Publications by authors named "Tarush Rustagi"

61 Publications

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

Letter to the Editor: The Effect of Head Loading on Cervical Spine in Manual Laborers.

Asian Spine J 2021 Jun 17;15(3):412-413. Epub 2021 Jun 17.

Geisinger Health System-Lewistown Hospital & Gray's Woods, State College, PA, USA.

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http://dx.doi.org/10.31616/asj.2021.0149DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8217857PMC
June 2021

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

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

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

Study Design: Prospective cohort study.

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

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

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

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

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

Cost Analysis With Use of Expandable Cage or Cement in Single level Thoracic Vertebrectomy in Metastasis.

Global Spine J 2020 Dec 14:2192568220975375. Epub 2020 Dec 14.

Department of Neurological Surgery, 12306Ohio State University Wexner Medical Center, The James Cancer Hospital & Solove Research Institute, Columbus, OH, USA.

Study Design: Retrospective case series.

Objective: Patient with metastatic cancer frequently require spinal operations for neural decompression and stabilization, most commonly thoracic vertebrectomy with reconstruction. Objective of the study was to assess economic aspects associated with use of cement versus expandable cage in patients with single level thoracic metastatic disease. We also looked at the differences in the clinical, radiological, complications and survival differences to assess non-inferiority of PMMA over cages.

Methods: The electronic medical records of patients undergoing single level thoracic vertebrectomy and reconstruction were reviewed. Two groups were made: PMMA and EC. Totals surgical cost, implant costs was analyzed. We also looked at the clinical/ radiological outcome, complication and survival analysis.

Results: 96 patients were identified including 70 one-level resections. For 1-level surgeries, Implant costs for use of cement-$75 compared to $9000 for cages. Overall surgical cost was significantly less for PMMA compared to use of EC. No difference was seen in clinical outcome or complication was seen. We noticed significantly better kyphosis correction in the PMMA group.

Conclusions: Polymethylmethacrylate cement offers significant cost advantage for reconstruction after thoracic vertebrectomy. It also allows for better kyphosis correction and comparable clinical outcomes and non-inferior to cages.
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http://dx.doi.org/10.1177/2192568220975375DOI Listing
December 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

Ligamentum Flavum Cyst: Rare Presentation Report and Literature Review.

Neurol India 2020 Sep-Oct;68(5):1207-1210

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

Ligamentum flavum cysts (LFC) are uncommon and their differentiation from other Juxta-facetal cysts & epidural cystic lesions is difficult based on imaging techniques. We present one such rare case of ligamentum flavum cyst with relevant review of the literature. An eighty-eight years male presented with progressively worsening radicular symptom in the left lower limb. His neurological examination was unremarkable. Magnetic resonance imaging of lumbar spine revealed an epidural cystic lesion narrowing the left lateral recess. Intra-operatively, a mass was found originating from ventral surface of ligamentum flavum. Pathological examination was suggestive of fibro-collagenous tissue without synovial lining. The exact pathogenic mechanism for the formation of LFCs is not well understood. Association with segmental instability and degenerative conditions of spine is postulated. They are commonly seen at the mobile junctional levels of the spine. Persistent micro-traumatic events with abnormal movement maybe contributory to their origin. They present either with radiculopathy or neurogenic claudication symptoms owing to compressive effect on adjacent neural structure. LFC should be considered as a differential in patients with radicular pain or claudication symptoms with epidural cystic lesion seen on MRI. Complete excision of such lesion provides excellent pain relief in symptomatic individuals.
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http://dx.doi.org/10.4103/0028-3886.299172DOI Listing
June 2021

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

Floating Vertebral Body Cement Ball After High-Viscosity-Cement Vertebroplasty for Lytic Defect: Report of 2 Cases.

Int J Spine Surg 2020 Aug 31;14(4):594-598. Epub 2020 Jul 31.

Ohio State University Wexner Medical Center and Arthur G. James Cancer Hospital, Columbus, Ohio.

Background: Percutaneous vertebroplasty (PVP) is an effective procedure for painful pathological vertebral fractures. High-viscosity cement is the preferred choice for vertebroplasty given its low risk of extravasation. We describe here 2 cases of high-viscosity cement vertebroplasty in large lytic defects and associated complications.

Case Description: Case 1 describes PVP in an 89-year-old male patient with L1 pathological fracture from prostrate metastasis. Case 2 describes PVP in a 68-year-old male with T7 and T8 vertebral fractures from multiple myeloma. In both cases, high-viscosity cement was used to fill large lytic cavities. This resulted in poor interdigitation of the cement with the trabeculae forming an unstable floating cement ball and dangerous retrieval of the cement trocar needle. The implications of this occurrence have been described.

Conclusions: High-viscosity-cement vertebroplasty in large lytic defects needs to be done with caution. The potential occurrence of poor cement interdigitation and the following complications can be catastrophic, and caution must be used.
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http://dx.doi.org/10.14444/7079DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7478018PMC
August 2020

Overview of the management of primary tumors of the spine.

Int J Neurosci 2020 Sep 28:1-15. Epub 2020 Sep 28.

Department of Neurosurgery, The Ohio State University and Wexner Medical Center, The James Cancer Hospital and Solvo Research Institute, Columbus, OH, USA.

Study Design: Narrative review.

Objective: To provide a narrative review for diagnosis and management of Primary spine tumors.

Methods: A detailed review of literature was done to identify relevant and well cited manuscripts to construct this narrative review.

Results: Primary tumors of the spine are rare with some racial differences reported. There are numerous adjuvant technologies and developments that influence the way we currently manage these tumors. Collimated radiation allows for heavy dosage to be delivered and have been reported to give good local control both as an adjuvant and neoadjuvant setting. These have made surgical decision making even more intricate needing a multicentric approach. Dedicated care has been shown to significantly improve health quality of life measures and survival.

Conclusion: While, it is beyond the scope of this paper to discuss all primary tumors subtypes individually, this review highlights the developments and approach to primary spine tumors.
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http://dx.doi.org/10.1080/00207454.2020.1825423DOI Listing
September 2020

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

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

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

Study Design: Observational Study.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Transpedicular Vertebrectomy With Circumferential Spinal Cord Decompression and Reconstruction for Thoracic Spine Metastasis: A Consecutive Case Series.

Spine (Phila Pa 1976) 2020 Jul;45(14):E820-E828

Ohio State University Wexner Medical, Columbus, OH.

Study Design: Retrospective case series.

Objective: To study the feasibility, outcomes, and complications of transpedicular vertebrectomy (TPV), and reconstruction for metastatic lesions to the thoracic spine.

Summary Of Background Data: Metastatic lesions to the thoracic spine may need surgical treatment requiring anterior-posterior decompression/stabilization. Anterior reconstruction may be performed using poly methyl meth acrylate (PMMA) cement or cages. Use of cement has been reported to be associated with complications.

Methods: From 2008 to 2016, consecutive cases (single surgeon) undergoing TPV for thoracic spine metastasis (T2-12) were included. Demographic, surgical, and clinical data were collected through chart review. MRI, CT, positron emission tomography images were used to identify extent of disease, epidural spinal cord compression (ESCC), and degree of vertebral body collapse. Hall-Wellner confidence band was used for the survival curve.

Results: Ninety six patients were studies with a median age 60 years. Most patients 56 (58%) presented with mechanical pain. 29% cases had lung metastasis. Single level TPV was performed in 73 patients (76%). Anterior reconstruction included PMMA in 78 patients (81.25%), and titanium cage in 18 patients (18.25%). Frankel grade improvement was seen in 16 cases (P = 0.013). ESCC improved by a median of 5.9 mm (P < 0.001). Kyphosis reduced by median of 7.5° (P < 0.001). VAS improved by median of seven (P < 0.001). Total 59 deaths were observed. The median survival time was estimated to be 6 months (95% CI: 5, 10). Surgical outcome and complication rates are similar between the two construct types. Correction of kyphosis was seen to be slightly better with the use of PMMA. Overall 29.16% cases developed complications (11.4% major). Two cases developed neurological deficit following epidural hematoma requiring surgery. One case had instrumentation failure from cement migration, needing revision.

Conclusion: The result of our study shows significantly improved clinical and radiological outcomes for TPV for thoracic metastatic lesions. We also discuss some important steps for use of PMMA to avoid complications.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000003450DOI Listing
July 2020

Venous Drainage of Lumbar Vertebral Bodies: Anatomic Study with Application to Kyphoplasty, Vertebroplasty, and Pedicle Screw Complications.

World Neurosurg 2020 05 31;137:e286-e290. Epub 2020 Jan 31.

Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA; Department of Anatomical Sciences, St. George's University, St. George's, Grenada; Department of Structural & Cellular Biology, Tulane University School of Medicine, New Orleans, Louisiana, USA; Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, Louisiana, USA.

Background: Bone cement augmentation with polymethylmethacrylate is a reliable method for stabilizing osteoporotic compression fractures and improving fixation of pedicle screws. However, cement extrusion into the vertebral venous system can result in pulmonary cement embolism. The goal of this anatomic study was to identify the relationship between the internal/external vertebral plexus and neighboring abdominal caval system.

Methods: Thirty-two lumbar vertebral levels were used in this study. Anterior abdominal dissection was performed to access the lumbar vertebral bodies through the peritoneal cavity, and a 16-gauge needle was placed into the center of each lumbar vertebral body at its anterior aspect. Fluoroscopy was used to confirm if the needle was correctly placed. Next, latex and/or continuous air injections were performed into each lumbar vertebral level (L1-L5). Observations confirmed if the latex or air traveled into the inferior vena cava. In addition, the spinal canal was opened to see if any latex was found to enter inside the vertebral canal in cadavers injected with the latex.

Results: Latex or air was found to flow into the inferior vena cava at all the lumbar vertebral levels. The latex/air was not observed in the spinal canal in any specimen.

Conclusions: An exact knowledge of the lumbar vertebral venous anatomy is essential when procedures that could affect the vertebral venous system are involved. Its complexity and anatomic variability necessitate such an understanding to better prevent/understand possible complications associated with polymethylmethacrylate extrusion.
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http://dx.doi.org/10.1016/j.wneu.2020.01.174DOI Listing
May 2020

Surgical Trend Analysis for Use of Cement Augmented Pedicle Screws in Osteoporosis of Spine: A Systematic Review (2000-2017).

Global Spine J 2019 Oct 27;9(7):783-795. Epub 2018 Sep 27.

Indian Spinal Injuries Center, New Delhi, India.

Study Design: Systematic review.

Objectives: (1) Study indications for cement-augmented pedicle screws (CAPS) in patients with osteoporosis. Have they changed over the years (2000-2017)? Are there any differences in usage of CAPS based on the geographical region? (2) What were the outcome of the studies? (3) What are the complications associated with this technique?

Methods: Electronic database and reference list of desired articles were searched from the database (2000-2017). Articles were selected discussing indications, clinical and radiological outcomes, and complications in cases of preexistent osteoporosis treated surgically using CAPS.

Results: Seventeen studies were identified; 3 were comparative studies and had a control arm (cemented vs noncemented screws). Most studies originated from Europe (10) or Asia (7). Painful vertebral fracture with or without neurological deficit, Kummell's lesion, deformity and failure to respond to conservative treatment are the common indications for cement augmentation. Visual analogue scale score was the most commonly used to assess pain and average improvement after surgery was 6.1. Average improvement in kyphosis was 13.21° and average loss of correction at the end of the study was 3°. Cement leak was the most common complication observed and pulmonary cement embolism was the most dreaded complication. Nevertheless, majority of cement leaks discussed in studies were asymptomatic.

Conclusion: CAPS are being increasingly used in osteoporotic spine. Pain scores, functional quality of life, and neurological function indices were studied. CAPS improved anchorage in osteoporotic vertebra and helped improve/maintain clinical and radiological improvement. Common risks of cement leak were observed.
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http://dx.doi.org/10.1177/2192568218801570DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6745638PMC
October 2019

Posterior occiput-cervical fixation for metastasis to upper cervical spine.

J Craniovertebr Junction Spine 2019 Apr-Jun;10(2):119-126

Ohio State University Wexner Medical Center, Columbus, OH, USA.

Background: Metastasis to craniocervical area may result in instability manifesting as disabling pain, cranial nerve dysfunction, paralysis, or even death. Stabilization is required to prevent complications. Nonoperative treatment modalities are ineffective in providing stability and adequate pain relief. We present our experience of diagnosis, presentation, and surgical management for metastatic tumors to the upper cervical spine (UCS).

Methods: Single-center single-surgeon database of consecutively operated posterior occiput-cervical fusion for metastasis to UCS was reviewed from 2007 to 2016. Demographics, clinical, and surgical data were collected through chart review. Pain scores based on Visual Analog Scale (VAS) and other radiological data were noted. Kaplan-Meier curve was used for survival analysis. Clinical outcomes and complications were recorded.

Results: A total of 29 patients (17 females/12 males) had the mean age of 56.7 ± 13.5 (24-82). Predominant metastasis included from the breast in 9 (31.03%) cases, followed by renal in 5, melanoma in 4, and 3 each from lung and colon. Axis was involved in 24 cases (C2 body in 21, pedicle in 8 cases). Atlas was involved in 9 cases (lateral mass in 8 cases and arch in 3 cases) and occiput was involved in three cases. Average Spinal Instability Neoplastic Score was 10 ± 2.3 (7-14). Mild cord compression was seen in 7 cases. Fusion extended from occiput to C4 fusion ( = 23), C5 ( = 5), and C6 ( = 1). Average blood loss was 364.8 ± 252.1 ml and operative time was 235 ± 51.9 min. Average length of stay was 7 ± 2.8 days (3-15). VAS improved from 8.3 ± 1.5 to 1 ± 1.1 ( < 0.001). C2 angulation corrected from 2.1° ±5.3° (0°-17°) to 0.5° ±1.2° ( = 0.045). Three patients each developed cardiopulmonary complications and deep infection. The average survival was 14.5 ± 15.1 (0.15-50) months.

Conclusion: C2 body is the most common site of metastasis. Occiput-cervical fusion for unstable upper cervical metastasis offers a good palliative treatment for pain relief and improved quality of life.
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http://dx.doi.org/10.4103/jcvjs.JCVJS_29_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6652252PMC
August 2019

Sensorineural Deafness After Spine Surgery: Case Series and Literature Review.

World Neurosurg 2019 Nov 2;131:e482-e485. Epub 2019 Aug 2.

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

Background: Sudden sensorineural hearing loss (SNHL) after nonotologic surgery is unusual, with most occurrences reported in patients having cardiopulmonary bypass. Reports of SNHL after nonotologic noncardiac surgery are rare, particularly after spine surgery. In patients undergoing subarachnoid anesthesia or intradural surgery, loss of cerebrospinal fluid pressure can result in hearing loss and cranial nerve palsy.

Methods: A 70-year-old male patient had ankylosing spondylitis with an Anderson lesion T11-12 with diabetes mellitus, hypertension, and American Spinal Injury Association Impairment Scale-A neurology. He underwent posterior stabilization of T10-L1 and developed a profound, painless, left-sided hearing deficit shortly afterward. An otorhinolaryngology consultation confirmed SNHL. An 82-year-old male reported claudication with L4-5 LCS and type 2 diabetes mellitus. Post L4-5 transforaminal lumbar interbody fusion, he complained of hearing loss in his left ear, confirmed by an otolaryngologist. A 72-year-old diabetic male had tuberculous spondylodiskitis of D2-3 with an epidural abscess. An emergent decompression and stabilization C7-D5 bone grafting at D2-3 was done. In the early postoperative period, the patient complained of marked hearing impairment on the right side. Audiometry indicated SNHL in his right ear.

Results: A course of intravenous corticosteroids was instituted in the first and second patients for severe hearing loss. Steroids were not given to the third patient in view of his Pott spine. No improvement in hearing impairment occurred until the latest follow-up in all patients.

Conclusions: Sudden-onset hearing loss post spine surgery is disastrous with multiple etiologies and remains poorly understood. Timely evaluation by an otolaryngologist and audiologist is recommended. The role of corticosteroids in treating SNHL is still unclear.
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http://dx.doi.org/10.1016/j.wneu.2019.07.204DOI Listing
November 2019

Iatrogenic Bowel Injury Following Minimally Invasive Lateral Approach to the Lumbar Spine: A Retrospective Analysis of 3 Cases.

Global Spine J 2019 Jun 20;9(4):375-382. Epub 2018 Nov 20.

Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA.

Study Design: Retrospective cohort study.

Objective: Anterior approaches are often used during lumbar interbody fusion procedures. Visceral injuries (bowel injuries) are rare but represent a primary risk during anterior approaches to the lumbar spine. Left untreated, these injuries can result in significant complications. The aim of this study was to investigate the presentation and management of bowel injury cases following anterior approaches to the lumbar spine to raise the surgeon's awareness of this rare complication.

Methods: All direct anterior, oblique anterior, and transpsoas lumbar interbody fusion surgeries performed at our institution between 2012 and 2016 were analyzed retrospectively. Charts were screened for cases requiring return to the operating room owing to a suspected bowel injury and details of the case were extracted for illustrative purposes.

Results: A total of 775 anterior lumbar surgeries were conducted at a single tertiary care institution between July 2012 and June 2017. A total of 590 transpsoas lumbar interbody fusion (TPIF) surgeries were performed. Four patients, each having undergone TPIF, were suspected of bowel injury and underwent an exploratory laparotomy. At surgery, 3 patients were confirmed to have a bowel injury, giving a procedure-specific incidence of 0.51% and overall incidence of 0.39%. Among the 3 confirmed bowel injury cases, average delay between surgery and visceral injury diagnosis was 4.7 days (range 3-7 days).

Conclusions: We noted abdominal pain, distention, and fever as the most common findings in the setting of a visceral injury. A high index of suspicion and computed tomography imaging remain critical for identifying postoperative bowel injuries.
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http://dx.doi.org/10.1177/2192568218800045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6562219PMC
June 2019

Extended L5 pedicle subtraction osteotomy for neglected sacropelvic dissociation injury: case report.

J Neurosurg Spine 2019 03;31(1):35-39

2Swedish Neurosciences Institute, Seattle, Washington.

The sacrum forms the distal end of the spine and communicates with the pelvis. Fractures involving the sacrum are complex and may disrupt this vital communication. Neglecting these fractures may result in malunion, which often causes significant alteration in the pelvic parameters and sagittal balance. Management of ensuing deformities is complex and poorly described. The authors present a case of sacral malunion with sagittal imbalance treated with a low lumbar osteotomy.
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http://dx.doi.org/10.3171/2019.1.SPINE181271DOI Listing
March 2019

Long-Term Survival After Brain and Spine Metastasis in Malignant Melanoma.

World Neurosurg 2019 05 11;125:164-169. Epub 2019 Feb 11.

Ohio State University Wexner Medical Center and Arthur G. James Cancer Hospital, Columbus, Ohio, USA.

Background: Metastasis from melanoma carries poor prognosis and survival. Average life expectancy is estimated 4 to 6 months after diagnosis of skeletal metastasis. Comprehensive treatment, along with newer immunotherapies, has shown promising results.

Case Description: We report a case of long-term survival after metastasis to the brain and spine and discuss associated factors.

Conclusions: Our report emphasizes the importance of regular and critical surveillance of the disease and aggressive surgical and medical management in melanoma.
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http://dx.doi.org/10.1016/j.wneu.2019.01.215DOI Listing
May 2019

Zygapophyseal Joint Orientation and Facet Tropism and Their Association with Lumbar Disc Prolapse.

Asian Spine J 2019 Feb 30;13(1):173-174. Epub 2019 Jan 30.

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

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http://dx.doi.org/10.31616/asj.2018.0267DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6365783PMC
February 2019

A New Search Algorithm for Reducing the Incidence of Missing Cottonoids in the Operating Theater.

Asian Spine J 2019 Feb 18;13(1):1-6. Epub 2018 Oct 18.

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

Study Design: Retrospective study.

Purpose: Missing cottonoids during and after spinal surgery is a persistent problem and account for the most commonly retained surgical instruments (RSIs) noticed during a final cottonoid count. The aim of this study was to enumerate risk factors and describe the sequence to look out for misplaced cottonoids during spinal surgery and provide an algorithm for resolving the problem.

Overview Of Literature: There are only a few case reports on RSIs among various surgical branches. The data is inconclusive and there is little evidence in the literature that relates to spinal surgery.

Methods: This retrospective study was conducted at Indian Spinal Injuries Centre. The data was collected from hospital records ranging from January 2013 to December 2017. The surgical cases in which cottonoid counts were inconsistent during or after the procedure were included in the study. The case files along with operating theater records were thoroughly screened for selecting those in which there was confirmed evidence of such an event.

Results: There were 7,059 spinal surgeries performed during the study period. Fifteen cases of miscounts were recorded with an incidence of one in every 471 cases. Cottonoids were most commonly lost under the shoes of the surgeon or assistants. In two instances, cottonoids were found in the surgical field and trapped in the interbody cage site. Based on these locations, a systematic search algorithm was created.

Conclusions: This study enumerates RSI risk factors in spinal surgical procedures and describes steps that can be followed to account for any missing cottonoids. The incidence of missing cottonoids can be decreased using a goal-oriented approach and ensuring that surgical teams work in collaboration.
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http://dx.doi.org/10.31616/asj.2018.0136DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6365781PMC
February 2019

Bladder Recovery Patterns in Patients with Complete Cauda Equina Syndrome: A Single-Center Study.

Asian Spine J 2018 Dec 16;12(6):981-986. Epub 2018 Oct 16.

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

Study Design: Retrospective case series.

Purpose: Cauda equina syndrome (CES) is associated with etiologies such as lumbar disc herniation (LDH) and lumbar canal stenosis (LCS). CES has a prevalence of 2% among patients with LDH and exhibits variable outcomes, even with early surgery. Few studies have explored the factors influencing the prognosis in terms of bladder function. Therefore, we aimed to assess the factors contributing to bladder recovery and propose a simplified bladder recovery classification.

Overview Of Literature: Few reports have described the prognostic clinical factors for bladder recovery following CES. Moreover, limited data are available regarding a meaningful bladder recovery status classification useful in clinical settings.

Methods: A single-center retrospective study was conducted (April 2012 to April 2015). Patients with CES secondary to LDH or LCS were included. The retrieved data were evaluated for variables such as demographics, symptom duration, neurological symptoms, bladder symptoms, and surgery duration. The variable bladder function outcome during discharge and at follow-up was recorded. All subjects were followed up for at least 2 years. A simplified bladder recovery classification was proposed. Statistical analyses were performed to study the correlation between patient variables and bladder function outcome.

Results: Overall, 39 patients were included in the study. Majority of the subjects were males (79.8%) with an average age of 44.4 years. CES secondary to LDH was most commonly seen (89.7%). Perianal sensation (PAS) showed a significant correlation with neurological recovery. In the absence of PAS, bladder function did not recover. Voluntary anal contraction (VAC) was affected in all study subjects.

Conclusions: Intactness of PAS was the only significant prognostic variable. Decreased or absent VAC was the most sensitive diagnostic marker of CES. We also proposed a simplified bladder recovery classification for recovery prognosis.
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http://dx.doi.org/10.31616/asj.2018.12.6.981DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6284130PMC
December 2018

Early Lumbar Nerve Root Deficit After Three Column Osteotomy for Fixed Sagittal Plane Deformities in Adults.

Int J Spine Surg 2018 Apr 3;12(2):131-138. Epub 2018 Aug 3.

Department of Orthopedic Surgery, SUNY Upstate Medical University, Syracuse, New York.

Background: Three-column osteotomy is an effective means of correcting fixed sagittal plane deformities. Deformity correction surgeries may be associated with early postoperative neurological deficits often presenting as palsies involving the lumbar roots. The objective was to retrospectively assess a subset of our series of adult deformity correction surgeries and analyze neurological deficits and associated patient and surgical factors.

Methods: Hospital records of 17 patients from a single center were examined. Inclusion criterion were adults (>18 years) who underwent a 3-column osteotomy (pedicle subtraction osteotomy) at the lumbar level for fixed sagittal plane deformities including positive sagittal balance, flat back syndrome, and posttraumatic kyphosis. These also included cases with associated degenerative lumbar scoliosis. Patients were divided in 2 groups: Group 1 with lumbar root deficit and Group 2 with no deficits. We examined the surgical details of the osteotomy, complications during surgery, and observed if the magnitude of correction in the sagittal or coronal plane bore any influence on the nerve deficit.

Results: All 17 patients had a single-level resection except 1 patient who had 2-level osteotomy; 23.5% (4 of 17) developed nerve deficit. Nerve deficit presented as bilateral foot drop (1); unilateral extensor hallucis longus (EHL) weakness (2); and unilateral quadriceps weakness (1). The patient with quadriceps weakness partially recovered to functional strength. Two patients with EHL weakness fully recovered; however, the patient with bilateral foot drop did not improve. L5-S1 interbody fusion was done in 3 of 4 cases in Group 1 and 4 of 13 cases in Group 2.

Conclusions: Nerve deficits after 3-column corrective osteotomies occurred in 23% cases. All but 1 case had significant improvement. Most nerve palsies are neuropraxia and unilateral and tend to recover. L5 weakness appears most common after high lumbar osteotomies. Significant correction of scoliosis at the osteotomy level (>50%) may be a reason for nerve palsy.
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http://dx.doi.org/10.14444/5020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6159628PMC
April 2018

Infected charcot spine arthropathy.

Spinal Cord Ser Cases 2018 8;4:73. Epub 2018 Aug 8.

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

Background: Charcot spinal arthropathy (CSA), a destructive spinal pathology, is seen in patients with impaired sensation. Superimposed infection in the affected spinal segments can lead to a challenge in the diagnosis and management. Spinal cord injury (SCI) is the leading cause of CSA as persons with SCI have significantly impaired sensation. Though infection of the CSA is rare, SCI persons are prone to superimposed infection of the Charcot spine. We report atypical presentations of three cases of CSA with superimposed infection.

Case Descriptions: A 47-year-old male with complete T7-8 SCI developed symptoms suggestive of infection and CSA. He was managed with a posterior vertebral column resection (PVCR) of T12 and intravenous antibiotics as the intraoperative culture showed the growth of and . A 26-year-old male with T12 complete paraplegia, post status post open reduction and internal fixation with subsequent implants removal developed infection and CSA over the pseudo-arthrotic lesion with destruction of T12 and L1 vertebrae and an external fistulous track. He was managed with debridement and anterior column T11-L1 reconstruction with a Titanium cage and four-rod pedicle screw stabilization construct. A 25-year-old male with complete paraplegia with CSA at L4-S1. He underwent PVCR of L5 and L3-S2 posterior stabilization. The intraoperative culture and histopathology were suggestive of tuberculous infection.

Conclusion: Pyogenic or tubercular infection of CSA should be considered as a diagnostic possibility in persons with SCI who are more prone to infections. The management includes aggressive debridement and circumferential fusion along with appropriate medications to control the infection.
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http://dx.doi.org/10.1038/s41394-018-0111-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6082833PMC
August 2018

Sclerosing Epithelioid Fibrosarcoma of the Coccyx: A Case Report and Review of Literature.

Cureus 2018 Apr 2;10(4):e2407. Epub 2018 Apr 2.

Surgery, Max Hospital Vaishali.

Coccydynia in adult patients is not uncommon and is frequently neglected. Coccydynia is mostly associated with fall on buttocks. In long-standing cases, coccydynia can be debilitating. Rarely coccydynia can be due to more sinister causes and surgeons should be aware of all differential diagnosis. We present a case of an elderly female who presented with a complaint of pain over coccyx which was not subsiding with conventional treatment methods. Biopsy was done and a diagnosis of sclerosing epitheloid fibrosarcoma was made. We describe an unusual case of coccydynia secondary to this tumour with the histopathology finding and surgical management.
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http://dx.doi.org/10.7759/cureus.2407DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5984259PMC
April 2018

Surgical treatment of early-onset idiopathic scoliosis in the United States: a trend analysis of 15 years (1997-2012).

Spine J 2019 02 23;19(2):314-320. Epub 2018 May 23.

Department of Orthopedic Surgery, SUNY Upstate Medical University, 750 E. Adams St, Syracuse, NY 13210, USA. Electronic address:

Background Context: Early-onset scoliosis is a challenging problem that is defined as a curvature of the spine of more than 10 degrees identified in a child less than 10 years. Early-onset idiopathic scoliosis (EOIS) can cause substantial morbidity and may require surgical intervention.

Purpose: The aim of the present study was to identify the trends of EOIS type of surgeries, length of hospital stay, in-hospital complications, and total inpatient admission charges over a 15-year study period in the United States from 1997 to 2012.

Study Design/setting: This retrospective study used the ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes from the Healthcare Cost and Utilization Project (HCUP) Kids Inpatient's Database (KID) for a 15-year period (1997-2012).

Patient Sample: We identified a total of 897 patients with EOIS over the 15-year study period.

Outcome Measures: The present study determines the current trends for EOIS surgeries.

Methods: The present study had no funding sources or any potential conflicts of interest associated biases. Idiopathic scoliosis patients with ages between 0 and <10 years were identified from the Kids' Inpatient Database with ICD-9-CM code 737.30. Posterior, anterior, and combined spinal surgeries were identified in EOIS through the procedure codes. Patients' gender, discharge diagnosis (comorbidities), hospital length of stay (LOS), mortality rates, hospital charges, and in-hospital complication rate data were collected between 1997 and 2012. The primary grouping variable of the study was the type of surgery (posterior, anterior, and combined). The trends of each variable (female gender, mortality rates, in-hospital complications rates, discharge diagnosis, LOS, and total hospital charges) were assessed for each surgical group separately. Cost inflation of hospital charges was adjusted for the year 2012. An analysis of variance test was used to analyze continuous variables and a chi-square test was used for categorical variables. A linear regression test was used to assess the trend of changes. p≤.05 was considered statistically significant.

Results: The study identified 897 patients, with 546 (61%) of them requiring surgery. Spine deformity surgery rates significantly decreased in patients with EOIS over time from 75% in 1997 to 47% in 2012, p=.019. In the surgery cohort, the male to female distribution was 37% and 63%, respectively. The overall mortality rate was 0.1%. The average length of hospital stay was 8 days and the average number of discharge diagnosis was 5.3. Aggregated complications were seen in 6% of the patients. The total mean hospital charge (per 2012 US dollars) was $119,613, which increased significantly for all types of surgeries. Over the 15-year study period, 62% (n=342) of the patients had posterior surgeries, 13% (n=71) of the patients had anterior surgeries, and 24% (n=133) of the patients had combined (anterior and posterior) surgeries. Posterior surgeries increased significantly from 33% in 1997 to 91% in 2012 (p<.004). Combined surgeries saw a significant decline from 50% to 4.3% (0<0.001). Anterior surgeries also decreased from 17% to 4.3% (p<.126), but this did not reach statistical significance.

Conclusions: From 1997 to 2012 (15 years) study period of patients with EOIS, posterior-based surgeries significantly increased. The overall surgery rate has significantly decreased for these patients. A significant increase in hospital charges were noticed in posterior, anterior, and combined surgeries.
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http://dx.doi.org/10.1016/j.spinee.2018.05.033DOI Listing
February 2019
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