Publications by authors named "Kalyan Kumar Varma Kalidindi"

24 Publications

  • Page 1 of 1

Radiological changes in sagittal parameters after C1-C2 arthrodesis and their clinical correlation: Is there a difference between traumatic and non-traumatic causes?

Int J Neurosci 2021 May 12:1-10. Epub 2021 May 12.

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

: Compensatory changes in cervical sagittal alignment after C1-C2 arthrodesis have been reported in a few studies. No studies have explored the differences in these compensatory changes between traumatic and non-traumatic pathologies. Conflicting reports exist on the correlation between cervical sagittal parameters and neck pain or function.: Medical records of 81 consecutive patients [Jan 2010 - Dec 2018] who underwent Harms arthrodesis were retrospectively reviewed. 53 patients were included in the final analysis. Radiological parameters [C0-C1, C1-C2, C2-C7 angles and T1 slope] and clinical parameters [VAS (Visual analogue scale) and NDI (Neck disability index)] were compared between the two groups, Group A (traumatic) and Group B (non-traumatic).: The 53 patients [Group A ( = 24,) and Group B ( = 29)] had a mean age of 49.98 ± 21.82 years (42 males, 11 females). Mean follow up duration was 48.9 months. Δ C1-C2 angle is significantly correlated with ΔC2-C7 angle (Group A,  = 0.004; Group B,  = 0.015) but not with ΔC0-C1 angle (Group A,  = 0.315; Group B,  = 0.938). Though significant improvement in the clinical parameters (VAS/NDI) has been noted in both groups, Group A showed a greater improvement in VAS scores [Group A, ( < 0.001); Group B, ( < 0.023)]. The sub-axial sagittal profile was strongly correlated with the ΔC1-C2 angle in both groups. Group B showed greater changes in sagittal parameters after Harms fixation and Group A showed greater improvement in long-term functional outcomes. The final functional outcomes were not related to the initial or final radiological sagittal profile in both groups.
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http://dx.doi.org/10.1080/00207454.2021.1929213DOI Listing
May 2021

Intradural Conus Medullaris Lipoma With Neurological Deficit: A Rare Occurrence.

Cureus 2021 Mar 23;13(3):e14053. Epub 2021 Mar 23.

Department of Orthopedics, Indian Spinal Injuries Center, New Delhi, IND.

Intradural lipoma without spinal dysraphism is a rare occurrence. Most of them are asymptomatic but can also present with neurological deficits. A 54-year-old male patient presented to us with progressive weakness in both lower limbs for six months. On physical examination and radiological workup, intradural lipoma was diagnosed. Due to progressive neurological deficit, the patient was treated surgically. On 2.5 years of follow-up, the patient showed complete neurological recovery. Intradural lipomas can also present with the neurological deficit at any age and should be managed surgically if the deficit is progressive in nature. Surgical management has a good outcome if done within two years of onset of symptoms.
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http://dx.doi.org/10.7759/cureus.14053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8059682PMC
March 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

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

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

"White Cord Syndrome" of Acute Tetraplegia after Posterior Cervical Decompression and Resulting Hypoxic Brain Injury.

Asian J Neurosurg 2020 Jul-Sep;15(3):756-758. Epub 2020 Aug 28.

Indian Spinal Injuries Center, New Delhi, India.

White cord syndrome (WCS) is a rare case of severe neurological deterioration after surgical decompression for cervical myelopathy. It was proposed to be secondary to an ischemia/reperfusion injury. An association of WCS with a hypoxic brain injury (HBI) has not been documented. A 63-year-old man presented to us with progressive symptoms of cervical myelopathy. Computed tomography scan and magnetic resonance imaging (MRI) scan findings were suggestive of an ossified posterior longitudinal ligament with cord atrophy and myelomalacia changes. He was managed surgically by decompression and fusion through a posterior approach. During the surgery, there was a sudden loss of neuromonitoring signals after laminectomy, and wake-up assessment revealed neurological deterioration. Immediate postoperative imaging revealed adequately placed screws and adequate cord decompression. A high dose of intravenous steroids was given. Repeat MRI scan on the 3 postoperative day suggested cord edema over a large area on T2-weighted images. He was diagnosed as WCS and managed conservatively. He had persistent abdominal distension postoperatively, and a diagnostic endoscopy was advised. At the start of the procedure, the patient had a sudden-onset loss of consciousness. Electrocardiogram suggested bradyarrhythmias with hypotension. The patient was resuscitated, intubated, and shifted to intensive care unit. He was diagnosed to have a HBI. He was managed with multidisciplinary rehabilitation and discharged at 4 months' postoperatively with stable vitals. There was no improvement in the neurology or his consciousness. Spine surgeons have to be aware of this potentially disastrous complication of WCS. One should take adequate postoperative care to avoid preventable complications like HBI associated with it.
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http://dx.doi.org/10.4103/ajns.AJNS_240_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7591215PMC
August 2020

Letter to the Editor: Clinical Implication of Mid-Range Dynamic Instability in Lumbar Degenerative Spondylolisthesis.

Asian Spine J 2020 Oct 14;14(5):764-765. Epub 2020 Oct 14.

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

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http://dx.doi.org/10.31616/asj.2020.0412.r1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7595821PMC
October 2020

An unusual complication of quadriparesis after trigger point injection: a case report.

Pain 2021 Mar;162(3):711-713

Department of Anaesthesia, Indian Spinal Injuries Center, Vasant Kunj, New Delhi, India.

Abstract: Quadriparesis after intramuscular trigger point injections for myofascial pain syndrome has been rarely reported in the literature. A 37-year-old male patient presented with myofascial pain syndrome and was given trigger point injections in trapezius muscles under ultrasound guidance. The patient noticed weakness in all the 4 limbs at approximately 12 hours after the procedure, which gradually progressed to functional quadriplegia at the time of presentation to the emergency department. On examination, he had quadriparesis with no sensory involvement and superficial reflexes were normal. MRI screening of the whole spine was unremarkable, and MRI brain suggested an incidental granuloma, which could not explain his symptoms. Blood tests revealed severe hypokalemia (2.2 mEq/L) and deranged thyroid function tests. Immediate potassium correction with intravenous and oral potassium chloride was initiated, and the patient showed improvement within 6 hours of initiating correction. Stress of the procedure, use of steroids with mineralocorticoid effects such as methylprednisolone, or deranged thyroid function tests may have acted as triggers to precipitate hypokalemic paralysis in the patient. Knowledge of this complication is essential as prompt diagnosis and timely management of hypokalemia can result in complete resolution of the symptoms.
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http://dx.doi.org/10.1097/j.pain.0000000000002094DOI Listing
March 2021

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

Advancements in osteoporotic spine fixation.

J Clin Orthop Trauma 2020 Sep-Oct;11(5):778-785. Epub 2020 Jul 6.

Department of Spine Service, Indian Spinal Injuries Center, Sector-C, Vasant Kunj, New Delhi, 110070, India.

With the global rise in the population of elderly along with other risk factors, spine surgeons have to encounter osteoporotic spine more often. Osteoporotic spine, however, causes problems in management, particularly where instrumentation is involved, resulting in screw loosening, pull out, pseudoarthroses or adjacent segment kyphosis. Osteoporosis alters the bio mechanics at the bone implant interface resulting in various degrees of fixation failure. Various advancements have been made in this field to deal with such issues in addition to modification of basic surgical techniques such as increasing the diameter and length of the screw, smaller pilot hole, under tapping, longer constructs, supplemental anterior fixation, sublaminar wires or laminar hooks, use of transverse connectors and triangulation techniques, among others. They include novel surgical techniques such as cortical bone trajectory, superior cortical trajectory, double screw technique, cross trajectory technique, bicortical screw technique or prophylactic vertebroplasty. Advances in the screw design include expandable screws, fenestrated screws, conical screws and coated screws. In addition to PMMA cement augmentation, other biodegradable cements have been introduced to mitigate the side effects of PMMA such as calcium phosphate, calcium apatite and hydroxyapatite. Pharmacotherapy with teriparatide can aid fusion and lower the rate of pedicle screw loosening. Many of these strategies have only bio mechanical evidence and require well designed clinical trials to establish their clinical efficacy. Though no single technique is fool proof, little modifications in the existing techniques or utilizing a combination of techniques without adding to the cost of the surgery may help to achieve a near-ideal result. Surgeons have to equip their armamentarium with all the recent advances, and should be open to novel thoughts and techniques.
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http://dx.doi.org/10.1016/j.jcot.2020.06.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7452352PMC
July 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

Letter to the Editor concerning "Handgrip strength correlates with walking in lumbar spinal stenosis" by Inoue H. et al. [Eur Spine J (2020): DOI 10.1007/s00586-020-06525-1].

Eur Spine J 2020 11 2;29(11):2845. Epub 2020 Sep 2.

Department of Spine Service, Indian Spinal Injuries Centre, Vasant Kunj, New Delhi, India, 110070.

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http://dx.doi.org/10.1007/s00586-020-06582-6DOI Listing
November 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

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

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

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

A Prospective Study on the Feasibility, Safety, and Efficacy of a Modified Technique to Augment the Strength of Pedicle Screw in Osteoporotic Spine Fixation.

Asian Spine J 2020 Apr 8;14(3):357-363. Epub 2020 Jan 8.

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

Study Design: Prospective case study.

Purpose: Osteoporotic spine fixation by pedicle screw instrumentation is complicated by screw loosening, migration, or pullout with rates of up to 62% documented in the literature. Contemporary solutions have not adequately addressed these complications. We propose a modified surgical technique of cement augmentation with bicortical pedicle screw fixation to address the issue related to implant failure in osteoporotic spine.

Overview Of Literature: Zindrick and his colleagues described a "windshield wiper" effect owing to the shift of center of rotation to the distal tip of the screw in the bicortical purchase of screws. An increase in pullout strength from 119% to 250% with polymethyl methacrylate augmentation has been documented in the literature. This technique has not been described in the literature.

Methods: A prospective study was conducted with 40 patients who underwent surgery by the modified technique. Intraoperative and postoperative complications directly related to the procedure were assessed. Improvement in pain and functional status were assessed. Follow-up radiographs were assessed to check for appreciable screw migration, loosening, or pullout.

Results: This technique was used in inserting 364 screws in 40 patients. We did not encounter any difficulty in inserting the screws. A total of 19 screws failed to breach the anterior cortex owing to an error in measurement. There were no complications during the procedure in any of the patients, and the postoperative period was uneventful. The mean follow-up period was 18 months. There were two patients in whom proximal junctional failure with kyphosis was noted during follow-up, who were surgically managed by extension of the fixation levels.

Conclusions: Bicortical fixation with cement augmentation is a technically feasible, safe, and effective technique to augment the strength of pedicle screws in osteoporotic spine fixation. It has the potential to be established as a standard of care in osteoporotic spine fixation.
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http://dx.doi.org/10.31616/asj.2019.0211DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7280929PMC
April 2020

Spinal Epidural Hematoma Post Evacuation of Spontaneous Spinal Intradural Hematoma.

World Neurosurg 2020 Mar 28;135:160-164. Epub 2019 Nov 28.

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

Background: Spinal hematomas are rarely associated with dengue syndrome and usually occur at the time of active dengue fever. Late presentation after recovery from dengue fever, intradural hematoma, presentation as a multiloculated cystic lesion with longitudinal extensive myelitis, and recurrence after surgery are rarely or not described. Due to the peculiar association of all these findings, we report this case to provide insight into the existence of such a rare presentation.

Case Description: A 79-year-old-male developed sudden-onset paraparesis after 1 week of recovery from dengue fever. The blood counts were normal. Magnetic resonance imaging of the thoracic spine was suggestive of intradural hematoma. The patient underwent emergency decompression and drainage of hematoma with recovery in the neurologic status over the next few weeks. He presented to our emergency department after 5 weeks of the first surgery with deterioration in the neurologic status to complete paraplegia. Repeat magnetic resonance imaging showed a posterior epidural collection bulging anteriorly, causing cord compression. The patient was reoperated on by decompression. There was no neurologic recovery. The patient was managed with multidisciplinary rehabilitation, and he was independent in most of the activities at the time of discharge.

Conclusions: Spinal hematoma should be kept in mind in patients who present with neurologic complications after dengue fever. It can have an atypical radiologic presentation and may present with recurrent hemorrhage after surgery. Attention should also be given to delayed presentation of neurologic complications, which may develop even after weeks of recovery from dengue fever.
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http://dx.doi.org/10.1016/j.wneu.2019.11.119DOI Listing
March 2020

Role of lordotic rod contouring in thoracic myelopathy: a technical note.

Spinal Cord Ser Cases 2019 22;5:74. Epub 2019 Aug 22.

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

Introduction: Decompressive surgery for thoracic myelopathy due to anterior pathology can be challenging. Direct decompression through anterior approaches is associated with approach-related complications, whereas anterior decompression through posterior approaches is technically demanding and may result in neurological deterioration. We present a simple and effective surgical technique of indirect decompression through lordotic rod contouring to reduce such complications.

Case Presentation: Patients who presented to our center between March 2016 and March 2017 with symptoms and signs suggestive of thoracic myelopathy predominantly due to anterior pathologies such as ossification of the thoracic posterior longitudinal ligament, posterior bony spur, and thoracic disc herniation were evaluated in our study. The indications for surgical treatment were progressive neurological impairment and severe myelopathy (grade III or more on Nurick grade). Only those patients classified as grade III and above on American Society of Anaesthesiologists (ASA) physical status scale were included in the study. All the cases were operated by a single surgeon by a posterior-only approach. We have used this technique in four patients with thoracic myelopathy due to combined or predominant anterior pathology. Postoperative imaging confirmed adequate decompression of the spinal cord. All the cases improved substantially in terms of clinical outcome.

Discussion: This surgical technique could be a useful alternative to direct anterior decompression in patients who present with symptoms of progressive severe myelopathy due to anterior compression and could be the standard of care in those at high risk for major surgery.
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http://dx.doi.org/10.1038/s41394-019-0218-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6786501PMC
July 2020

A rare cause of neurological deterioration to complete paraplegia after surgery for thoracic myelopathy: a case report.

Spinal Cord Ser Cases 2019 5;5:55. Epub 2019 Jun 5.

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

Introduction: Progressive deterioration of neurological status post-thoracic myelopathy surgery after a clinically stable period is rare and can pose a diagnostic dilemma. We present our experience with such a case where all known etiologies were ruled out and the cause of deterioration could not be conclusively identified. The course was found to be similar to sub-acute post-traumatic ascending myelopathy (SPAM). However, the condition has only been described for traumatic injuries so far.

Case Presentation: Our patient presented a history of back pain and associated gait instability for one and a half months. There was no history of trauma. Investigations suggested an Anderson-like lesion at T11-T12 with cord edema at the same level suggestive of instability. She underwent posterior stabilization T9 to L2 and laminectomy of T11 as well as T12 under neuromonitoring. The postoperative sequence of events included an episode of pyrexia on the fifth day of surgery, neurological deterioration from the seventh day of surgery proceeding to complete paraplegia by the fourteenth day, no response to steroid treatment and no signs of recovery till two years post surgery. MRI findings were suggestive of SPAM, and there was no evidence of infection.

Discussion: Ascending myelopathy is a potential but rare cause of delayed deterioration in neurological status after surgical intervention. MRI findings of cord edema extending more than four levels above the involved segments is a characteristic finding of the condition. Ascending myelopathy may lead to complete cord injury. The precise cause of the condition is unknown and prognosis remains poor.
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http://dx.doi.org/10.1038/s41394-019-0202-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6786435PMC
July 2020

Conservative Management for Late Presenting Dural Tears After Spine Surgery: An Institutional Experience and Literature Review.

World Neurosurg 2020 Feb 19;134:e82-e92. Epub 2019 Sep 19.

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

Background: Symptoms and evidence of cerebrospinal fluid (CSF) leak after an uneventful intraoperative and immediate postoperative course are a rare entity in spine surgery. The literature is sparse on the description of such late presenting dural tears (LPDTs). They may need further admissions, wound management, and additional surgical procedures that add to the morbidity of the patient.

Methods: A retrospective review of spine surgeries done at our institute for degenerative spinal conditions between January 2017 and January 2018 was conducted. A mini meta-analysis was performed on studies comparing conservative and surgical management of LPDTs.

Results: Among 1929 patients, 6 cases (5 lumbar and 1 cervical) had an LPDT. Five of them had a CSF fistula and 1 patient had a pseudomeningocele. Two patients with CSF fistula were complicated by superficial surgical site infection (SSI). There was additional evidence of pneumocephalus and pneumorachis in 1 case. The SSI was managed by bedside debridement, regular dressing, and culture-sensitive antibiotics. CSF fistulas were managed by deep suturing, and pseudomeningocele was managed by excision of the sac and plication of the neck. All the patients had a good to an excellent outcome at the end of a 1-year follow-up.

Conclusions: One should be aware of the possibility of LPDTs. A combination of history, clinical examination, and imaging may aid in the diagnosis. It can be associated with complications like CSF fistula, pseudomeningocele, SSI, pneumocephalus, or pneumorachis. Conservative trial can have good to excellent outcomes in the management of such cases though there is insufficient evidence to establish it.
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http://dx.doi.org/10.1016/j.wneu.2019.09.067DOI Listing
February 2020

An Unusual Cause of Buttock Pain after Posterior Thoracolumbar Fixation: Rod Migration into the Pelvis.

J Orthop Case Rep 2019 ;9(5):31-34

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

Introduction: Posterior surgical stabilization is commonly indicated for unstable thoracolumbar fractures. Short segment stabilization has the advantage of preserving mobile segments and reducing excessive loads on the adjacent discs but is not without complications. Rod migration is an extremely rare complication after thoracolumbar fracture fixation and can lead to catastrophic visceral and vascular injuries. To the best of our knowledge, this is the first case report of a surgically managed distant rod migration into the posterior sacrum and pelvis after a posterior thoracolumbar trauma fixation.

Case Report: A 25-year-old male patient presented to our center with complaints of the right buttock and groin pain for 8weeks. He had a history of an unstable thoracolumbar fracture treated by a short segment posterior stabilization 5years back. On examination and investigations, we found that the right-sided rod migrated into the posterior sacrum and partly into the pelvis. The fracture had united well in kyphosis. Anticipating complications, the rod was removed through an incision over buttock. The other implants were also removed. The patient was asymptomatic at 2-year follow-up.

Conclusion: One should keep in mind the rare possibility of rod migration during follow-up of thoracolumbar trauma fixation. A proper history and clinical examination may guide the surgeon into such a rare possibility. Radiological investigations should be performed if there is suspicion and surgery may be advised when complications are anticipated depending on the location of the rod.
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http://dx.doi.org/10.13107/jocr.2019.v09.i05.1520DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7276621PMC
January 2019