Publications by authors named "Nandan Marathe"

75 Publications

A Rare Case of Sphingomonas paucimobilis Spondylodiscitis Managed Surgically.

J Orthop Case Rep 2021 Apr;11(4):91-96

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

Introduction: Sphingomonas paucimobilis is an opportunistic pathogen and a rare cause of human infection. This case report shows bacteremia with pyogenic spondylodiscitis in lumbosacral spine caused by Sphingomonas and discusses its clinical diagnosis, treatment, and literature reviews.

Case Report: Patient presented with severe low back pain, inability to walk and fever following a L5-S1 decompression elsewhere, which corresponded clinico-radiologically with a picture of a spondylodiscitis on radiographs, magnetic resonance imaging, and computed tomography. His blood culture was positive for S. paucimobilis. He was treated successfully by surgical debridement, stabilization, and fusion along with intravenous Linezolid followed by oral therapy, based on the antibiotic susceptibility profile. Repeat blood culture was negative after 7 weeks of antibiotic therapy. Patient improved symptomatically with radiographs showing good fusion at 1 year follow-up. S. paucimobilis, though a low virulence organism, is an emerging pathogen and should be dealt with cautiously.

Conclusion: This reiterates the importance of culture as unusual organisms may be isolated and appropriate antibiotics form the mainstay of treatment.
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http://dx.doi.org/10.13107/jocr.2021.v11.i04.2166DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8310646PMC
April 2021

Degenerative Cervical Spondylosis: A Cause of Vertigo?

Global Spine J 2021 Jul 16:21925682211027840. Epub 2021 Jul 16.

Department of Orthopedics, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India.

Study Design: Prospective observational study.

Objectives: Studying the effect of degenerative cervical spondylosis(CS) on blood flow velocity of vertebral artery (VA) during cervical spine rotation in different head positions and its association with vertigo.

Introduction: Vertigo is one of the most common complaints seen in an out-patient clinic. Its association with CS remains an enigma for a treating physician. This study planned to systematically analyze the association between vertigo and CS by evaluating VA blood flow dynamics in different head positions.

Methods: 100 patients with ages ranging from 20-80 years were recruited. First group of 50 patients with CS with vertigo were compared with second study group of 50 patients having CS without vertigo. Cervical radiographs were used to evaluate CS using cervical degenerative index (CDI). Color doppler was used to measure VA blood flow with head in neutral position and 60° lateral rotation with 30° extension. Same procedure was repeated on opposite side. Measurements performed included peak systolic blood flow velocity(PSV) and end diastolic blood flow velocity (EDV).

Results: Among patients with CS, patients having vertigo showed significantly more evident degenerative changes (CDI ≥25) (=<0.001). High grade CS patients (CDI ≥25) with vertigo had statistically significant lower blood flow parameters with head rotation in the left and right VAs as compared to CS patients without vertigo.

Conclusion: This study highlights important pathophysiological mechanism of vertigo observed in patients of CS. The magnitude of reduction in VA blood flow was significantly higher in patients with advanced CS presenting as vertigo.
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http://dx.doi.org/10.1177/21925682211027840DOI Listing
July 2021

Does a high BMI affect the outcome of minimally invasive TLIF? A retrospective study of 207 patients.

Eur Spine J 2021 Jul 5. Epub 2021 Jul 5.

Department of Orthopaedics and Spine Surgery, KEM Hospital, Mumbai, India.

Purpose: We investigated whether a high Body Mass Index (BMI) affects the outcomes following Minimally Invasive TLIF (MI-TLIF) for degenerative lumbar pathologies.

Methods: A retrospective study was undertaken to include patients operated between January 2016 and January 2020 with at least one-year follow-up. Various preoperative and demographic parameters were recorded and the patients were classified into normal, overweight and obese based on the BMI. The operative and outcome measures used for assessment were surgical time, blood loss, number of levels operated upon, skin incision length, day of independent mobilisation, total hospital stay including ICU stay, return to work and Visual Analogue Score (VAS) for back pain (VAS-BP) and leg pain (VAS-LP) and Oswestry Disability Index (ODI). Attainment of Minimal Clinically Important Difference (MCID) for the scores was calculated. Multivariate analyses were done to assess the effect of BMI on different parameters.

Results: Blood loss and postoperative ICU stay were found to be higher in the obese patients. However, the other variables were comparable. VAS-BP, VAS-LP and ODI scores were significantly improved in all the patients with no inter-group variability. The MCID attainment was also similar. The satisfaction rating at 1-year and willingness for surgery again for similar disease was also similar. The overall complication rate was 14.9% and was comparable among the groups. Multivariate analyses revealed no significant association between BMI and various parameters.

Conclusion: In patients treated by MI-TLIF for degenerative lumbar spine pathology, BMI is not a factor that negatively affects the functional and clinical outcomes.
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http://dx.doi.org/10.1007/s00586-021-06907-zDOI Listing
July 2021

Pharyngocutaneous Fistula and Horner's Syndrome following Loosening of Locking Screw of Anterior Cervical Plating: A Rare Case Report and Management.

Asian J Neurosurg 2021 Jan-Mar;16(1):196-199. Epub 2021 Feb 23.

Department of Orthopaedics, Seth G.S. Medical College and KEM Hospital, Mumbai, Maharashtra, India.

We hereby present a rare case of pharyngocutaneous fistula associated with locking screw loosening causing internal cricopharynx perforation and Horner's syndrome following anterior cervical plating. A 27-year-old male patient had undergone anterior cervical plating at C5-C7 level due to gunshot injury to the neck, and 1 month postsurgery, he developed fistula in the neck showing discharge of consumed food contents. He presented to us 1 year postsurgery with the discharging fistula, left upper-limb weakness, and Horner's syndrome that developed after surgery. The previously unexplored right side was used to remove implant, and owing to solid union at corpectomy, no additional fixation was performed. Intraoperatively, pharyngeal wall dehiscence was observed. Attempt of removal of impinged screw was abandoned since it migrated into the esophagus. Serial abdomen radiographs revealed successive passage of screw through the gastrointestinal (GI) tract until it could not be visualized. As the patient showed reduced discharge, a GI surgeon gave a conservative trial with nasogastric intubation. Currently, fistula is showing minimal discharge with no food. Having knowledge of this possible rare outcome and awareness of various multidisciplinary approaches for management makes practicing spine surgeon equipped to handle such undesirable complications.
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http://dx.doi.org/10.4103/ajns.AJNS_230_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8202369PMC
February 2021

A Rare Case Report of Flexion Teardrop Cervical Fracture with Blunt Vertebral Artery Injury Leading to Stroke.

Asian J Neurosurg 2021 Jan-Mar;16(1):187-190. Epub 2021 Feb 23.

Department of Orthopedics, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India.

Non penetrating trauma to vertebral artery is a known complication in craniovertebral trauma. They are mainly reported with facet dislocations or injuries involving the foramen transversarium. Such a type of injury is rarely seen with flexion injuries. We report such a case leading to cerebellar stroke in a young male presenting to us with hemiparesis. A 43-year-old male presented to us 1 month post trauma after a motor vehicular accident with complaint of weakness of right half of the body since the trauma. He suffered blunt trauma to head and neck and complained of a flail right upper limb since trauma and weakness of the right lower limb which had partly improved. He was conservatively managed elsewhere. Radiographic investigations revealed complete occlusion of the right vertebral injury above the level of 6 cervical vertebra and flexion teardrop fracture of 5 cervical vertebra. He was managed conservatively for the vertebral artery injury (VAI) and corpectomy of C5 vertebra with anterior cervical plating and fusion. Such a rare type of injury can present with unexplained neurodeficit which needs appropriate radiological investigations for diagnosis before ascribing the cause to cord trauma. Hence, all high velocity motor vehicular accidents with associated fractures and neurodeficit should be screened for blunt VAIs.
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http://dx.doi.org/10.4103/ajns.AJNS_31_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8202375PMC
February 2021

Proximal Junctional Kyphosis after Pediatric Angular Kyphotic Deformity Correction: Are we Missing Something?

Asian J Neurosurg 2021 Jan-Mar;16(1):106-112. Epub 2021 Feb 23.

Indian Spinal Injuries Centre, New Delhi, India.

Purpose: Corrective maneuvers in an angular kyphotic deformity have its own problems including early complications such as neurological deficit and late complications such as proximal junctional kyphosis (PJK) and proximal junctional failure (PJF). This article discusses the probable mechanisms, leading to PJK in pediatric severe angular kyphotic deformities and preventive strategies for the same. We will also assess natural course of untreated PJK and its devastating consequences.

Materials And Methods: Three patients, two 13-year males presented with progressive, painless thoracolumbar kyphoscoliotic deformity, with segmental kyphosis 100° and 140° and scoliosis of 33° and 78°, respectively, and one 14-year-old female presented with angular kyphotic deformity of 60° with apex at D11-12 level.

Results: Posterior vertebral column resection with segmental deformity correction with good coronal and sagittal balance was done. In the follow-up, PJF was seen. Second surgery was done with the extension of instrumentation to D4 along with deformity correction in both the male patients. The female patient did not opt for a revision surgery, and we are following the natural history of this case.

Conclusion: In severe thoracolumbar angular kyphotic deformities with normal or negative sagittal balance, it might be a safer option to select the sagittal stable vertebra as upper instrumented vertebra based on the C2 plumb line on the preoperative standing lateral radiographs. However, a study with a larger sample size is needed to validate our hypothesis.
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http://dx.doi.org/10.4103/ajns.AJNS_311_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8202394PMC
February 2021

Extramedullary myeloid sarcoma mimicking tuberculosis of spine: A case report and literature review.

Surg Neurol Int 2021 19;12:178. Epub 2021 Apr 19.

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

Background: A definitive diagnosis of spinal tuberculosis (TB) remains challenging. The "gold standard" is to obtain histopathological confirmation of the lesion. This analysis highlights how to avoid missing the diagnosis of an extramedullary myeloid sarcoma (EMS) versus TB.

Case Description: A 25-year-old male presented with paraparesis. Although this was first attributed to TB spondylodiscitis, a PET-CT and reevaluation of the biopsy specimen both confirmed the diagnosis of an EMS.

Conclusion: Nontubercular spinal disease should be suspected when a patient deteriorates despite the institution of antitubercular therapy for a reasonable duration. Further, microbiological and/or pathological confirmation is warranted to direct appropriate treatment and differentiate spinal TB from other entities as, in this case, an EMS.
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http://dx.doi.org/10.25259/SNI_855_2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8168697PMC
April 2021

Mid thoracic intra-spinal facet cyst with lumbar canal stenosis: a rare 'double crush'.

Int J Neurosci 2021 Jul 15:1-7. Epub 2021 Jul 15.

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

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

Case Presentation: A 67-year-old woman presented with complaints of back pain with neurogenic claudication with significant loss of touch sensation and motor power of MRC grade 3/5 in lower extremities bilaterally. However, patient was hyperreflexic with Babinski sign positive. She was unable to perform tandem walking test and complained of instability. MRI of lumbar spine revealed lumbar canal stenosis. However, in view of the UMN signs, an MRI of the dorsal spine was done. It revealed an extradural, well-delineated lesion along the dorsal aspect of spine at T6-7 level. Thus the patient had a 'double crush' due to the FC along with lumbar canal stenosis.

Clinical Findings Correlated With The Imaging: Two teams simultaneously operated the 2 pathologies and T6-7 laminectomy along with left sided TLIF at L4-5 level was performed. Presently she is asymptomatic for back pain, claudication distance has improved to 800 m.

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

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

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

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

Study Design: Prospective cohort study.

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

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

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

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

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

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

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

Study Design: This is a descriptive observational study.

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

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

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

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

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

Iatrogenic postoperative spondylodiscitis attributed to infection in an immunocompetent patient.

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

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

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

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

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

Outcome Analysis of Subaxial Cervical Spine Tuberculosis Operated by the Anterior Approach: A Single-Center Experience.

Int J Spine Surg 2021 Feb 12;15(1):18-25. Epub 2021 Feb 12.

Department of Orthopedics, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India.

Background: Though spinal tuberculosis has a predilection for the dorsal and lumbar spine, a high percentage of morbidity and mortality is associated with cervical tuberculosis. Cervical tuberculosis accounts for about 10% of cases, with the major concerns being quadriparesis/quadriplegia and kyphotic deformity. Herein we describe our experience with the use of anterior instrumentation with titanium implants in 46 patients with subaxial tuberculosis.

Materials And Methods: Included in the study were a total of 46 patients with subaxial cervical (C3-C7) and upper dorsal (D1-D3) tuberculosis who underwent operations with anterior debridement, decompression, bone grafting, and anterior instrumentation by a single surgeon at our institute between January 2007 and December 2014. A review of the demographic data, medical records, and x-rays before and after surgery and at subsequent follow-ups was performed retrospectively from the departmental database.

Results: Neurological involvement in the postoperative period was seen in 29 of the 30 patients, 26 of whom showed complete neurological recovery. The Cobb angle at presentation ranged from 2°-58° of kyphosis with an average kyphosis of 15.4°. The average lordosis after surgery was found to be 17.5° (ie, a mean correction of 32.9°).

Conclusions: Anterior instrumentation of subaxial cervical tuberculosis with titanium implants provides good correction of kyphosis and provides reasonable neurologic recovery in patients and ensures a long-lasting functional outcome.

Level Of Evidence: 4.
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http://dx.doi.org/10.14444/8002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7931704PMC
February 2021

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

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

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

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

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

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

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

Adolescent Lumbar Disc Herniation with a Peculiar Gait Pattern Managed by Transforaminal Endoscopic Spine Surgery.

J Orthop Case Rep 2020 Nov;10(8):93-96

Department of Spine, Indore Spine Centre, Indore, Madhya Pradesh, India.

Introduction: Lumbar disc herniation (LDH) is common manifestation of a degenerative disease involving tensile failure of the annulus to contain the gel like nuclear portion of the disc. Lumbar herniated discs can often cause muscle weakness, reduced motor function, and change in walking capacity and gait pattern.

Case Presentation: We present the case of an 18-year-old obese hypertensive male, with multiple level lumbar disc herniation, with a neurological deficit and failed conservative treatment. The patient was successfully operated by minimal invasive endoscopy approach and had a marked improvement in the neurological status post-surgery. Post-surgery, his neck regained normal posture, with no back or leg pain. At present, he is walking with a normal gait pattern after a 2-year follow-up.

Conclusion: Here, we describe a unique gait abnormality in a patient with adolescent LDH. Transforaminal endoscopic spine surgery had good functional outcomes with minimal morbidity.
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http://dx.doi.org/10.13107/jocr.2020.v10.i08.1876DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7933625PMC
November 2020

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

Bilateral Transcervical Femur Neck Fracture in a Case of Pseudohypoparathyroidism: A Rare Case Report and Review of Literature.

J Orthop Case Rep 2020 Oct;10(7):85-87

Department of Orthopedics, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India.

Introduction: Pseudohypoparathyroidism (PHP) is an uncommon metabolic bone disorder characterized by biochemical hypocalcemia, hyperphosphatemia and raised parathyroid hormone (PTH), and target tissue unresponsiveness to the biological actions of PTH. In addition, many patients with PHP exhibit a distinctive constellation of developmental and skeletal defects.

Case Report: An 11-year-old girl was brought to emergency pediatric department for the assessment of fever with generalized tonic-clonic seizure (GTCS) with inability to walk. She had hypocalcemia and hyperphosphatemia. The diagnosis of PHP was made and was started on Vitamin D3 and oral calcium. Physical examination revealed no dysmorphic features. Biochemical investigations revealed normal complete blood count, liver and renal functions, and arterial blood gas. However, serum PTH was high with slightly decreased Vitamin D3.

Conclusion: As per our knowledge, this is the first reported case in literature of bilateral pathological transcervical neck femur fracture in a case of PHP following episode of GTCS. Multidisciplinary team approach with the involvement of pediatrician, endocrinologist, and orthopedic surgeon and devising a plan after thorough workup keeping in mind the infrequent presentations of hypoparathyroidism and adequate pre-operative optimization helps provide appropriate management of this rare presentation. This case report was prepared following the CARE guidelines.
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http://dx.doi.org/10.13107/jocr.2020.v10.i07.1930DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7857650PMC
October 2020

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

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

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

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

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

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

Management dilemma of tuberculous paraplegia in pregnancy - A case report and review of literature.

Surg Neurol Int 2020 29;11:470. Epub 2020 Dec 29.

Department of Spine Services, B. Toronto Western Hospital and Krembil Neuroscience Centre, Toronto, Ontario, Canada.

Background: Tuberculosis (TB)/tuberculous spondylodiscitis of the spine causing paraplegia in the 2 trimester of pregnancy is rare and poses significant management dilemmas. Pregnancy, a relatively immunocompromised state with high hormonal levels, may prompt rapid TB destruction of a vertebral body resulting in an acute/ profound neurological deficit. Here, a pregnant paraplegic mother was diagnosed with spondylodiscitis that warranted immediate decompression/fusion to achieve neurological recovery.

Case Description: A 26-year-old female was 23 weeks pregnant when she presented with an acute spastic paraplegia (complete motor, sensory deficit, and sphincter loss). Operative decompression utilized a Versatile Approach along with a "Hartshill rectangle" for fusion and sublaminar wiring. This procedure accomplished simultaneous anterior and posterior fixation with a single approach without the need for intraoperative radiologic imaging. Although the pregnancy was continued with an uneventful perioperative period, intra-uterine fetal demise was documented 1 month postoperatively. Within 18 postoperative months the patient was neurologically intact, and fusion was confirmed on a computed tomography scan.

Conclusion: A 23-week pregnant female acutely became paraplegic due to T5 tuberculous spondylitis confirmed on an X-ray (only source of radiation), and magnetic resonance imaging. Following a decompression/ instrumented fusion performed without fluoroscopic guidance, the patient regained full neurological function. However, 1 month postoperatively, the fetus spontaneously aborted.
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http://dx.doi.org/10.25259/SNI_772_2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7827534PMC
December 2020

An Unusual Midfoot Dislocation Involving Naviculocuneiform and Calcaneocuboid Joint Following Low-Energy Injury: A Case Report.

J Orthop Case Rep 2020 Sep;10(6):41-43

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

Introduction: Midfoot injuries involving naviculocuneiform and calcanealcuboid joints are very rare. These injuries result from high-energy crushing trauma and most often causes dislocation of the midfoot in plantar direction.

Case Report: A 30-year-old female sustained an injury to the left foot after a fall from a very low height. A radiograph of the left foot demonstrated naviculocuneiform joint and calcaneocuboid joint fracture-dislocation. This unusual pattern of injury required open reduction and internal fixation with K-wires after a failed attempt of closed reduction. K-wires were removed after 8 weeks. At 24 months follow-up, she achieved a complete range of movements of left foot and ankle without any complications.

Conclusion: Injuries involving naviculocuneiform and the calcaneocuboid joint can occur following low-energy impact. Such complex injuries should be diagnosed and treated as early as possible. Initial open reduction and stable anatomical fixation are the keys to achieve a good functional outcome in such kind of injuries.
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http://dx.doi.org/10.13107/jocr.2020.v10.i06.1868DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7815663PMC
September 2020

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

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

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

Study Design: Retrospective observational.

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

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

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

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

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

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

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

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

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

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

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

Recovery of Long Standing Neurological Deficit in Pediatric Dorsal Spinal Tuberculosis: A Single Center Experience of 13 Cases.

Global Spine J 2020 Dec 17:2192568220973615. Epub 2020 Dec 17.

Department of Orthopaedics, 29549Seth G.S. Medical college and K.E.M hospital, Mumbai, Maharashtra, India.

Study Design: Retrospective analysis of case series.

Objective: The aim is to study the recovery of neurological deficit in pediatric spinal tuberculosis cases presenting to us more than 6 months after onset of motor weakness in lower limbs.

Methods: This is a retrospective analysis of 13 consecutive patients of pediatric spinal tuberculosis presenting to us at least 6 months after the onset of neurologic deficit. All these patients underwent surgical intervention at our center and their neurological recovery was noted in terms of improvement in Frankel grading and spasticity improvement by modified Ashworth scale. All the patients were followed up to at least 18 months post op and final neurologic status was assessed at that time.

Results: The mean age of the patients at presentation was 8.5 years. The mean duration of neurologic deficit at the time of presentation was 10.23 months (6-24 months). Seven patients had a Frankel grade B at presentation out of which 6 improved to Frankel grade D and one improved to Frankel C at final follow up. Out of the other 3 patients with Frankel A at presentation, 2 improved to Frankel grade D and 1 to Frankel grade C. The remaining 3 patients presented with Frankel grade C at presentation, 2 improved to Frankel D and one improved to Frankel E at the time of final follow up.

Conclusion: Neurologic recovery in patients with neurological deficit is possible even in cases of long standing deficit more than 6 months and in some cases upto 24 months as shown in our study.
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http://dx.doi.org/10.1177/2192568220973615DOI 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

Missing Disc Fragment: A Rare Surgical Experience.

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

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

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

Varicella-Zoster Radiculitis Mimicking Sciatica: A Diagnostic Dilemma.

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

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

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

Outcome Analysis of Anterior Reconstruction with Rib Grafts in Tuberculosis of the Thoracic Spine.

Asian J Neurosurg 2020 Jul-Sep;15(3):648-652. Epub 2020 Aug 28.

Department of Orthopaedics, Lokamanya Tilak Medical College and Sion Hospital, Mumbai, Maharashtra, India.

Introduction: Tricortical iliac bone is the gold standard as an autograft for the reconstruction of the anterior column in tuberculosis (TB) of the thoracic spine. However, the quantity of graft needed is significant. It creates a considerable defect in the pelvic bone, causing graft site complications, including pain, pelvic instability, fractured ilium, herniated muscle, or abdominal contents. To prevent these donor site morbidities, ribs that were removed during the versatile approach were used for anterior reconstruction. The aim of this study was to assess the clinical and radiological results of the reconstruction of the anterior column of the spine with the help of an excised rib during the versatile approach.

Subjects And Methods: This retrospective study was undertaken at a tertiary care center with a study duration of 14 years. Between January 2004 and December 2016, 52 patients with thoracic Koch's spine had anterior column reconstructed with multiple rib grafts. A single surgeon performed all operations. Indications for the surgery in these patients were the presence of neurologic deficit (49 patients) and vertebral column instability (3 patients). The preoperative kyphosis angle and visual analog scale (VAS) score were compared with postoperative values using a paired t-test.

Results: All patients underwent a minimum follow-up of 18 months and were evaluated clinicoradiologically. Good bony fusion with neurological recovery was achieved in all cases. The VAS score for back pain improved significantly postsurgery. There was one case of graft buckling treated conservatively.

Discussion: Appropriate anterior reconstruction forms the cornerstone of successful surgical management of spinal TB. The "Versatile approach" used offers anterior and posterior access in the lateral position. In these patients, we obviated the need for iliac crest graft using multiple segments of the rib for anterior column reconstruction. This meticulous rib grafting technique gives good functional outcome in terms of solid bony fusion.

Conclusion: Meticulous rib grafting technique gives 360° bony fusion and good functional outcome in surgery for thoracic spinal TB. It has the advantage of avoiding the complications associated with a tricortical iliac crest graft.
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http://dx.doi.org/10.4103/ajns.AJNS_52_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7591174PMC
August 2020

Incidence and Outcome Analysis of Vertebral Artery Injury in Posttraumatic Cervical Spine.

Asian J Neurosurg 2020 Jul-Sep;15(3):644-647. Epub 2020 Aug 28.

Department of Orthopaedics, Seth G. S. Medical College and KEM Hospital, Mumbai, Maharashtra, India.

Objective: Vertebral artery injury (VAI) after cervical spine trauma often remains undiagnosed. Despite various clinical studies suggesting simultaneous occurrence of VAI with cervical spine trauma, guidelines regarding screening and management of posttraumatic VAI are yet to be formulated. The primary objective of the current study was to formulate a low-cost screening protocol for posttraumatic VAI, thereby reducing the incidence of missed VAI in developing countries.

Materials And Methods: This was a single-center prospective study performed on 61 patients using plain magnetic resonance imaging (MRI) as a screening tool to assess the frequency of VAI and routine X-ray to detect morphological fracture patterns associated with the VAI in posttraumatic cervical spine cases. If the MRI study showed any evidence of vascular disruption, then further investigation in the form of computed tomography angiography was done to confirm the diagnosis.

Results: This study showed the incidence of VAI was 14.75% (9/61). Of 61 patients, 16 had supraaxial, and 45 patients sustained subaxial cervical spine fractures. In the cohort of nine cases of VAI, eight patients had subaxial cervical spine injuries, of which seven were due to flexion-distraction injury. C5-C6 flexion-distraction injury was most commonly associated with VAI (4 cases). Of the nine cases, five succumbed to injury (mortality 55.55%), and 19 patients from the non-VAI group succumbed to injury (mortality 36.53%). From surviving four cases with VAI, two had improvement in the American Spinal Injury Association scale by Grade 1.

Conclusion: VAI in cervical spine trauma is an underrecognized phenomenon. Plain MRI axial imaging sequence can be an instrumental low-cost screening tool in resource-deficient parts of the world. VAI has tendency to occur with high-velocity trauma like bi-facetal dislocation, which has a high mortality and poor neurological recovery.
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http://dx.doi.org/10.4103/ajns.AJNS_45_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7591224PMC
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
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