Deep Sharma

Prognostic Importance of Spinopelvic Parameters in the Assessment of Conservative Treatment in Patients with Spondylolisthesis

Study Design This was a prospective, two-group comparative study. Purpose The present study aimed to determine the importance of the spinopelvic parameters in the causation and progression of spondylolisthesis. Overview of Literature Spondylolisthesis is slippage of one vertebra over the vertebra below. Since the discovery of pelvic incidence (PI) in 1998 in addition to documentation of other parameters in spinopelvic balance, slippage in spondylolisthesis has been attributed to these parameters. Many studies on the Caucasian population have implicated high PI as a causative factor of spondylolisthesis. To the best of our knowledge, no study has described the role of these parameters in the progression of spondylolisthesis. Methods The study was conducted in Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India. Seventy-nine patients with spondylolisthesis consented to participate in the study. All patients were advised to undergo conservative treatment and were regularly followed up according to the protocol. Seventy-five asymptomatic volunteers were recruited as a control group. Of the total of 79 patients, 54 were followed up for 6 months, during which 46 improved, eight showed no improvement, and 25 were lost to follow-up. Sagittal spinopelvic parameters were measured by a single observer using the Surgimap spine software ver. 2.1.2 (Nemaris, New York, NY, USA). Parameters measured were PI, pelvic tilt (PT), sacral slope (SS), thoracic kyphosis, and lumbar lordosis. The results from patients and controls were compared using appropriate statistical methods. Results The normal and spondylolisthesis groups significantly differed with respect to PI, SS, and PT (p<0.001). There were no significant differences in the measured spinopelvic parameters between patients with high- and low-grade spondylolisthesis or between those whose condition improved and those whose condition worsened. Conclusions PI, the most important of all spinopelvic parameters, is responsible for the slip in spondylolisthesis, but not for its progression.

Does operative fixation of isolated fractures of ulna shaft results in different outcomes than non-operative management by long arm cast?

Objective The optimal treatment for isolated fractures of ulnar shaft is debatable. The purpose of this study was to compare functional outcomes and radiological union in patients treated for isolated fractures of the ulnar shaft by open reduction and internal fixation and a long arm cast. Methods This prospective study was conducted at level I trauma center from November 2014 to March 2016. 30 patients with isolated fractures of ulnar shaft were randomized to two groups to receive treatment by open reduction and internal fixation by plates and screws and a long arm cast. Outcome assessment was done by Disabilities of Arm Shoulder and Hand (DASH) score, range of motion at wrist and elbow, grip strength and radiological union. Quantitative variables were summarized Mean or Median. Normality was assessed using Kolmogorov-Smirnov test. Independent samples t-test and Mann-Whitney test were used for normally distributed variables and non-normally distributed variables respectively. Categorical variables were summarized as proportions. Effect of the intervention for categorical variables was assessed using Chi-square test. Results There was no difference between the groups for pain on Visual Analogue Scale (VAS), grip strength, DASH score, and union at the end of 12 months. There was no difference between the groups for range of motion at the elbow and wrist. 12 (85.7%) patients in the ORIF group and 15 (93.7%) in the cast group united at the end of 12 months. The mean time to union was 13 weeks in the ORIF group and 18 weeks in the cast group. Conclusion Open reduction and internal fixation results in anatomical restoration of ulna, but this does not translates to better functional outcomes in short term (12 months).

Pelvic Incidence as a Prognostic Variable to Assess the Outcome of Conservative Treatment in the Patients with Spondylolisthesis

Introduction Spondylolisthesis is defined as slippage of one vertebra over the below one. Ever since the discovery of pelvic incidence by legaye et al. in 1998 and as well as documentation of the other parameters for spinopelvic balance, the slippage in listhesis has been attributed to these parameters. Many studies were done in the Caucasian population, which implicates high pelvic incidence as a causative factor for the listhesis. But to our knowledge, no study has described the implication of these parameters in the progression of listhesis. The main aim of our present study was to know the importance of the spinopelvic parameters in the causation and progression of the listhesis and also to know the response to conservative treatment. Materials and Methods: The study was approved by our institute review board and the ethical committee. We included all the patients visiting our OPD with complaints of LBP for more than three months, whose X-ray shows spondylolisthesis and who gave consent for the study. All patients were advised conservative treatment (NSAIDS, physiotherapy and short wave diathermy) and were followed once in 2 weeks regularly and were evaluated once in 6 weeks with the help of modified Oswestry questionnaire. At the end of 6 months, patients who were improved were advised the same conservative treatment and followed up. Those who have not improved were suggested repeat X-rays and the parameters and grade of listhesis recalculated. A total of 79 patients were thus included in the study. Another age and sex matched group of asymptomatic volunteers (n = 75) were also recruited as a control group. Out of the total of 79 patients, 35 were followed for six month period of which 27 improved and in 8 there was no improvement. 25 have lost follow-up and in 19 follow-up was still pending. All the patients and volunteers underwent a standardized lateral sagittal digital radiograph of the whole spine including the base of the skull till the proximal ⅓ thigh. The sagittal spinopelvic parameters were measured using the Surgimap spine software version 2.1.2 by a single observer. The parameters measured were pelvic incidence PI, pelvic tilt PT, sacral slope SS, thoracic kyphosis TK, lumbar lordosis LL, lordotic and kyphotic vertebra. The comparisons were drawn between the patients and controls using appropriate statistical methods. Results The mean values in the asymptomatic group are PI-47.85, PT-13.03, SS-34.8, LL-54.68, TK-24.03. In the listhesis group are PI-65.32, PT-21.30, SS-44.13, LL-54.08, TK-25.49. There was a significant difference between the normal and the listhesis groups among PI, SS, PT (p < 0.001). There was no significant difference in pelvic incidence between the patients with high-grade(grade 3,4,5) and low-grade listhesis(grade 1,2). Conclusion The progression of slip and the response of the conservative treatment depends on- pelvic incidence, initial grade and how many levels of slip and finally on the sagittal vertical axis and its distance from the posterior superior corner of sacrum.

Low Back Pain- How Significant are the Spinopelvic Parameters?:

Introduction Since the discovery of pelvic incidence by Legaye et al. in 1998, many other sagittal spinopelvic radiographic parameters have been described as determinants of good sagittal balance. Alteration in these parameters has been linked to various spinal ailments producing degeneration to deformity. This have been proved by Roussouly et al. in his landmark paper, which showed a positive correlation between PI and Low Back Pain (LBP). However in the subsequent studies the same correlation could not be derived. Thus, we aim to study the role of high PI as a causative variable for Low back pain in our population. Materials and Methods: The study was approved by our institute review board and the ethical committee. We included all the patients visiting our OPD with complaints of LBP for more than three months and giving consent for the study. All patients underwent a thorough clinical and radiological examination, to rule out any apparent cause of LBP. We excluded patients with spinal deformity, fracture, infection, malignancy and with a history of previous spine surgery. A total of 67 patients were thus included in the study. Another age and sex matched group of asymptomatic volunteers (n = 75) were also recruited as a control group. All the patients and volunteers underwent a standardized lateral sagittal digital radiograph of the whole spine including the base of the skull till the proximal ⅓ thigh (subject naturally standing up, looking horizontally, hands resting on a vertical support, upper limbs relaxed and elbows half bent). All the subjects were at a specific distance from the radiographic source and a single shot of x- rays have been used centering around D12. The sagittal spinopelvic parameters were measured using the Surgimap spine software version 2.1.2 by a single observer. The parameters measured were pelvic incidence PI, pelvic tilt PT, sacral slope SS, thoracic kyphosis TK, lumbar lordosis LL, lordotic and kyphotic vertebra. The comparisons were drawn between the patients and controls using appropriate statistical methods. Results The mean values obtained in patients with low back pain were PI-48.04, PT-12.61, SS-35.5, LL-50.57 and TK-26.79. Corresponding values in healthy volunteers were PI-47.85, PT-13.03, SS-34.8, LL-54.68 and TK-24.03. We have found no statistically significant difference in the values of any sagittal spinopelvic parameters measured between the two groups. Conclusion Based on the results derived from our study we conclude that there is no statistically significant correlation between any of the measured sagittal spinopelvic radiographic parameters and the occurrence of LBP.

Analysis of Normal Values of Sagittal Spinopelvic Radiographic Parameters in Indian Population

Introduction Ever since Legaye et al. in 1998 first described the importance of pelvic incidence as an important determinant of sagittal spinal balance, several other radiographic spinopelvic parameters have been defined. There are an increasing number of reports and studies from around the world signifying the role of these parameters in the maintenance of global spinal balance. Alteration in the normal values of the spinopelvic parameters has been implicated in causing accelerated degeneration, low back pain and even sagittal plane deformities. The recent literature has suggested that the best functional outcomes after any spinal surgery were achieved when these parameters have been normalized. In this setting, it is extremely important to know the normal values of these parameters in the target population. Though these values have been well quantified in the Caucasian population, there is a dearth of information in other racial groups. A few studies done in other population groups have shown some ethnic differences in the normal values of these parameters. Thus in our study we aim to quantify the normal values of sagittal spinopelvic radiographic parameters in Indian population. Materials and Methods The study was approved by our institute review board and the ethical committee. A total of 75 young, healthy and asymptomatic volunteers were enrolled into the study after taking a formal consent. There were 21 male and 54 female volunteers. Lateral sagittal digital radiographs of the whole spine including the base of skull up to the proximal ⅓ thigh were taken in standing position (patient is naturally standing up, looking horizontally, hands resting on a vertical support, upper limbs relaxed and elbows half bent). All the subjects were at a specific distance from the radiographic source and a single shot of X-rays have been used centering around D12. The parameters measured were pelvic incidence PI, pelvic tilt PT, sacral slope SS, thoracic kyphosis TK, lumbar lordosis LL, lordotic and kyphotic vertebra. All measurements were performed by two independent observers using the Surgimap spine software version 2.1.2. The values thus obtained were compared with the values described in other population groups. Results The mean values obtained in our population group were PI-47.85, PT-13.03, SS-34.8, LL-54.68, TK-24.03. A significant correlation was found between SS-LL (r-0.817), PI-SS(R-0.813), PI-LL(r-0.692), PI-PT(r-0.589), LL-TK (r-0.505). Comparing our data with European data, the pelvic incidence of our study was lower. We also found that the values of spinopelvic parameters did not vary much between males and females except PT, which was found to have a statistically significant difference between sexes (p = 0.019). Conclusion The study demonstrated that pelvic incidence of the Asian population varied when compared with that of the Caucasian population. The pelvic incidence of our present study was similar to Japanese and Korean population. It was lower than that of the Caucasian population.