2 weeks. Functional outcomes as per the Prolo score were reported by patients as excellent, good, and poor in 89.85%, 1.59%, and 8.55%, respectively. Repeat surgery was required at same level in 16 patients and at a different level in 21 patients. Total 605 patients (63.49%) were symptom-free during the 70-month followup, while 344 complained of residual back pain, and four complained of persistent leg pain.

Conclusions: ULBD using the Endospine system achieves adequate decompression in most cases and is a good alternative to open laminectomy, with the advantage of avoiding damage to the structural integrity of the spine and preserving soft tissue attachments.
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http://dx.doi.org/10.31616/asj.2020.0120DOI Listing
November 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

Ligamentum Flavum Cyst With Acute Onset Motor Deficit: A Literature Review and Case Series.

Int J Spine Surg 2020 Aug 31;14(4):544-551. Epub 2020 Jul 31.

Indian Spinal Injuries Centre, Vasant Kunj, New Delhi, India.

Background: Ligamentum flavum cysts have been rarely described in the literature and are one of the rare causes of neural compression and canal stenosis. Very few cases of their association with neurologic deficits are reported to date, and association with acute onset weakness is even rarer.

Clinical Presentation: We report our experience with 3 cases of ligamentum flavum cyst that presented with acute onset weakness and also present a comprehensive literature review on lumbar ligamentum flavum cysts reported to date. All 3 patients had symptoms of severe neurogenic claudication and presented to us with acute onset of motor weakness in lower limbs. Ligamentum flavum cyst was located in the midline in 2 cases and laterally in 1 case. We performed excision of the cyst and decompression with fusion in 2 cases and decompression alone in 1 case. All 3 cases had significant improvement in their neurologic status postoperatively. Histopathological examination confirmed ligamentum flavum cyst in all 3 cases. We performed a PUBMED and EMBASE database search using the MeSH (Medical Subject Headings) terms "ligamentum flavum" and "cysts" for articles published to April 2019. We could identify 7 studies describing 20 cases of lumbar ligamentum flavum cysts with motor weakness in the literature. Only 1 case had been described with an acute onset of weakness.

Conclusions: Ligamentum flavum cysts should remain in the differential diagnosis of a patient who has symptoms of lumbar canal stenosis and presents with acute onset of neurological deficits. Such patients have a good improvement with surgery.
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http://dx.doi.org/10.14444/7072DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7478069PMC
August 2020

Robotic spine surgery: a review of the present status.

J Med Eng Technol 2020 4;44(7):431-437. Epub 2020 Sep 4.

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

With technological advancements being introduced and dominating many fields, spine surgery is no exception. In view of the patient safety and surgeon's comfort, robotics has been introduced in spine surgery. Due to small corridors for work, little room for inaccuracy, lengthy and tedious procedures, spine surgery is an ideal scenario for robotics to establish as the standard of care. Spine robotics received their first FDA clearance in 2004. New generation of spine robotics with integrated navigation systems has become available now. The primary role of spine robotics, at present, is to aid pedicle screw fixation. High quality studies have been performed to establish its role in increasing the accuracy of pedicle fixation. Studies have also reported decreased radiation and decreased operative time with spine robotics. However, few studies have reported otherwise. It is still in its nascent stage in both industrial view and surgeon familiarity. Continued research to overcome the challenges such as high cost and steep learning curve is crucial for its widespread use. Also, expanding the scope of spine robotics beyond pedicle screw fixation such as osteotomies and dural procedures would be an area for potential research. This review is intended to provide an overview of various studies in the field of robotic spine surgery and its present status.
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http://dx.doi.org/10.1080/03091902.2020.1799098DOI Listing
September 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

Spinal Injury in Indian Children: Review of 204 Cases.

Global Spine J 2020 Dec 18;10(8):1034-1039. Epub 2019 Nov 18.

76434Indian Spinal Injuries Centre, New Delhi, India.

Study Design: Retrospective study.

Objective: The purpose of the study was to analyze the epidemiological parameters and associated factors after spinal cord injury (SCI) in children, in the last 14 years admitted at a tertiary care center (Indian Spinal Injury Centre [ISIC], New Delhi, India).

Method: The demographic and injury-related data was analyzed descriptively. The incidence, type, and level of injury were compared across the age groups using a χ test. Wherever appropriate, Fisher exact test was used.

Results: There were 1660 pediatric trauma cases admitted at ISIC from 2002 to 2015, where 204 cases presented with spine injuries. The average age of children sustaining spine injury was 15.69 years (3-18 years of range). There were 15 patients in the age group 0 to 9 years, 27 patients in the age group 10 to 14 years, and 162 patients in the age group 15 to 18 years. This difference in spine injury incidence among the age groups was statistically significant. Fall from height was a common mode of injury. In our sample, boys were 3 times more likely to be injured than girls. Burst fractures were common among the type of injuries.

Conclusion: Our study confirms the predominance of cervical spine injury and the high incidence of multilevel contiguous with a lesser percentage of noncontiguous multilevel spinal involvement. SCIWORA (spinal cord injury without radiological abnormality) incidences were in a similar context to the literature available. There was a very low incidence of death. Neurological improvement was seen in 8 operated cases and 4 conservatively treated cases.
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http://dx.doi.org/10.1177/2192568219887155DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7645094PMC
December 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

Self-inflicted injuries: Three case reports.

Med Leg J 2020 Dec 23;88(4):223-227. Epub 2020 Jul 23.

Department of Radiodiagnosis, AIIMS, Bathinda, India.

The means by which people self-harm are diverse and so are the motives that drive them. They are intended for personal gain which may be psychological, legal or material. Fabricated injuries may be self-inflicted or permitted by others. We present three cases of fabricated injuries over the shoulder and upper limbs both alleging assault with a firearm. In all the cases meticulous examination elicited suspicion on how these were caused. Meticulous examination is essential to differentiate true from false accusations so that no innocent person is punished.
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http://dx.doi.org/10.1177/0025817220935909DOI Listing
December 2020

Nucleus Polposus Embolism Causing Anterior Spinal Artery Occlusion: A Rare but Possible Cause of Fibrocartilaginous Embolic Myelopathy.

Int J Spine Surg 2020 Jun 30;14(3):391-396. Epub 2020 Jun 30.

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

Background: Fibrocartilaginous embolic myelopathy (FCEM) is a rare cause of spinal cord infarction. It has been confirmed by autopsy in postmortem cases. Herein we describe a case of FCEM diagnosed based on clinical grounds.

Methods: A 58-year-old man presented with acute onset of complete paraplegia with bladder and bowel involvement developing a few hours after a trivial trauma. There were no upper motor neuron signs. His magnetic resonance imaging (MRI) was suggestive of longitudinally extensive transverse myelitis from T5 to the conus. There was left paracentral disc protrusion at the T4-T5 level. However, no features of inflammatory, infectious, or autoimmune etiology were found on history, on examination, or in blood or cerebrospinal fluid analysis, and there was no contrast enhancement on MRI.

Results: A diagnosis of anterior spinal artery occlusion was made based on clinical examination with sparing of posterior column sensations in the lower limbs, predominant involvement of anterior half of the spinal cord on MRI, and accompanying new onset of back pain with rapid symptom progression to nadir as opposed to inflammatory etiology. Fibrocartilaginous embolism was suspected after ruling out all other causes of vascular compromise and presence of disc herniation at T4-T5. He was managed with rehabilitation and showed no signs of recovery.

Conclusion: FCEM, though rare, should be kept in mind as a differential diagnosis of acute medical myelopathy when no other cause can be identified.
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http://dx.doi.org/10.14444/7051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7343251PMC
June 2020

Magnetic resonance imaging findings in intervertebral disc herniation: Comparison of canal compromise and canal size in patients with and without cauda equina syndrome.

Surg Neurol Int 2020 27;11:171. Epub 2020 Jun 27.

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

Background: Surgical decompressions are typically warranted in patients with magnetic resonance (MR) and clinical evidence of cauda equina syndromes (CESs). However, it is still unclear what MR findings best correlate with such CES. Here, we compared MR-documented canal size and level/extent of compromise in 52 patients with and 56 others without CES attributed to lumbar disc herniation.

Methods: This was a retrospective study of 52 patients with and 56 patients without CES attributed to MR- documented lumbar disc herniations (IDHs). The anteroposterior diameters of the spinal canal and the levels of maximal compression were documented and compared utilizing MR scans from both groups.

Results: The 52 patients with CES had more extensive narrowing of the canal diameters at the L4-L5 and L5- S1 levels and higher mean canal compression ratios versus 56 patients without CES. The mean percentage of compression in the CES group at L4-L5 and L5-S1 levels (70% and 67.5%, respectively) was less versus L2-L3 and L3-L4 levels (89.7% and 81.8%, respectively).

Conclusion: The 52 patients with CES due to IDH had greater canal compromise versus 56 without CES. Further, the percentage of canal compromise was less at L4-L5 and L5-S1 levels compared to other levels in patients with CES.
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http://dx.doi.org/10.25259/SNI_242_2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7332702PMC
June 2020

Validation Study of Rajasekaran's Kyphosis Classification System: Do We Clearly Understand Single- and Two-Column Deficiencies?

Asian Spine J 2020 Aug 5;14(4):475-488. Epub 2020 Jun 5.

Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India.

Study Design: Multicenter validation study.

Purpose: To evaluate the inter-rater reliability of Rajasekaran's kyphosis classification through a multicenter validation study.

Overview Of Literature: The classification of kyphosis, developed by Rajasekaran, incorporates factors related to curve characteristics, including column deficiency, disc mobility, curve magnitude, and osteotomy requirements. Although the classification offers significant benefits in determining prognosis and management decisions, it has not been subjected to multicenter validation.

Methods: A total of 30 sets of images, including plain radiographs, computed tomography scans, and magnetic resonance imaging scans, were randomly selected from our hospital patient database. All patients had undergone deformity correction surgery for kyphosis. Twelve spine surgeons from the Asia-Pacific region (six different countries) independently evaluated and classified the deformity types and proposed their surgical recommendations. This information was then compared with standard deformity classification and surgical recommendations.

Results: The kappa coefficients for the classification were as follows: 0.88 for type 1A, 0.78 for type 1B, 0.50 for type 2B, 0.40 for type 3A, 0.63 for type 3B, and 0.86 for type 3C deformities. The overall kappa coefficient for the classification was 0.68. Regarding the repeatability of osteotomy recommendations, kappa values were the highest for Ponte's (Schwab type 2) osteotomy (kappa 0.8). Kappa values for other osteotomy recommendations were 0.52 for pedicle subtraction/disc-bone osteotomy (Schwab type 3/4), 0.42 for vertebral column resection (VCR, type 5), and 0.30 for multilevel VCRs (type 6).

Conclusions: Excellent accuracy was found for types 1A, 1B, and 3C deformities (ends of spectrum). There was more variation among surgeons in differentiating between one-column (types 2A and 2B) and two-column (types 3A and 3B) deficiencies, as surgeons often failed to recognize the radiological signs of posterior column failure. This failure to identify column deficiencies can potentially alter kyphosis management. There was excellent consensus among surgeons in the recommendation of type 2 osteotomy; however, some variation was observed in their choice for other osteotomies.
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http://dx.doi.org/10.31616/asj.2020.0014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7435303PMC
August 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

COVID-19: Current Knowledge and Best Practices for Orthopaedic Surgeons.

Indian J Orthop 2020 May 18:1-15. Epub 2020 May 18.

8Department of Orthopaedics and Spine Surgery, Ganga Hospital, Coimbatore, 641043 India.

Background: A mysterious cluster outbreak of pneumonia in Wuhan, China in December 2019 was traced to Severe Acute Respiratory Syndrome Coronavirus 2 and declared a Pandemic by WHO on 11th March 2020. The pandemic has spread rapidly causing widespread devastation globally.

Purpose: This review provides a brief understanding of pathophysiology, clinical features, diagnosis and management of COVID-19 and highlights the current knowledge as well as best practices for orthopaedic surgeons. These are likely to change as knowledge and evidence is gained.

Results: Orthopaedic surgeons, like other front-line workers, carry the risk of getting infected during their practice, which as such is already substantially affected. Implementation of infection prevention and control as well as other safety measures for health care workers assumes great importance. All patients/visitors and staff visiting the hospital should be screened. Conservative treatment should be the first line of treatment except for those requiring urgent/emergent care. During lockdown all elective surgeries are to be withheld. All attempts should be made to reduce hospital visits and telemedicine is to be encouraged. Inpatient management of COVID-19 patients requires approval from concerned authorities. All patients being admitted to the hospital in and around containment zones should be tested for COVID-19. There are special considerations for anaesthesia with preference for regional anaesthesia. A separate Operation room with specific workflow should be dedicated for COVID-19 positive cases.

Conclusions: Despite the magnitude of challenge, the pandemic offers significant lessons for the orthopaedic surgeon who should seek the opportunity within the adversity and use this time wisely to achieve his/her Ikigai.
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http://dx.doi.org/10.1007/s43465-020-00135-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7232909PMC
May 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

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

Cauda equina syndrome: false-positive diagnosis of neurogenic bladder can be reduced by multichannel urodynamic study.

Eur Spine J 2020 06 6;29(6):1236-1247. Epub 2020 Jan 6.

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

Background: The present consensus suggests urgent surgical decompression if clinical features of cauda equina syndrome (CES) are supported by MRI evidence of pressure on cauda equina. However, clinical diagnosis has a high false-positive rate and MRI is a poor indicator. Though urodynamic studies (UDS) provide objective information about the lower urinary tract symptoms experienced by patients including neurogenic bladder, its role in the diagnosis of CES is not established.

Objective: To evaluate the ability of an objective urological assessment protocol using uroflowmetry + USG-PVR as screening test and invasive UDS as confirmatory test in patients with suspected CES to rule out neurological impairment of the bladder function.

Methods: A retrospective study was conducted on all patients who were referred to our institution with equivocal findings of cauda equina syndrome from January 2014 to December 2018 with positive MRI findings. An algorithm using multichannel UDS was followed in all the included patients.

Results: Out of 249 patients who fulfilled the inclusion criteria, 34 patients (13.65%) had normal uroflowmetry and USG-PVR findings; 211 patients underwent the invasive UDS. Only 141(57.6%) patients out of 245 patients had neurovesical involvement due to compression of cauda equina; 67 patients were treated conservatively using the objective protocol. Only one patient treated conservatively had to undergo emergency decompression for deterioration in symptoms.

Conclusions: Multichannel UDS provides an objective diagnostic tool to definitively establish the neurovesical involvement in CES. Utilising multichannel UDS as an adjunct to clinical findings avoids the probability of false-positive diagnosis of CES. These slides can be retrieved under Electronic Supplementary Material.
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http://dx.doi.org/10.1007/s00586-019-06277-7DOI Listing
June 2020