Nirmal Raj Gopinathan

Comparison of the oswestry disability index and magnetic resonance imaging findings in lumbar canal stenosis: an observational study.

Study Design Cross-sectional study. Purpose The aim of the study was to determine relationship between the degrees of radiologically demonstrated anatomical lumbar canal stenosis using magnetic resonance imaging (MRI) and its correlation with the patients disability level, using the Oswestry Disability Index (ODI). Overview of Literature The relationship between the imaging studies and clinical symptoms has been uncertain in patients suffering from symptomatic lumbar canal stenosis. There is a limited number of studies which correlates the degree of stenosis with simple reproducible scoring methods. Methods Fifty patients were selected from 350 patients who fulfilled the inclusion criteria. The patients answered the national-language translated form of ODI. The ratio of disability was interpreted, and the patients were grouped accordingly. They were subjected to MRI; and the anteroposterior diameters of the lumbar intervertebral disc spaces and the thecal sac cross sectional area were measured. Comparison was performed between the subdivisions of the degree of lumbar canal stenosis, based on the following: anteroposterior diameter (three groups: normal, relative stenosis and absolute stenosis); subdivisions of the degree of central canal stenosis, based on the thecal sac cross-sectional area, measured on axial views (three groups: normal, moderately stenotic and severely stenotic); and the ODI outcome, which was also presented in 20 percentiles. Results No significant correlation was established between the radiologically depicted anatomical lumbar stenosis and the Oswestry Disability scores. Conclusions Magnetic resonance imaging alone should not be considered in isolation when assessing and treating patients diagnosed with lumbar canal stenosis.

Giant cell tumour of peroneus brevis tendon sheath – a case report and review of literature

Giant cell tumour of tendon sheath is a benign soft tissue lesion most commonly found in the flexor aspect of hand and wrist. Being rare in foot and ankle, the unusual presentation of this lesion may sometimes mimic other lesions like lipoma, synovial sarcoma, malignant fibrous histiocytoma, synovial cyst and ganglion. Hence it is important to include this lesion in differential diagnoses especially if the lesion is found to be anchored to any of the surrounding tendons. This article describes the unusual occurrence of giant cell tumour of the tendon sheath of peroneus brevis which is rarely described in literature.

Safety Profile, Feasibility and Early Clinical Outcome of Cotransplantation of Olfactory Mucosa and Bone Marrow Stem Cells in Chronic Spinal Cord Injury Patients

Study Design Prospective case series. Purpose To study the safety and feasibility of cotransplantation of bone marrow stem cells and autologous olfactory mucosa in chronic spinal cord injury. Overview of Literature Stem cell therapies are a novel method in the attempt to restitute heavily damaged tissues. We discuss our experience with this modality in postspinal cord injury paraplegics. Methods The study includes 9 dorsal spine injury patients with American Spinal Injury Association (ASIA) Impairment Scale (AIS) A neurological impairment who underwent de-tethering of the spinal cord followed by cotransplantation with bone marrow stem cells and an olfactory mucosal graft. Participants were evaluated at the baseline and at 6 monthly intervals. Safety and tolerability were evaluated through the monitoring for adverse events and magnetic resonance imaging evaluation. Efficacy assessment was done through neurological and functional outcome measures. Results Surgery was tolerated well by all participants. No significant difference in the ASIA score was observed, although differences in the Functional Independence Measure and Modified Ashworth Scale were statistically significant. No significant complication was observed in any of our patients, except for neurogenic pain in one participant. The follow-up magnetic resonance imaging evaluation revealed an increase in the length of myelomalacia in seven participants. Conclusions The cotransplantation of bone marrow stem cells and olfactory mucosa is a safe, feasible and viable procedure in AIS A participants with thoracic level injuries, as assessed at the 24-month follow-up. No efficacy could be demonstrated. For application, further large-scale multicenter studies are needed.

Surgical Technique: Simple Technique for Removing a Locking Recon Plate With Damaged Screw Heads

BackgroundThe introduction of locking plates in the treatment of periarticular fractures was a major breakthrough in orthopaedic evolution. Removal of these implants is extremely difficult as a result of cold welding and stripping of screw heads.Description of TechniqueA 31-year-old man had a schwannoma of the left C5-C6 nerve roots and upper trunk of the brachial plexus. One year before presentation he had undergone excision of the lesion through an approach using a clavicular osteotomy. The osteotomy had been fixed with a titanium locking recon plate. While surgically removing the implant, only one screw could be removed. The remaining five screws could not be turned owing to cold welding; repeated attempts at removing the screws damaged the screw heads. A large bolt cutter was used to cut the plate between the holes, and the resulting rectangular sections with the screws then were unscrewed from the bone.Review of LiteratureLimited literature is available regarding techniques for locking screw removal. These include using a carbide drill bit or diamond-tipped burr, high-speed disc, or conical extraction screw.ConclusionsNot all centers have specialized instruments such as carbide drill bits to remove screw heads, but a large bolt cutter usually is available when screws cannot be unscrewed owing to cold welding. The technique of cutting is easily reproducible and does not require additional soft tissue stripping.

Isolated Tuberculosis of Sacrum with Monoparesis: An Atypical Presentation

Tuberculosis is a major health problem in developing nations. Spine is the most commonly affected site for skeletal tuberculosis but involvement of sacrum is rare. Isolated involvement of sacrum has been reported in literature but none of the reports has mentioned its clinical presentation as monoparesis. Our case presented with symptoms of sensory and motor deficit in right lower limb. The magnetic resonance imaging spine and non contrast computerized tomogram revealed a sacral lesion but were inconclusive of diagnosis. Histological examination after computed tomography guided biopsy revealed the condition as tuberculosis. Anti tubercular treatment was started after confirmation of diagnosis and continued for 18 months. Erythrocyte sedimentation rate and C-reactive protein drooped to normal range and patient was symptom free at two-year follow up. This case report intends to emphasize that sacral tuberculosis, being itself a rare condition, may present atypically as monoparesis.

T-condylar fracture delayed for 10 days in a 5-year-old boy: a case report and review of the literature

T‐condylar fracture is rare in paediatric age group, especially in skeletally immature children less than 9 years old, with very few cases reported in available literature. We present such a case in a 5 year old child that was initially managed as a supracondylar fracture at another centre before referral to us, 10 days after the injury. The child was diagnosed as having a displaced T‐condylar fracture on plain radiograph. Open reduction and internal fixation with K‐wires was performed. At 2 years follow‐up, the child had good range of motion at elbow with 5° of cubitus varus. With this background we discuss the pertinent principles of management of T‐condylar fractures in skeletally immature children.

Predictors of early outcome in unstable pelvic fractures.

Objective: To define the preoperative and intraoperative variables which may affect the immediate postoperative outcome in surgically managed patients with unstable pelvic fractures. Methods: This study was performed prospectively from January 2009 to June 2011 on 36 consecutive patients admitted to the trauma ward of Postgraduate Institute of Medical Education and Research, Chandigarh, with unstable pelvic injuries. Results: In the present study of 36 patients, 29 were managed surgically. Surgical duration was 2 hours in patients operated on within 1 week and 3.4 hours in those operated on after 1 week. The blood loss was 550 ml when surgery was done after a week, but when done within a week it was 350 ml. The average blood loss through Pfanenstial approach was 360 ml, through posterior approach was 408 ml and through combined approach was 660 ml which was significantly high. Conclusion: Anterior approach to the pelvis would cause significantly more amount of blood loss than posterior approach and external fixation. Surgical approaches do not have any influence on the surgical duration or the infection rate. The blood loss significantly increases when the surgical time is more than 1 h. The infection rate is not influenced by the duration of surgery. Presence or absence of associated injuries to the head, chest or abdomen is the main determinants of patients survival and it greatly influences the duration of hospital stay.

Epidemiology of lower limb musculoskeletal trauma with associated vascular injuries in a tertiary care institute in India

Background: Vascular trauma associated with bony injuries is an orthopaedic emergency. Lack of timely intervention can lead to loss of limb or even life. Inspite of the rising incidence of high speed road traffic accidents in India, there is paucity of literature regarding the demographic pattern, clinical morbidity, management strategies and outcome of arterial injuries associated with lower limb trauma. The aim of this study is to describe the epidemiology and outcome of lower extremity musculoskeletal trauma with associated vascular injuries in a tertiary care institute in India. Materials and Methods: All individuals who presented to our tertiary care trauma center from July 2013 to December 2014 with lower extremity vascular injury associated with lower limb fractures were identified from a retrospective trauma database for this descriptive study. For the 17 months, there were 82 lower extremity vascular trauma cases admitted in our trauma center, of which 50 cases were included in the study. 32 patients with crush injuries, traumatic amputations, and those with head injury and blunt trauma to chest or abdomen were excluded from the study. Results: Out of the 50 cases of lower extremity vascular injury with associated lower limb fractures, 19 limbs were salvaged, 28 amputated, and three patients expired. Young males in the age group of 20–39 years were frequently injured. Motor vehicle accident (MVA) (82%) was found to be the most common cause followed by pedestrian injury. Popliteal artery (62%) was the most common vessel injured, followed by femoral artery (28%). The salvageability percentage was much higher (64%) in the femoral artery injury group when compared to popliteal artery injury group (25%). There were 32 open fractures, with amputation rates (60%) being higher and all three cases of death falling in this group. In addition, the limb salvageability percentage was 43.2% when the patient presented within 12 h of injury and this decreased to a mere 16.7% when the patient had presented more than 24 h after injury. Conclusion: MVAs are the leading cause of vascular injuries in India. Road safety measures and prevention programs are the need of the hour to prevent these kinds of injuries in the future.

Awareness of osteoporosis in postmenopausal Indian women: An evaluation of Osteoporosis Health Belief Scale

Context: The level of awareness about osteoporosis in postmenopausal women who are the common sufferers. Aims: This study aims to evaluate the level of awareness in postmenopausal women using the Osteoporosis Health Belief Scale (OHBS). Settings and Design: Osteoporosis has emerged as a common health problem in geriatric population. A proactive role needs to be played for preventing its consequences. Before initiating any preventive measures, an evaluation of awareness level of the target population is necessary. The questionnaire-based study design was used for this study. Subjects and Methods: A questionnaire (OHBS)-based study in 100 postmenopausal women in Chandigarh was conducted. The bone mineral density (BMD) was measured in each case by dual energy X-ray absorptiometry. Height, weight, and body mass index (BMI) of the participants were noted. Statistical Analysis Used: Statistical analysis was conducted to evaluate any correlation between the various components of the OHBS and the BMD. Results: No statistically significant difference was noted in the seven component parameters of OHBS among the normal, osteopenic, and osteoporotic women suggesting that the health belief regarding susceptibility is not much different between the three groups of the study population. A statistically significant difference between the mean BMI of normal and osteoporotic population was noted. Conclusions: The results show that there is a great deficit in the awareness level of postmenopausal Indian women regarding osteoporosis. Most of the women were unaware of the condition and the means to prevent it. The study emphasizes that health care professionals have lot of ground to cover to decrease the incidence of osteoporosis and its associated health problem.

Early, reliable, utilitarian predictive factors for fat embolism syndrome in polytrauma patients

Background: Fat embolism is one of the apocalyptic pulmonary complications following high energy trauma situations. Since delay in diagnosis may have devastating consequences, early, easily accessible and relatively inexpensive investigations for risk stratification may prove useful, especially in developing nations. Materials and Methods: This prospective trial included a total of 67 young polytrauma patients, in whom the role of nine easily available, rapidly performable clinical or laboratory investigations (or observations noted at admission) in predicting the later occurrence of fat embolism syndrome were assessed. All the patients also underwent continuous monitoring of oxygen saturation with pulsoximetry. Results: The correlation between initial serum lactate (within 12 hours of injury) and hypoxia was statistically significant. There was a trend towards correlation with FES(by Gurds criteria) (P=0.07), Sensitivity of 24-hour monitoring of oxygen saturation in predicting later pulmonary deterioration approached 100%. Conclusions: The combination of three factors including polytrauma (with NISS >17), serum lactate >22 mmol/l at admission (within 12 hours of injury) fall in oxygen saturation (SaO2 below 90% in the initial 24 hours) predict the development of post-traumatic pulmonary complications, especially the fat embolism syndrome.