Publications by authors named "Tushar Rathod"

29 Publications

  • Page 1 of 1

Are we neglecting long-term effects of vertebral shortening on pulmonary function in spinal tuberculosis?

Spine Deform 2021 Aug 16. Epub 2021 Aug 16.

Department of Orthopedics, Seth G S Medical College and K.E.M. Hospital, Mumbai, 400012, India.

Purpose: In developing part of the world, it is common to see complete destruction of vertebral bodies in tuberculosis. Our study aims to assess the effect of spinal tuberculosis with vertebral shortening on pulmonary function.

Methods: Fifty cases of spinal TB (14 males, 36 females) managed both operatively and non-operatively, who presented to tertiary care institute between years 2011 and 2016 were assessed. Vertebral height loss was assessed by spinal deformity index (SDI). All patients underwent pulmonary function testing using same equipment sitting in upright position.

Results: Mean age was 27.9 years (27.9 ± 11.9). 11 patients with mean SDI of 2.7 ± 1.1 showed normal lung function. 36 patients showed restrictive pattern of which 12 were mild, 14 were moderate and 10 showed severe pattern with a mean SDI of 3.8 ± 1.2, 5.6 ± 1.3 and 6.1 ± 1.4, respectively. 3 cases showed obstructive pattern. As the apex of curve shifted proximally, FVC% reduced. Increase in SDI value was associated with a fall in the vital capacity and FEV. Increase in the kyphotic angle was associated with a deleterious effect on PFT results.

Conclusions: Risk stratification of pulmonary dysfunction resulting from vertebral body height loss due to kyphosis will emphasize the need for early detection of spinal tuberculosis before deformity occurs.
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http://dx.doi.org/10.1007/s43390-021-00400-9DOI Listing
August 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

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

Reconstruction of First Metatarsal Bone Loss Following Osteomyelitis by a Modified Masquelet Technique: A Case Report.

J Orthop Case Rep 2020 Dec;10(9):118-120

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

Introduction: The literature regarding reconstruction of foot bone defects is limited. The reconstruction of diaphyseal bone defects is technically challenging and is often associated with poor outcomes. Associated osteomyelitis adversely affects the healing rates following a reconstruction procedure.

Case Report: We report a case of a 62-year-old male with lytic lesion involving the head of first metatarsal and proximal part of proximal phalanx following osteomyelitis treated with a two-stage reconstruction utilizing a modification of Masquelet's-induced membrane technique. A follow-up at 24 months post-surgery revealed a fully incorporated fibular graft with satisfactory functional outcomes.

Conclusion: This two-stage modification of Masquelet technique provided an effective method to reconstruct the defect and restoration of the metatarsal length using minimal hardware to achieve a good functional recovery of the patient.
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http://dx.doi.org/10.13107/jocr.2020.v10.i09.1930DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8046436PMC
December 2020

A Rare Case of Vanishing Bone Disease of Metacarpals.

J Orthop Case Rep 2021 ;11(1):101-103

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

Introduction: Vanishing bone disease is rare phenomenon of idiopathic origin that leads to extensive osteolysis of bone. Prognosis of disease is unpredictable and definitive guidelines for management are still unknown. The vanishing bone disease has been reported for multiple other bones, however, this probably is the 1st time that vanishing bone disease of the metacarpals is being reported.

Case Report: A 22-year-old male presented with shortening middle finger and poor grip strength of the left hand. Serial radiographs revealed progressive concentric reduction of third and then fourth metacarpal shaft, with a sucked candy appearance. All the blood parameters were normal including calcium and parathormone levels. There was no evidence of any tumor elsewhere in the body. Biopsy showed myxoid areas, proliferating vessels interposed with skeletal muscles. Thus, based on clinical, radiological, and histopathological findings, we made the diagnosis of vanishing bone disease. The patient was treated with autologous non-vascularized fibula graft and was fixed with transverse k-wires to adjacent metacarpals. At 2-year follow-up, graft was completely incorporated and the patient gained full functional recovery.

Conclusion: Vanishing bone disease affecting the metacarpals is very rarely reported in the literature. The diagnosis should be made by excluding all the other conditions such as primary bone tumors or secondary from other sites. There are no fixed treatment guidelines. However, we could treat this condition successfully with autologous non-vascularized fibular graft.
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http://dx.doi.org/10.13107/jocr.2021.v11.i01.1982DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8046473PMC
January 2021

Recurrent symptomatic vertebral hemangioma in pregnancy managed with decompression and vertebroplasty.

Surg Neurol Int 2021 8;12:150. Epub 2021 Apr 8.

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

Background: Vertebral hemangioma is a benign vascular tumor of the spine that occurs in the endothelial lining of blood vessels. The majority of these lesions are detected incidentally on routine magnetic resonance imaging scans. Rarely, lesions can increase in size and result in neurological deterioration.

Case Description: A 19-year-old post-partum female, presented with paraplegia due to a recurrent vertebral hemangioma with exophytic extension into the epidural space resulting in spinal cord compression. Early decompressive surgery facilitated adequate early recovery of neurological function.

Conclusion: Exophytic vertebral hemangiomas that have extended into the spinal canal resulting in cord compression require urgent surgical decompression.
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http://dx.doi.org/10.25259/SNI_34_2021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8088490PMC
April 2021

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

Eur Spine J 2021 Oct 22;30(10):3081-3088. 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
October 2021

Bicentric Synchronous Giant cell tumor: A Rare Managed Case Report of Bilateral Fibula Neck Tumor.

J Orthop Case Rep 2020 Oct;10(7):22-24

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

Introduction: Multicentric giant cell tumor (GCT) of bone is an uncommon variant of the typical solitary lesion, with numerous large series reporting an incidence of 0-1.4%. Multifocal lesions also appear to be more locally aggressive than their solitary counterparts and have higher rates of recurrence. Solitary GCT of proximal fibula usually involves fibular head, bicentric synchronous bilateral fibular neck involvement is a rare presentation.

Case Presentation: An otherwise healthy 24-year-old boy presented with a palpable mass in the region of his left proximal fibula and B/L knee pain. He reported pain with activity but no peroneal nerve symptoms. Radiographs of his left knee revealed an expansile lytic lesion at the proximal fibula epimetaphyseal level while the right knee X-ray showed a similar smaller lesion. MRI was done to delineate the accurate extent of the tumor. On the left side, the patient underwent partial fibulectomy (en bloc resection) and chemical cauterization of the edges with 5% phenol. The other side GCT was smaller and the patient was largely asymptomatic, hence was planned for conservative management.

Conclusion: Multicentric GCT is a known entity and diagnosis should be considered after thorough metabolic workup and after ruling out more common polyostotic skeletal lesions. Selected patients with aggressive (benign) and malignant tumors of the proximal fibula can be treated successfully by resection and with supplementary soft-tissue reconstruction, a good functional outcome can be anticipated.
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http://dx.doi.org/10.13107/jocr.2020.v10.i07.1902DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7857652PMC
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

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

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

Association of Thrombophilic Factors in Pathogenesis of Osteonecrosis of Femoral Head in Indian Population.

Indian J Orthop 2020 Sep 2;54(Suppl 1):33-38. Epub 2020 Jul 2.

Department of Orthopedics, Seth G. S. Medical College and KEM Hospital, 6th Floor, New Multi-Storeyed Building, Parel, Mumbai, 400012 India.

Purpose: Role of heritable blood clotting disorders, both thrombophilias and hypofibrinolysis in causing avascular necrosis (AVN) of femoral head have been studied in regions like Europe and U.S.A. This study was done to investigate the role of heritable thrombophilias in ethnic Indian population.

Materials And Methods: A case control study of 150 patients (100 cases and 50 age and sex matched controls) of Indian Ethnicity with clinico-radiographically documented idiopathic AVN of femoral head was done after ethics committee approval. DNA was extracted from the blood and PCR analysis was used to study heritable thrombophilic gene mutation (G1691A Factor V Leiden). Enzyme-linked immunosorbent assay (ELISA)-based assays, were utilized to measure antigen levels of protein C, antithrombin III levels and protein S.

Results: Nine cases out of 100 showed deficiency of Protein C (9%) while no control showed deficiency of Protein C ( value: 0.028-significant, Odds ratio: 9.791) Ten cases showed deficiency of Protein S (10%) in study population as compared to one case (2%) in control population ( value: 0.038-significant, Odds ratio: 5.44). ATIII deficiency was more prevalent in control group i.e. 22% compared to 11% in study group. Factor V mutation was present in 3% cases as compared to one (2%) in control group. ( value is 0.393-not significant).

Conclusion: Difference in thrombophilic mutations in various populations indicates possible effect of ethnicity on genetic profile in the development of AVN. This risk stratification will enable in near future early diagnosis and possible role of antithrombotics in disease prevention.
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http://dx.doi.org/10.1007/s43465-020-00181-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7474030PMC
September 2020

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

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

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

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

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

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

It's Never Too Late: Neurological Outcome of Delayed Decompression in Tuberculosis of Spine.

Global Spine J 2021 Jun 19;11(5):716-721. Epub 2020 May 19.

Department of Orthopaedics, 29549Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India.

Study Design: Retrospective observational study.

Objective: To study the neurological recovery in patients with progressive neurological deficit undergoing delayed decompression and fixation in tuberculosis of spine.

Methods: Retrospective analysis of 50 cases with thoracolumbar tuberculosis of spine, undergoing posterior decompression and instrumentation was done. Parameters like time interval between appearance of neurological deficit to decompression surgery, maximal spinal cord compression, neurology on admission, presence of drug resistance, and number of vertebrae involved were evaluated. The subjects were divided into 2 groups depending on neurological improvement measured with LEMS (Lower Extremity Motor Score) at the end of 1-year follow-up.

Results: The mean LEMS score on admission was 27.72 (SD 12.88), which improved to 40.80 (SD 10.46) at the end of 1 year ( < .001). A total of 26 (52%) subjects were categorized into "Satisfactory" outcome (LEMS >10) group and remaining 24 subjects formed the "nonsatisfactory" outcome group. The median time interval between the appearance of neurological deficit and decompression surgery was 23.50 days in the satisfactory group and 29.50 days ( = .110) in the nonsatisfactory group. Maximal spinal cord compression was 0.370 in satisfactory group and 0.357 in nonsatisfactory group ( = .754). The mean preoperative LEMS score was 34.62 in the satisfactory outcome group while that in the nonsatisfactory outcome group was 20.25 ( < .001).

Conclusion: There is significant scope for neurological improvement even after delayed decompression and fixation in cases of tuberculosis of spine with progressive neurological deficits. Preoperative neurological status was found to be the most significant determinant of postoperative neurological outcome.
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http://dx.doi.org/10.1177/2192568220922209DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8165910PMC
June 2021

Tuberculosis-The Great Mimicker: A Case of Traumatic Drainage of Cold Abscess.

World Neurosurg 2020 11 27;143:163-167. Epub 2020 Jul 27.

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

Background: Tuberculosis is characterized by cold abscess, which classically lacks the usual signs and symptoms of inflammation. This case report highlights an atypical presentation of tuberculous cold abscess in the form of appearance of massive swelling in the back overnight after a blunt trauma, mimicking post-traumatic hematoma.

Case Description: A 32-year-old man came to our outpatient department with sudden swelling over the right side of the upper back (25 × 8 × 8 cm) and loin (10 × 4 × 4 cm) after a fall from 1.5 to 2 m height the previous night. The possible differential diagnosis of a traumatic pathology, complicated by a bleeding disorder, resulting in massive hematoma was initially made. However, hematologic investigations were within normal limits. Magnetic resonance imaging suggested an anterior subligamentous abscess at the C7-T1 level tracking through the paraspinal muscles and communicating with the subcutaneous abscess, and at the L3 level, paraspinal abscess tracking to the subcutaneous plane. There was no cord compression or signal changes in the cord. Both the abscesses were pigtailed in antigravity fashion, and material was sent for culture, which proved to be tuberculosis. The patient was treated with antituberculosis treatment for 18 months and improved over the course with complete resolution of symptoms. At 4-year follow-up, the patient is asymptomatic with no evidence of recurrence.

Conclusions: Appearance of massive swelling overnight in patients with cold abscess has not been described in the literature. While evaluating an atypical presentation such as sudden post-traumatic swelling over the thoracolumbar area, the clinician should keep a differential diagnosis of tuberculous abscess and investigate clinicoradiologically to rule out tuberculosis, especially in developing countries.
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http://dx.doi.org/10.1016/j.wneu.2020.07.142DOI Listing
November 2020

Intradural Disc Herniation in the Lumbar Spine: A Case Report.

JNMA J Nepal Med Assoc 2020 May 30;58(225):345-348. Epub 2020 May 30.

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

Intradural disc herniation is a rare presentation of a common pathology, comprising around 0.28-0.3% of all disc herniations. It occurs when disc material related to an intervertebral disc penetrates the spinal dura and lies in an intradural extramedullary location. A 60 years old male patient presented with complaints of low back pain and right lower limb radiculopathy of 2 weeks duration. Neurological examination revealed the weakness of extensor hallucis longus and ankle dorsiflexion with diminished sensation corresponding to fourth and fifth lumbar (L4-L5) dermatome on the right side. Magnetic resonance imaging showed a large sequestered fragment with intradural extensions and posterior longitudinal ligament tear. Intradural nerve root showed significant displacement with severe central canal and right lateral recess stenosis. Discectomy was performed along with the removal of the intradural extension. The postoperative course was uneventful.
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http://dx.doi.org/10.31729/jnma.4798DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7654472PMC
May 2020

Learning from Mistakes: Pancreatic Laceration: Devastating Complication During Spine Surgery.

World Neurosurg 2020 09 6;141:81-84. Epub 2020 Jun 6.

Department of Orthopaedics, Seth GS Medical College and KEM Hospital, Parel, Mumbai, India.

Background: Posterior decompression and fusion surgery is one of the most commonly performed surgeries for thoracolumbar tuberculosis with destruction of vertebral bodies. Tuberculosis causes gross destruction of the vertebral bodies and surrounding tissue, making them friable.

Case Description: We present an unusual but dreaded complication which we encountered during posterior decompression and instrumentation surgery in a 65-year-old woman with T10-11 tuberculosis of the spine. During surgical exposure, while reflecting posterior paraspinal muscles on the left side, there was an accidental slip of the Cobb elevator around the transverse process to the extent of two-thirds of its length on the left side anteriorly. The instrument was immediately withdrawn. There was no active bleeding in the field. The rest of the surgery was uneventful. In the postoperative period, however, the patient developed severe abdominal pain with abdominal distention. General surgery opinion was immediately taken and the patient was immediately investigated in the form of a computed tomography scan. It was found that there was a traumatic laceration of the pancreas. The patient underwent emergency exploratory laparotomy and repair of the pancreatic laceration. The patient required intensive monitoring and critical care unit stay and ultimately went on to recover fully over the next few weeks.

Conclusions: This case illustrates the possibility of pancreatic injury should always be kept in mind if the patient develops acute abdominal discomfort in the postoperative period. Also, a multidisciplinary approach along with intensive care backup and vigilant postoperative monitoring is of utmost importance, especially when an unusual event has occurred during the surgery.
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http://dx.doi.org/10.1016/j.wneu.2020.05.261DOI Listing
September 2020

Multidrug-resistant tuberculosis of lumbosacral spine producing extensive destruction with lumbosacral kyphosis.

BMJ Case Rep 2020 May 14;13(5). Epub 2020 May 14.

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

It is uncommon to get lumbosacral junction deformity due to tuberculosis. Lumbosacral junction alignment is of paramount importance in maintaining global sagittal balance. In this case report, we present a case of a 42-year-old woman with multidrug-resistant tuberculosis of lumbosacral spine with complete destruction of L3, L4 and L5 vertebra with partial destruction of L2 and S1 vertebra leading to significant shortening and lumbosacral kyphosis. The patient had severe axial low back pain, inability to sleep in supine position due to deformity and difficulty in walking due to loss of spinal alignment. The patient was treated with 6 weeks of antituberculous drugs followed by all posterior decompression with instrumentation from D10 to S2 with a reconstruction of anterior vertebral bodies with the help of an expandable cage. Antituberculous treatment was continued for 18 months. At present, the patient is asymptomatic with no neurological deficit and has completed 3.5 years of regular follow-up.
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http://dx.doi.org/10.1136/bcr-2020-234246DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7232617PMC
May 2020

Patient satisfaction related outcome after total hip arthroplasty; does bearing surface play a role?

J Clin Orthop Trauma 2020 Mar 3;11(Suppl 2):S196-S200. Epub 2020 Jan 3.

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

Background: The aim of this study was to compare the functional outcome, the patient's perception of the replaced hip joint with different bearing surfaces and to study the effect of femoral head size on joint perception as well.

Methods: One hundred and ten (110) patients, who underwent primary total hip replacement with an average follow-up of 48 months (12-156 months), were assessed for their functional outcome and joint perception. The functional outcome was calculated based on Oxford hip score (OHS) and SF-36. Joint perception was categorized as to whether the replaced joint was perceived like a natural joint or artificial joint with or without restriction of movements.

Results: There were 50 patients operated for ceramic on ceramic (CoC-hard-on-hard bearing), 60 patients for hard-on-soft bearing (Metal on Polyethelene-MoP 46, Ceramic on Polyethelene-CoP 14). Most of the patients with hard-on-hard bearings perceived their operated hip like a natural joint (p = 0.04) compared to hard-on-soft bearings. There was no significant difference in the functional outcome (OHS, SF-36) between the two bearing surface groups (p > 0.05). There were fifty patients with 28 mm size head while remaining 60 had larger heads (>32 mm). Patients with large heads felt like natural joint compared to small heads (p = 0.007).

Conclusion: The hard-on-hard bearing surfaces (CoC) and large femoral heads (32 mm, 36 mm) are perceived more like a natural joint. Different bearing surfaces do not affect the functional outcome after total hip replacement in a medium term follow up.
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http://dx.doi.org/10.1016/j.jcot.2019.12.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7068008PMC
March 2020

Vertebral column resection for post tuberculosis severe kyphotic deformity: Results of 5 year follow-up.

J Orthop 2020 May-Jun;19:122-127. Epub 2019 Nov 28.

Department of Orthopaedics, Seth G S Medical College & KEM Hospital, Parel, Mumbai, India.

Background: Spinal TB is endemic in our study region and many patients present with severe kyphotic deformities and neurological deficit. We corrected such deformities with all posterior single stage surgeries. This study was undertaken to evaluate the results, efficacy and safety of this technique.

Methods: Deformity correction of 16 patients was done during January 2012 to December 2014. All patients underwent posterior only approach for vertebral column resection at peri-apical region, posterior instrumentation with pedicular screws and anterior reconstruction using mesh cage. Postoperative X-ray films were evaluated. All patients were followed up at six weeks, 12 weeks, 18 weeks, six months and yearly thereafter. At follow-up patients were evaluated neurologically and radio-graphically.

Results: Mean age of the patients was 19.43 years. (Range 3-37) An average 1.62 vertebrae were excised and 5.93 vertebral levels were instrumented. Mean blood loss was 1013 ml and the mean duration of surgery was 6.78 h. The decrease in mean kyphotic deformity from preoperative 90.08⁰ to postoperative 38.06⁰ was statistically significant. (P < 0.000) Mean percentage correction was 57.59%. No pseudoarthrosis was found on X-rays. The decrease in Oswestry's Disability Index was from 55.43 to 10.06 was statistically significant. (P < 0.000) Two patients had neurological complications and one patient had wound complication.

Conclusion: The safety and efficacy of Posterior VCR technique for post tuberculosis severe kyphotic deformity is favorable with no severe late stage complications. Excision of ribs, careful handling of cord and gradual correction of deformity with good hemostasis is important.
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http://dx.doi.org/10.1016/j.jor.2019.11.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6997645PMC
November 2019

Does Mesh Cage Subsidence Have any Effect on Functional Outcome in Spinal Tuberculosis?

Asian J Neurosurg 2019 Oct-Dec;14(4):1168-1174. Epub 2019 Nov 25.

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

Introduction: Occurrence of mesh cage subsidence in patients undergoing anterior column reconstruction following Tuberculosis spine is frequent radiological finding as bone quality of affected vertebrae is poor. This study aims at determining effect of mesh cage subsidence on functional outcome.

Methods: Retrospective demographics of 30 patients of consecutive series in age range 4-60 year were collected with Clinical outcome evaluation using VAS, ODI and ASIA scale. 30 patient having Dorsolumbar tuberculosis with vertebral involvement ranging from 1-6 with mean vertebral level involvement of 2.71, underwent anterior column reconstruction through posterior only approach between 2011-15 were reviewed. Patients were followed at regular intervals of 6 weeks, 12 weeks, 6 months & thereafter on yearly basis. They were evaluated for interbody height loss with subsidence, fusion & segmental angle.

Results: Clinical parameters i.e. VAS & ODI showed improvement in postoperative period which continued to remain same even after subsidence ( < 0.05). Subsidence was categorized as combined anterior + posterior < 5mm; 5 -10mm; >10mm. ODI at follow up was 8.5 ±4.62, 9 ± 2 and 9 ± 4.2 ( = 0.961) respectively & VAS score in above group was 1.3 ± 0.51, 1.5 ± 1.2 & 1.5 ± 0.7 ( = 0.975) respectively. Subsidence was age, spinal level nonspecific.

Conclusion: Study indicates that though Cage subsidence occurs to varying severity due to weakened vertebral bodies, it did not have significant impact on functional outcome in terms of VAS, ODI or radiological evidence of fusion following reconstruction in Spinal tuberculosis.
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http://dx.doi.org/10.4103/ajns.AJNS_261_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6896648PMC
November 2019

A managed case of rare intraosseous lipoma of femoral neck.

J Clin Orthop Trauma 2019 Oct 8;10(Suppl 1):S222-S225. Epub 2019 Mar 8.

Department of Orthopaedics, Seth GS Medical College & KEM Hospital, Parel, Mumbai, 400012, India.

43 year-old female presented with anterior hip pain not responding to conservative treatments. Plain radiograph showed radio-lucent area with sclerotic margin in the femoral neck region. On MRI scan the diagnosis of intraosseous lipoma was confirmed. Due to persistent pain and risk of fracture, decision of operative treatment was made. She underwent curettage of the lesion under image-intensifier and reinforcement of femoral neck with non-vascularised fibular grafting. Post-operative x-rays showed incorporation of the fibular graft with good clinical and functional outcome. Intraosseous lipoma in the femoral neck is a rare presentation and in cases with persistent symptoms or risk of impending fracture, operative treatment gives a good functional outcome.
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http://dx.doi.org/10.1016/j.jcot.2019.03.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6823791PMC
October 2019

Bimalleolar Fracture: A Unique Case of Complication of Complex Regional Pain Syndrome of Lower Extremity After Prolonged Undue Immobilisation.

J Orthop Case Rep 2019 ;9(5):20-22

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

Introduction: The complex regional pain syndrome (CRPS) is an agonizing and disabling condition that can affect one or more extremities. Contrary to expectation, sporadic case reports about lower limb CRPS are present in literature. The usual sequence of events with respect to CRPS has always been prior trauma or inciting event, leading to manifestations. We hereby present a case of prolonged and undue immobilization without physical therapy, leading to CRPS in a susceptible phenotype. However, the unique feature of this case was severity of osteoporosis leading to bimalleolar fracture. To the best of our knowledge, there has been no case report of CRPS, leading to fracture.

Case Report: A 30-year-old female presented 2 months after trauma to the right ankle due to a fall from a bike. A radiograph of the ankle demonstrated no evidence of any bony injury. As per records, there was no evidence of ligament injury based on magnetic resonance imaging evaluation. As the patient had severe pain and swelling, she underwent conservative treatment in the form of lower limb immobilization in a non-weight-bearing below knee splintage for a period of 8 weeks. After removal of the splintage, the patient continued to have severe pain and swelling and was unable to bear weight. At this point of time, the patient presented to our clinic where follow-up radiographs demonstrated a bimalleolar fracture of the right ankle and diffuse osteoporosis involving talus-calcaneusand metatarsals. After thorough exclusion of other metabolic bone diseases based on various laboratory parameters, the diagnosis of CRPS was made as per Budapest criteria.The case here was diligently managed with multidisciplinary approach. It emphasized on the well-designed rehabilitation of the affected extremity to interrupt the vicious cycle of disuse along with well-controlled analgesia, cognitive psychotherapy, and supervised regular physical therapy. Meticulous medical management included bisphosphonates, careful balance of analgesics including nonsteroidal anti-inflammatory drugs, opioids, and beta-blockers.

Conclusion: This case report highlights the importance of multimodal stepped care approach in CRPS 1 involving ankle joint. Our report also reiterates the relevance of early mobilization and avoiding undue immobilization.
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http://dx.doi.org/10.13107/jocr.2019.v09.i05.1514DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7276611PMC
January 2019

High sensitive C-reactive protein-Effective tool in determining postoperative recovery in lumbar disc disease.

Indian J Orthop 2014 Jul;48(4):354-9

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

Background: It is common in medical practice to see patients having persistent pain and radiculopathy even after undergoing discectomy surgery. Inflammatory cytokines, such as interleukins are produced at the site of disc herniation and are now considered responsible for the pain perceived by the patient. This study has used high sensitive C-reactive protein (HSCRP) assay for predicting inflammation around the nerve roots on very same principle, which has used HSCRP for predicting coronary artery diseases in current clinical practice. Thus, purpose of this study is to test whether HSCRP can stand as an objective tool to predict postoperative recovery in patients undergoing lumbar discectomy. That is, to study association between preoperative HSCRP blood level and postoperative recovery with the help of modified Oswestry Back Disability Score.

Materials And Methods: A study group consisting of 50 cases of established lumbar disc disease and control group of 50 normal subjects, matched with the study group. Both the study and control groups were subjected to detailed evaluation with the help of modified Oswestry Low Back Pain Scale both pre and postoperatively at 3 months, 6 months and 1-year. The preoperative blood samples were analyzed to assess the HSCRP concentration. All the cases underwent surgery over a period of 1-year by the same surgeon.

Results: The level of HSCRP in the study group was between 0.050- and 0.710 mg/dL and in the control group, 0.005-0.020 mg/dL. There was highly significant positive correlation between preoperative HSCRP level and postoperative score at P < 0.005. Cases with HSCRP level in the range of 0.1820 ± 0.079 mg/dL, showed better recovery (score improved > 10 points), while those with HSCRP level in the range of 0.470 ± 0.163 mg/dL, showed poor recovery (score improved < 10 points).

Conclusion: HSCRP will serve as a good supplementary prognostic marker for operative decision making in borderline and troublesome cases of lumbar disc disease.
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http://dx.doi.org/10.4103/0019-5413.136216DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4137511PMC
July 2014

Association between single nucleotide polymorphism in collagen IX and intervertebral disc disease in the Indian population.

Indian J Orthop 2012 Jul;46(4):420-6

Department of Orthopaedics, Grant Medical College, Sir J. J. Group of Hospitals, Mumbai, India.

Background: Symptomatic intervertebral disc degeneration is being recently reported in younger population, questions the basis of its degenerative etiology. Latest evidences show that genetics play a significant role. Collagen IX, an important constituent of disc, is found to be altered in genetically predisposed individuals. Mutations have been reported in COL9A2 and COL9A3 genes, which encode Collagen IX, in Finnish and various other populations. The purpose of the present study is to test the significance of these genes in the Indian population.

Materials And Methods: One hundred proven cases of intervertebral disc disease (IDD) of various regions of spine were selected for the study, along with matched controls. They were tested for the above mentioned alleles by allelic discrimination method with real-time polymerase chain reaction (PCR) study after isolation of DNA from blood sample. Each blood sample was classified into one of the three types - homozygous, heterozygous, and wild (normal) type allele - separately for COL9A2 and COL9A3 genes.

Results: Homozygosity for COL9A2 allelic variation was associated with 100% occurrence of the disease. Heterozygous allele of COL9A2 was significantly higher in the study group (42%) as compared to the control group (17%). In contrast, allelic variation in COL9A3 gene was found to have no significant correlation with disc disease. There was no single patient with homozygous allelic variation for COL9A3, suggesting predominance of COL9A2 variation in the Indian population.

Conclusion: This candidate gene strategy approach adds considerably to our knowledge of genetic makeup of Indian populations in relation with disc disease. This study highlights importance of COL9A2 gene variation especially of homozygous variety in contrast to COL9A3 variation in causing disc disease in Indian population.
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http://dx.doi.org/10.4103/0019-5413.97261DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3421932PMC
July 2012

Juvenile systemic lupus erythematosus: A diagnostic dilemma.

J Nat Sci Biol Med 2011 Jul;2(2):229-31

Department of Paediatrics, Grant Medical College and Sir J.J. Group of Hospitals, Mumbai, India.

Juvenile systemic lupus erythematosus is an autoimmune disorder characterized by inflammatory damage to joints, kidney, central nervous system, and hematopoietic system in the form of fever, cutaneous lesion including skin rash, arthritis, anemia, and fatigue. We report a case in which the patient had features mimicking idiopathic thrombocytopenic purpura and juvenile dermatomyositis, but on a detailed Hematological investigation and kidney biopsy patient was diagnosed as juvenile SLE.
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http://dx.doi.org/10.4103/0976-9668.92319DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3276022PMC
July 2011

Aqueductal stenosis with optic atrophy in case of malignant osteopetrosis.

J Nat Sci Biol Med 2011 Jul;2(2):222-4

Department of Paediatrics, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, India.

Malignant osteopetrosis is a rare autosomal recessive bone disease usually present with short stature, severe anemia, thrombocytopenia, hepatosplenomegaly, and macrocephaly. Here we report a rare case of malignant osteopetrosis presented with evidence of short stature, anemia, thrombocytopenia, hepatosplenomegaly, rickets, aqueductal stenosis, and hydrocephalus with resultant optic atrophy.
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http://dx.doi.org/10.4103/0976-9668.92315DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3276020PMC
July 2011

Polyarthritic, symmetric arthropathy in reactive arthritis.

J Nat Sci Biol Med 2011 Jul;2(2):216-8

Department of Orthopedics, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, India.

Reactive arthritis (ReA) is an immune mediated disease, clinically associated with oligoarthritis of the lower limbs and sometimes with urethritis and conjunctivitis. In our case, a 24-year-old male presented with severe mutilating arthritis involving both upper and lower extremities in contrast to conventional Reiter's syndrome which presents with asymmetric oligoarthritis. He had multiple well-defined, irregular, erythematous, hyperkeratotic, scaly and itchy plaques, not easily distinguishable from pustular psoriasis. The patient also gave history of circinate balanitis and urethritis. He was started on methotrexate (7.5 mg/week, later escalated to 15 mg/week with 15 mg/day folinic acid supplementation) to which he responded. But when he stopped it on his own, the symptoms recurred. Hence, methotrexate was restarted, but still the patient suffers from fixed flexion deformities in affected joints. Histopathological examination of skin lesions is also suggestive of ReA. Thus, this case report suggests that diagnosis of Reiter's should be considered in symmetrical, mutilating polyarthritis patients with typical skin lesions.
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http://dx.doi.org/10.4103/0976-9668.92312DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3276018PMC
July 2011
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