Krishnan Venkatesh

Treatment of haematogenous pyogenic vertebral osteomyelitis by single-stage anterior debridement, grafting of the defect and posterior instrumentation

Anterior debridement, grafting of the defect and posterior instrumentation as a single-stage procedure is a controversial method of managing pyogenic vertebral osteomyelitis. Between 1994 and 2005, 37 patients underwent this procedure at our hospital, of which two died and three had inadequate follow-up. The remaining 32 were reviewed for a mean of 36 months (12 to 66). Their mean age was 48 years (17 to 68). A significant pre-operative neurological deficit was present in 13 patients (41%). The mean duration of surgery was 285 minutes (240 to 360) and the mean blood loss was 900 ml (300 to 1600). Pyogenic organisms were isolated in 21 patients (66%). All patients began to mobilise on the second post-operative day. The mean hospital stay was 13.6 days (10 to 20). Appropriate antibiotics were administered for 10 to 12 weeks. Early wound infection occurred in four patients (12.5%), and late infection in two (6.3%). At final follow-up, the infection had resolved in all patients, neurological recovery was seen in ten of 13 (76.9%) and interbody fusion had occurred in 30 (94%). The clinical outcome was excellent or good in 30 patients according to Macnabs criteria. This surgical protocol can be used to good effect in patients with pyogenic vertebral osteomyelitis when combined with appropriate antibiotic therapy.

The use of titanium mesh cages in the reconstruction of anterior column defects in active spinal infections: can we rest the crest?

Study Design Retrospective clinical series. Purpose To assess whether titanium cages are an effective alternative to tricortical iliac crest bone graft for anterior column reconstruction in patients with active pyogenic and tuberculous spondylodiscitis. Overview of Literature The use of metal cages for anterior column reconstruction in patients with active spinal infections, though described, is not without controversy. Methods Seventy patients with either tuberculous or pyogenic vertebral osteomyelitis underwent a single staged anterior debridement, reconstruction of the anterior column with titanium mesh cage and adjuvant posterior instrumentation. The lumbar spine was the predominant level of involvement. Medical co-morbidities were seen in 18 (25.7%) patients. A significant neurological deficit was seen in 32 (45.7%) patients. At follow up patients were assessed for healing of disease, bony fuson, and clinical outcome was assessed using Macnabs criteria. Results Final follow up was done on 64 (91.4%) patients at a mean average of 25 months (range, 12 to 110 months). Pathologic organisms could be identified in 42 (60%) patients. Forty two (60%) patients had histopathological findings consistent with tuberculosis. Thirty of 32 (93.7%) patients showed neurological recovery. The surgical wound healed uneventfully in 67 (95.7%) patients. Bony fusion was seen in 60 (93.7%) patients. At final follow up healing of infection was seen in all patients. As per Macnabs criteria 61 (95.3%) patients reported a good to excellent outcome. Conclusions Inspite of the theoretical risks, titanium cages are a suitable alternative to autologous tricortical iliac crest bone graft in patients with active spinal infections.

Open intramedullary nailing in neglected femoral diaphyseal fractures

INTRODUCTION Neglected femoral diaphyseal fractures are not uncommon in developing nations however there is a paucity of literature in this regard. Due to lack of effective traction, reduction or immobilisation these fractures are invariably associated with shortening and adjacent joint stiffness, presenting a challenging problem to the treating surgeon. The socioeconomic constraints in our society which result in patients seeking non-medical forms of treatment in the first place also warrant the need for an economically viable, simple effective form of treatment which can be carried out in a less advanced setup, gives reliable outcomes and allows early return to work. METHODS Eleven patients with neglected or late presenting femoral diaphyseal fractures were considered for the study. All patients underwent open intramedullary nailing, bone grafting and manipulation of the knee under anaesthesia. Iliac crest graft was harvested when local callus did not suffice. All patients received a supervised regimen of physiotherapy. Patients were followed up clinically and with plain radiographs at 6 weeks and 3 months to assess union and at monthly intervals thereafter. RESULTS The mean patient age was 28.8 years (15-48). The mean delay in presentation was 14 weeks (3-32 weeks). The mean shortening was 3.8 cm with four fractures showing signs of malunion. Five patients were given preoperative traction and bone resection was performed in only one patient. The mean hospital stay was 11 days (5-25 days). One patient was lost to follow up, of the remaining 10 patients all united at a mean of 11.9 weeks with 7 patients regaining full range of motion. The mean knee range of motion was 142.5 degrees . There were no wound related or neurological complications. One patient had a patellar tendon rupture which was repaired and another required dynamisation and bone marrow injection for delayed union. CONCLUSION We conclude that the treatment of neglected femoral diaphyseal fractures with open intramedullary nailing and bone grafting followed by manipulation of the knee with preoperative traction in selected cases is a satisfactory method of treatment showing reliable bony union however knee mobilisation should be undertaken with caution.

Extended Posterior Circumferential Approach to Thoracic and Thoracolumbar Spine

ObjectivePosterior spinal surgical approach to achieve a retropleural/ retroperitoneal corpectomy with circumferential spinal cord decompression following subtotal vertebrectomy, posterior instrumentation and interbody spacer placement under compression as well as kyphosis correction with spinal column shortening.IndicationsInfective, traumatic or neoplastic lesions of the vertebral body that lead to vertebral body destruction, instability and neurologic deficit.Need for immediate postoperative loading stability to permit ambulation and rehabilitation.ContraindicationsMultiple contiguous vertebral disease.Instances where the graft bed preparation and stable interbody spacer placement may be suboptimal due to the limited access offered by this approach.Surgical TechniquePosterior midline exposure two to three levels above and below lesion, dissection at level of lesion extended bilaterally exposing transverse processes, costotransverse articulations and medial 5–8 cm of ribs. Placement of pedicle screws at proximal and distal levels; in case of osteoporotic bone augment screws with cement. Bilateral costotransversectomy at one or more levels to drain prevertebral abscess and expose diseased vertebral bodies. After temporary stabilization, laminectomy and corpectomy are carried out from both sides to permit circumferential decompression. A temporary rod is placed on the contralateral side in the position of deformity to prevent any inadvertent translatory movements during the subsequent surgical step. After completion of the procedure an appropriately contoured rod is placed. The interbody spacer is positioned. Kyphosis correction by spinal column shortening and compression along the posterior implant is performed.Postoperative ManagementBy day 3 ambulation and rehabilitation are initiated.Results22 patients were operated in the last 8 years with tuberculosis (18 patients – twelve paraplegics), osteoporotic fractures (two patients), congenital kyphosis and Ewing’s sarcoma (one patient each). All patients were followed up at 3, 6, 9, and 12 months and then annually. At each followup, clinical, hematologic and radiologic parameters were assessed. All interbody grafts and cages incorporated without significant loss of correction. Ten of twelve tuberculous paraplegics recovered. No patient had postoperative infection, interbody spacer- or implant-related complications.ZusammenfassungOperationszielDorsaler Zugang zur Wirbelsäule zur retropleuralen oder retroperitonealen Korpektomie mit vollständiger zirkulärer Rückenmarkdekompression nach subtotaler Vertebrektomie, dorsaler Instrumentierung und Einbringen eines intervertebralen Platzhalters unter Kompression sowie zur Kyphosekorrektur mit Verkürzung der Wirbelsäule.IndikationenInfektiöse, traumatische oder neoplastische Läsionen, welche zu Wirbelkörperdestruktion, Instabilität und neurologischem Defizit führen.Notwendigkeit einer unmittelbaren postoperativen Belastung, um Mobilisierung und Rehabilitation zu gestatten.KontraindikationenErkrankung oder Verletzung multipler kontinuierlicher Wirbelsegmente.Situationen, in denen wegen des beschränkten Zugangs eine nicht ausreichende Darstellung der Deckplatten zu erwarten ist und dadurch die stabile Platzierung des intervertebralen Platzhalters erschwert wird.OperationstechnikDorsaler Hautschnitt über zwei bis drei Wirbelsegmente ober- und unterhalb der Läsion. Darstellung beider Querfortsätze bilateral auf Höhe der Läsion, der kostotransversalen Gelenke und der anschließenden 5–8 cm der Rippen. Platzierung von Pedikelschrauben in den proximalen und distalen Segmenten. Bei osteoporotischem Knochen Augmentation der Schrauben mit Zement. Bilaterale Kostotransversektomie auf einer oder mehreren Höhen zur Drainage prävertebraler Abzesse oder zur Darstellung erkrankter Wirbelkörper. Nach temporärer Stabilisation werden Laminektomie und Korpektomie beidseits durchgeführt, um eine zirkuläre Dekompression des Rückenmarks zu gestatten. Ein temporärer Stab wird auf der kontralateralen Seite der Deformität platziert, um intraoperativ unbeabsichtigte translatorische Bewegungen zu vermeiden. Am Operationsende wird dann ein angemessen vorgebogener Stab platziert. Der interkorporelle Platzhalter wird positioniert. Die Korrektur der Kyphose wird durch Verkürzung der Wirbelsäule und Kompression entlang dem posterioren Implantat erreicht.WeiterbehandlungMobilisierung und Rehabilitation ab dem 3. postoperativen Tag.Ergebnisse22 Patienten wurden in den letzten 8 Jahren wegen Tuberkulose (18 Patienten – zwölf Paraplegiker), osteoporotischer Fraktur (zwei Patienten), kongenitaler Kyphose und Ewing- Sarkom (je ein Patient) mit o.g. Methode operiert. Die Patienten wurden 3, 6, 9 und 12 Monate postoperativ sowie anschließend jährlich nachuntersucht, und der klinische, hämatologische und radiologische Verlauf wurde erhoben. Alle interkorporellen Transplantate und Implantate heilten ohne wesentlichen Korrekturverlust ein. Zehn der zwölf tuberkulösen Paraplegiker erholten sich neurologisch. Kein Patient entwickelte eine postoperative Infektion. Postoperative Probleme mit Platzhalter oder Implantat traten ebenfalls nicht auf.

Salmonella spondylodiscitis in the immunocompetent: our experience with eleven patients.

Study Design. Retrospective case series. Objective. To report the clinical features, diagnostic dilemmas and management options of 11 immunologically normal patients with salmonella spondylodiscitis. Summary of Background Data. Majority of existing data on salmonella spondylodiscitis in the immunologically normal patient is from anecdotal case report. Methods. From 1995 to 2008, 11 patients with salmonella spondylodiscitis proven by positive culture, biopsy, and Widal test were included. One patient died, and the average follow-up of the remaining 10 patients was 36 months (12-122 months). Five (50%) patients had a documented history of typhoid fever. Intravenous antibiotics for 2 weeks and oral antibiotics for at least 10 weeks were given to all patients. Indications for surgical intervention were unrelenting pain and osseous instability. Clinical outcome was evaluated according to Macnab criteria. Results. Salmonella typhi was cultured in 4 and S. Paratyphi in 5 patients. No organism was identified in 2 patients, on whom the diagnosis was performed by a characteristic history, high Widal titers, and a positive biopsy. Widal titers were positive for all patients (Average + 1360). Five patients were managed with antibiotics only, 1 with surgical debridement and uninstrumented fusion and 4 with single-stage debridement, anterior fusion, and posterior instrumentation. Healing of disease with a good to excellent outcome was seen in all patients. Conclusion. Salmonella and tuberculous spondylitis must be differentiated as they both have similar epidemiological and clinicoradiologic presentations. Prodromal gastrointestinal symptoms are usually not present. The diagnosis rests largely on the recovery of the organism by appropriate culture techniques. However, when this is not apparent the Widal test, in the setting of a suggestive history and radiograph, may be used as a diagnosis tool. Though antibiotics are the mainstay of treatment, surgical debridement with the use of instrumentation may be indicated in selected patients.

Telangiectatic osteosarcoma of the spine: a case report

Telangiectatic osteosarcoma (TOS) of the spine is rare accounting for only 0.08% of all primary osteosarcomas. Though a well described radio-pathological entity it is not often thought of as a cause of paraplegia. We describe the clinical, radiological and pathological features and discuss the treatment options of telangiectatic osteosarcoma of the dorsal spine presenting in a young man. The diagnostic pitfalls are discussed emphasising the fact that the diagnosis of TOS of the spine requires not only a multi modal approach of appropriate radiological and pathological tests but also an awareness of this condition.

Chondrosarcoma of the Spinous Process: A Rare Presentation

Chondrosarcomas are malignant cartilage forming tumours. They form the second most common primary malignant tumour involving the vertebral axis. We present a rare presentation of a secondary chondrosarcoma from the spinous process of lumbar vertebra and discussed its management. The main emphasis is on the rare presentation and the need for awareness and suspicion of the pathology.

Lumbar plexopathy following instrumented posterior lumbar interbody fusion: a complication with use of Hohmann’s retractor

IntroductionA series of 12 patients in our centre following single level instrumented posterior lumbar interbody fusion at L4–L5 developed unexplainable motor weakness in the proximal lumbar nerve roots (L2, L3) and numbness of the whole limb, a clinical picture resembling lumbar plexopathy. Even though lumbar plexopathy has been reported following gynaecological procedures and in transpsoas interbody fusion surgeries, there is no literature reporting this complication following conventional instrumented posterior lumbar interbody fusions.Study designRetrospective observational study.ObjectiveTo find the possible mechanism of development of lumbar plexopathy in patients who underwent posterior lumbar interbody fusion surgeries in our centre.Material and methodsWe analyzed retrospectively the medical records, electrophysiological reports of the patients, literatures on the anatomy of lumbar plexus and other literature reporting similar complications. We also dissected lumbar plexus of three cadavers and simulated surgical technique on them to find the mechanism of development of this unusual complication.ResultsWe found injury to lumbar plexus that probably occurred intraoperatively with Hohmann’s retractor that was used for retraction of the paraspinal muscles. This theory was favoured by many clinical factors and further confirmed by cadaveric dissections.ConclusionWe conclude that surgical technique with improper use of Hohmann’s retractor causes traction and compression injury to the lumbar plexus resulting in this complication. We propose proper technique of insertion of Hohmann’s retractor and also recommend use of modified Hohmann’s retractor with shorter tips for spinal procedures to prevent such complication.

Recurrent Echinococcal Infection of the Lumbar Spine: An 11 Year Follow-up

Spinal hydatid cyst is a rare occurrence in non endemic countries. We present a case of recurrent lumbar hydatid disease in a 21-year-old male who following initial treatment had a good functional outcome and healing for 8 years, following which he came back with complaints of low back ache and neurological deficit. Patient underwent a second surgery with global debridement of L3-L5 vertebrae followed by medical management for two years. He had a good surgical outcome with recovery from the neurological deficit. Patient has returned to his routine activities and is being reviewed every year; there is no evidence of recurrence in the past 3 years. To the best of our knowledge recurrence after 8 years of initial treatment, followed by good clinical and radiological outcome for 3 years after surgery and treatment of the recurrence has not been reported in literature.

Left second rib exostosis, spinal cord compression and left upper thoracic scoliosis: a rare triad.

Exostosis of the rib with neural foraminal extension as a cause of spinal cord compression and scoliosis has to the best of our knowledge not been reported. We describe a young male with hereditary multiple exostosis who presented with a spastic gait, lower limb weakness and a deformity of the upper back. Radiographic imaging revealed a lesion arising from the left second rib which was encroaching the spinal canal and a scoliotic deformity of the upper thoracic spine. Through a single T shaped posterior approach he underwent a decompressive laminectomy of T1 and T2 vertebra and excision of the lesion. The diagnosis of osteochondroma was confirmed by histopathological studies. He was followed up at one year when his neurological condition had returned to normal however the scoliosis had increased.