Shekhar Y Bhojraj

Occipito-atlanto-axial osteoarthritis: a cross sectional clinico-radiological prevalence study in high risk and general population.

Study Design. A cross-sectional clinico-radiologic evaluation of occipito-atlantoaxial (OC1C2) region of 2 population groups. Objective. Determine the prevalence of OC1C2 osteoarthritis in porters involved in carrying loads on the head and general male population. Describe its clinico-radiologic manifestations. Summary of the Background Data. In addition to age, head loading is a known cause of degeneration affecting the occipito-cervical region. The impact of head loading in the population aged between third and sixth decade is unknown. Head loading is a common custom in the developing countries. Material and Methods. Study group (n = 107) included randomly selected male porters from railway stations who underwent computed tomography (CT) study of the OC1C2 region, plain radiographs of the cervical spine and detailed clinical examination. Control group (n = 107) included randomly selected male patients undergoing CT scan study for diseases of paranasal sinuses with coincidental screening of OC1C2 region along with clinical assessment. The data were analyzed using SPSS 15 software. Result. Mean age for study group was 32.6 years and controls was 34.6 years (P = 0.156). In the study group, duration of occupational exposure was 10.9 (±8.7) years; 81.3% porters being symptomatic with an age of 33.4 (±9.6) years. Radiologic prevalence of OC1C2 osteoarthritis in study group was 91.6% and in control group was 6.8%; age of affected individuals was 33.4 (±9.3) and 47.9 (±8.0) years, respectively. Most common complaint was suboccipital neck pain (69.7%); while the CT finding was decreased joint space with sclerosis and irregularity of the margins (81.3%). No statistically significant association was found between presence of radiologic changes and symptoms. Age, duration of occupational exposure and its relationship with various clinico-radiologicmanifestations was studied. Conclusion. This condition has significant prevalence in porters, beginning at an early age. Diagnosis is based on the clinico-radiologic presentation. CT is the investigation of choice. Resultant functional limitations make early identification of this condition imperative.

Spinal instability in ankylosing spondylitis

Background: Unstable spinal lesions in patients with ankylosing spondylitis are common and have a high incidence of associated neurological deficit. The evolution and presentation of these lesions is unclear and the management strategies can be confusing. We present retrospective analysis of the cases of ankylosing spondylitis developing spinal instability either due to spondylodiscitis or fractures for mechanisms of injury, presentations, management strategies and outcome. Materials and Methods: In a retrospective analysis of 16 cases of ankylosing spondylitis, treated surgically for unstable spinal lesions over a period of 12 years (1995-2007); 87.5% (n=14) patients had low energy (no obvious/trivial) trauma while 12.5% (n=2) patients sustained high energy trauma. The most common presentation was pain associated with neurological deficit. The surgical indications included neurological deficit, chronic pain due to instability and progressive deformity. All patients were treated surgically with anterior surgery in 18.8% (n=3) patients, posterior in 56.2% (n=9) patients and combined approach in 25% (n=4) patients. Instrumented fusion was carried out in 87.5% (n=14) patients. Average surgical duration was 3.84 (Range 2-7.5) hours, blood loss 765.6 (± 472.5) ml and follow-up 54.5 (Range 18-54) months. The patients were evaluated for pain score, Frankel neurological grading, deformity progression and radiological fusion. One patient died of medical complications a week following surgery. Results: Intra-operative adverse events like dural tears and inadequate deformity correction occurred in 18.7% (n=3) patients (Cases 6, 7 and 8) which could be managed conservatively. There was a significant improvement in the Visual analogue score for pain from a pre-surgical median of 8 to post-surgical median of 2 (P=0.001), while the neurological status improved in 90% (n=9) patients among those with preoperative neurological deficit who could be followed-up (n =10). Frankel grading improved from C to E in 31.25% (n=5) patients, D to E in 12.5% (n=2) and B to D in 12.5% (n=2), while it remained unchanged in the remaining - E in 31.25% (n=5), B in 6.25% (n=1) and D in 6.25% (n=1). Fusion occurred in 11 (68.7%) patients, while 12.5% (n=2) had pseudoarthrosis and 12.5% (n=2) patients had evidence of inadequate fusion. 68.7% (n=11) patients regained their pre-injury functional status, with no spine related complaints and 25% (n=4) patients had complaints like chronic back pain and deformity progression. In one patient (6.2%) who died of medical complications a week following surgery, the neurological function remained unchanged (Frankel grade D). Persistent back pain attributed to inadequate fusion/ pseudoarthrosis could be managed conservatively in 12.5% (n=2) patients. Progression of deformity and pain secondary to pseudoarthrosis, requiring revision surgery was noted in one patient (6.2%). One patient (6.2%) had no neurological recovery following the surgery and continued to have nonfunctional neurological status. Conclusion: In ankylosing spondylitis, the diagnosis of unstable spinal lesions needs high index of suspicion and extensive radiological evaluation Surgery is indicated if neurological deficit, two/three column injury, significant pain and progressive deformity are present. Long segment instrumentation and fusion is ideal.

Non-Surgical Management of Cord Compression in Tuberculosis: A Series of Surprises

Study Design Prospective study. Purpose We present a series of 50 patients with tuberculous cord compression who were offered systematic non-surgical treatment, and thereby, the author proposes that clinico-radiological soft tissue cord compression is not an emergency indication for surgery. Overview of Literature Spinal cord compression whether clinical or radiological has usually been believed to be an indication for emergency surgery in spinal tuberculosis. Methods Fifty adults were prospectively studied at our clinic for spinal cord compression due to tuberculous spondylitis, between May 1993 and July 2002. The inclusion criteria were cases with clinical and/or radiological evidence of cord compression (documented soft tissue effacement of the cord with complete obliteration of the thecal sac at that level on magnetic resonance imaging scan). Exclusion criteria were lesions below the conus level, presence of bony compression, severe or progressive neurological deficit (<than Frankel grade C) and children below the age of maturity. All patients were treated with a fixed, methodically applied non-surgical protocol including hospital admission, antitubercular medications, baseline somatosensory evoked potentials and a regular clinico-radiological follow-up. Results At the time of presentation, 10 patients had a motor deficit, 18 had clinically detectable hyper-reflexia and 22 had normal neurology. Forty-seven of the 50 patients responded completely to non-operative treatment and healed with no residual neurological deficit. Three patients with progressive neurological deficit while on treatment were operated on with eventual excellent recovery. Conclusions Radiological evidence of cord compression and early neurological signs need not be an emergency surgical indication in the management of spinal tuberculosis.

Giant cell tumor of the spine: A review of 9 surgical interventions in 6 cases

Background: Giant cell tumor (GCT) of the spine is uncommon but most aggressive benign tumor of the spine with unpredictable outcome. We present our observation on six cases of GCT of the spine. We treated six patients with giant cell tumors (GCT) of the spine between 1993 and 2006. A total of nine surgical interventions were carried out. Four interventions were carried out in patients presented as ‘new’ cases, while five on recurrences from past GCT resections. All presented with cord compression and neurological deficits of varying grades. All patients also presented with clinical as well as radiological instability. Preoperative tissue diagnosis was available only in the five recurrences (tissue from the old resection). Posterior only (n=2), anterior only (n=4) and single-stage back and front (n=3) surgeries were carried out depending on the nature of the tumor. Results: Overall results were satisfactory, as all patients were symptom-free postoperatively. Two out of our four new patients had tumor recurrence and both needed repeat resection. Both have been disease-free at last follow-up. Conclusion: Surgical intervention is mandatory. Close follow up is needed for early diagnosis of recurrences.

Does Segmental Kyphosis Affect Surgical Outcome after a Posterior Decompressive Laminectomy in Multisegmental Cervical Spondylotic Myelopathy

Study Design Retrospective analysis. Purpose To compare results of laminectomy in multisegmental compressive cervical myelopathy (CSM) with lordosis versus segmental kyphosis. Overview of Literature Laminectomy is an established procedure for decompression in CSM with cervical lordosis. However in patients with segmental kyphosis, it is associated with risk of progression of kyphosis and poor outcome. Whether this loss of sagittal alignment affects functional outcome is not clear. Methods We retrospectively reviewed 68 patients who underwent laminectomy for CSM from 1998 to 2009. As per preoperative magnetic resonance images, 36 patients had preoperative lordosis (Group 1) and 32 had segmental kyphosis (Group 2). We studied age at the time of surgery, duration of preoperative symptoms, recovery rate, magnitude of postoperative backward shifting of spinal cord and loss of sagittal alignment. Results Mean follow up was 5.05 years (range, 2–13 years) and mean age at the time of surgery 61.88 years. Group 1 had 20 men and 16 women and Group 2 had 19 men and 13 women. Mean recovery rate in Group 1 was 60.32%, in Group 2 was 63.7% without any statistical difference (p-value 0.21, one tailed analysis of variance). Two patients of Group 1 had loss of cervical lordosis by five degrees. In Group 2 seven patients had progression of segmental kyphosis by 5–10 degrees and two patients by more than 10 degrees. Mean cord shift was more in Group 1 (mean, 2.41 mm) as compared to Group 2 (mean, –1.97 mm) but it had no correlation to recovery rate. Patients with younger age (mean, 57 years) and less duration of preoperative symptoms (mean, 4.86 years) had better recovery rate (75%). Conclusions Clinical outcome in CSM is not related to preoperative cervical spine alignment. Thus, lordosis is not mandatory for planning laminectomy in CSM. Good outcome is expected in younger patients operated earliest after onset of symptoms.

Thoracic Hemangioma From Rib Presenting as Compressive Paraparesis in a Young Adult: A Treatment Dilemma.

Study Design. A case report. Objective. To describe the presentation of compressive paraparesis as a result of thoracic rib hemangioma in a young adult and its nonsurgical management. Summary of Background Data. Hemangiomas are rare bone tumors and those arising from rib are rarer. Only about 50 such cases have been reported in literature so far. Methods. A 21‐year‐old male student, presented to us with a 6‐week history of progressive weakness in both lower limbs and loss of bowel bladder control. Patient gave history of being operated for left periscapular tumor treated with wide excision and proven with biopsy to be a hemangioendothelioma (benign but locally aggressive hemangioma variant) a year ago. Results. New radiograph of the chest showed an expansile lesion of left fifth rib and magnetic resonance image showed a tumor of left dorsal thoracic wall with AV malformation causing compressive thoracic myelopathy at T5 level vertebrae. We planned for immediate decompression surgery for spine along with excision of tumor with the help of a thoracic surgeon. However, on preoperative digital subtraction angiography, the tumor was found to be highly vascular with high risk of intraoperative bleeding and morbidity. So, the plan was revised and the patient underwent digital subtraction angiography, followed by embolization by an expert interventional neurosurgeon. The patient showed signs of recovery within a week. Lower limb power improved from grade 2 to 3/5 to grade 4 to 4+/5. The patient became ambulatory with single stick at 3‐month follow‐up; he was a nonwalker to start with. At 2 years plus follow‐up, the patient fully recovered and walks without stick. Conclusion. This unique case brings to light the dilemma a spine surgeon sometimes faces. A case that warranted immediate surgical intervention based on clinical findings was treated with interventional fibrin glue embolizations with excellent results. Level of Evidence: N/A

Hydatid disease of spine: Multiple meticulous surgeries and a long term followup

We present a long term followup (13 years) of spinal hydatid disease with multiple recurrences and intradural dissemination of the disease at the last followup. Intradural extension of the disease in our case was supposedly through the dural rent which has not been reported in English literature. An early followup of the same case has been reported previously by the authors. A 53 year-old female came with progressive left leg pain and difficulty in walking since 2 months. On examination, she had grade four power of ankle and digit dorsiflexors (L4 and L5 myotomes) on the left side (Medical Research Council grade). There was no sensory loss, no myelopathy and sphincters were intact. Plain radiographs showed consolidation at D10-D11 (old operated levels) with stable anterior column and there were no implant related problems. Magnetic resonance imaging showed a cystic lesion at L3-L4, signal intensity same as of cerebrospinal fluid in T2 and T1, displacing the cauda equina roots. The proximal extent of the lesion could not be identified because of artifacts from previous stainless steel instrumentation. Computed tomography myelogram showed complete block at L3-L4 junction with “meniscus sign”. This is the longest followup of hydatid disease of the spine that has ever been reported. Hydatid disease should always be included in the differential diagnosis of destructive or infectious lesions of the spine. Aggressive radical resection whenever possible and chemotherapy is the key to good results. Recurrence is known to occur even after that. Disease can have long remission periods. Possibility of intradural dissemination through dural injury is highly likely. Hence, it should always be repaired whenever possible.

Buckling Collapse of Midcervical Spine Secondary to Neurofibromatosis

Buckling collapse is the term typically used to describe severe kyphosis >100 degrees, characteristically seen in thoracolumbar tuberculosis. Neurofibromatosis is rarely associated with severe cervical kyphosis. Dystrophic changes in vertebra make surgical correction and fusion challenging. Single-stage cervical osteotomies (e.g., pedicle subtraction osteotomy, vertebral column resection) are commonly done in cervicothoracic junction. However, it is technically challenging and associated with high risk of vertebral artery injury, neural injury, etc. when performed in higher cervical spine. Hence in our case we did a staged procedure performing circumferential osteotomy for buckling kyphosis in the midcervical spine. Because it involved midcervical spine and there was no chin-to-chest deformity, we preferred the anterior-posterior-anterior sequence.

Management of Andersson Lesion in Ankylosing Spondylitis Using the Posterior-Only Approach: A Case Series of 18 Patients

Study Design This retrospective study was conducted including 18 patients who underwent posterior-only stabilization and fusion procedure for pseudoarthrosis in the ankylosed spine from October 2007 to May 2015. Purpose This study aimed to describe the treatment outcomes in 18 patients with Andersson lesion (AL) who were managed using the posterior-only approach. Literature Review AL is an unstable, localized, vertebral, or discovertebral lesion of the spine. It is observed in patients with ankylosing spondylitis. The exact etiology of this disorder remains unclear, and the treatment guidelines are not clearly described. Methods We analyzed 18 patients with AL who were treated with posterior long segment spinal fusion without any anterior interbody grafting or posterior osteotomy. Pre- and postoperative radiography, computed tomography, and recent follow-up images were examined. The pre- and postoperative Visual Analog Scale score and the Oswestry Disability Index score were evaluated for all patients. Whiteclouds’ outcome analysis criteria were applied at the follow-up. Moreover, at study completion, patient feedback was collected; all the patients were asked to provide their opinion regarding the surgery and were asked whether they would recommend this procedure to other patients and them self undergo the same procedure again if required. Results The most common site was the thoracolumbar junction. The symptom duration ranged from 1 month to 10 years preoperatively. Most patients experienced fusion by the end of 1 year, and the fusion mass could be observed as early as 4 months. Pseudoarthrosis void of up to 2.5 cm was noted to be healed in subsequent imaging. In addition, clinically, the patients reported good symptomatic relief. No patient required revision surgery. Whiteclouds’ outcome analysis score at the latest follow-up revealed good-to-excellent outcomes in all patients. Conclusions ALs can be treated using the posterior-only approach with long segment fixation and posterior spinal fusion. This is a safe, simple, and quick procedure that prevents the morbidity of anterior surgery.

Intraosseous disc prolapse: A diagnostic puzzle

Background : Schmorls node or intraosseous disc prolapse is herniation of the nucleus pulposus material through the vertebral end plates. Presence of Schmorls nodes as end plate lesions following trauma, tumours and osteoporosis further complicates diagnosis. The present study was done to understand diagnosis and approach to management of symptomatic Schmorls nodes. Methods : During a period of three years we came across 14 patients who presented with severe back pain. Conventional radiographs, CT Scans and MRI showed the presence of end plate lesions with varied radiological appearance. The first group, comprising of seven patients had lytic lesions without any sclerosis on only one side of the intervertebral disc as seen on the CT scan. The second group comprising of five patients had sclerotic lesions with new bone formation associated with disc space reduction. The two patients in the third group showed a combined lytic and sclerotic lesion without any soft tissue changes. MRI of eleven patients revealed hypointense lesion on T 1 and T 2 weighted images with surrounding zone of hyper intensity on T 2 weighted images. The remaining three patients, did not have this hyper intense zone on T 2 weighted images . In five patients multiple Schmorls nodes were observed. Diagnosis of symptomatic Schmorls nodes was mainly done by exclusion. All patients were given rest and anti-inflammatory drugs followed by exercises. Results : The first two groups of patients responded to the treatment and had complete relief of symptoms but both the patients in third group had persistent symptoms. MRI repeated after eight weeks showed an enhancing lesion with prevertebral soft tissue. A transpedicular core biopsy proved the lesion to be tuberculosis in one patient. Anti Kochs therapy was promptly started and follow up study showed resolution of the lesions. At the end of the study period all the patients were asymptomatic and returned to their active profession. Conclusion : The difficulty in diagnosis is attributed to the fact that every person with Schmorls node is not symptomatic. For accurate diagnosis it is necessary to have high index of suspicion, close follow up and exclusion of other associated conditions. In case of poor response to conservative treatment an alternative diagnosis has to be considered and if required it should be proved or disproved by a biopsy of the lesion (percutaneous or open).