Tarush Rustagi

Sciatica from a foraminal lumbar root schwannoma: case report and review of literature.

Sciatica is commonly caused by lumbar prolapsed intervertebral disc (PID) and other spinal lesions. Uncommon causes like nerve root schwannoma are rarely considered in the differential diagnosis of sciatica. Spinal schwannomas occur both sporadically and in association with neurofibromatosis type 1 (NF1; von Recklinghausens disease). This case report describes lumbar foraminal schwannoma as an unusual cause of radiculopathy, presenting clinically as a lumbar disc prolapse. The diagnosis was confirmed on MRI scan. Patient had complete symptomatic recovery following surgical enucleation of the tumour mass from the L5 nerve root. This case report is of particular interest as it highlights the diagnostic confusion, which is bound to arise, because the clinical presentation closely mimics a lumbar PID. This often leads to delay in diagnosis and “failure of conservative treatment.”

Tuberculosis of spine with neurological deficit in advanced pregnancy: a report of three cases

BACKGROUND CONTEXT Early decompression in spinal tuberculosis (TB) with complete paraplegia has a better prognosis in relation to the neurological recovery and deformity progression. Advanced pregnancy can complicate this picture in view of the various fetomaternal factors. The prevalent literature is inconclusive regarding the time and extent of surgical intervention. Delay in the surgical intervention may adversely affect the prognosis. PURPOSE To emphasize the importance of early decompression in spinal TB complicated by neurological deficit in advanced pregnancy. STUDY DESIGN A case report of three patients to analyze the surgical management of neurological deficit because of spinal TB in pregnancy. OUTCOME MEASURES Neurological recovery, progression of deformity, healing of the TB lesion, and outcome of the pregnancy. METHODS Three patients presented with spinal TB with neurological deficit complicating third trimester of pregnancy. The first patient was initially managed conservatively but was operated after a spontaneous abortion. The remaining two patients were managed by urgent Caesarean section followed by spinal decompression and fusion. RESULTS The first patient who underwent delayed decompression showed good healing of the TB lesion but continued to have spastic paraparesis with kyphosis. This was later managed by repeat decompression and instrumented fusion, without neurological recovery. The other two patients treated by early decompression and fusion showed complete healing with neurological recovery. CONCLUSIONS Early decompression and instrumented fusion in spinal TB, complicated by neurological deficit in advanced pregnancy, can give good results with respect to neurological recovery, healing of the lesion, and arrest of deformity progression. Neonatal prognosis depends on the fetal maturity. Antitubercular therapy is an essential component of the management; it poses little hazard of inducing congenital anomalies, but possibility of maternal drug toxicity should be considered.

Early Lumbar Nerve Root Deficit After Three Column Osteotomy for Fixed Sagittal Plane Deformities in Adults

ABSTRACT Background: Three-column osteotomy is an effective means of correcting fixed sagittal plane deformities. Deformity correction surgeries may be associated with early postoperative neurological deficits often presenting as palsies involving the lumbar roots. The objective was to retrospectively assess a subset of our series of adult deformity correction surgeries and analyze neurological deficits and associated patient and surgical factors. Methods: Hospital records of 17 patients from a single center were examined. Inclusion criterion were adults (>18 years) who underwent a 3-column osteotomy (pedicle subtraction osteotomy) at the lumbar level for fixed sagittal plane deformities including positive sagittal balance, flat back syndrome, and posttraumatic kyphosis. These also included cases with associated degenerative lumbar scoliosis. Patients were divided in 2 groups: Group 1 with lumbar root deficit and Group 2 with no deficits. We examined the surgical details of the osteotomy, complications during surgery, and observed if the magnitude of correction in the sagittal or coronal plane bore any influence on the nerve deficit. Results: All 17 patients had a single-level resection except 1 patient who had 2-level osteotomy; 23.5% (4 of 17) developed nerve deficit. Nerve deficit presented as bilateral foot drop (1); unilateral extensor hallucis longus (EHL) weakness (2); and unilateral quadriceps weakness (1). The patient with quadriceps weakness partially recovered to functional strength. Two patients with EHL weakness fully recovered; however, the patient with bilateral foot drop did not improve. L5-S1 interbody fusion was done in 3 of 4 cases in Group 1 and 4 of 13 cases in Group 2. Conclusions: Nerve deficits after 3-column corrective osteotomies occurred in 23% cases. All but 1 case had significant improvement. Most nerve palsies are neuropraxia and unilateral and tend to recover. L5 weakness appears most common after high lumbar osteotomies. Significant correction of scoliosis at the osteotomy level (>50%) may be a reason for nerve palsy.

Infected charcot spine arthropathy

BackgroundCharcot spinal arthropathy (CSA), a destructive spinal pathology, is seen in patients with impaired sensation. Superimposed infection in the affected spinal segments can lead to a challenge in the diagnosis and management. Spinal cord injury (SCI) is the leading cause of CSA as persons with SCI have significantly impaired sensation. Though infection of the CSA is rare, SCI persons are prone to superimposed infection of the Charcot spine. We report atypical presentations of three cases of CSA with superimposed infection.Case descriptionsA 47-year-old male with complete T7–8 SCI developed symptoms suggestive of infection and CSA. He was managed with a posterior vertebral column resection (PVCR) of T12 and intravenous antibiotics as the intraoperative culture showed the growth of E. coli and Pseudomonas. A 26-year-old male with T12 complete paraplegia, post status post open reduction and internal fixation with subsequent implants removal developed infection and CSA over the pseudo-arthrotic lesion with destruction of T12 and L1 vertebrae and an external fistulous track. He was managed with debridement and anterior column T11–L1 reconstruction with a Titanium cage and four-rod pedicle screw stabilization construct. A 25-year-old male with complete paraplegia with CSA at L4–S1. He underwent PVCR of L5 and L3–S2 posterior stabilization. The intraoperative culture and histopathology were suggestive of tuberculous infection.ConclusionPyogenic or tubercular infection of CSA should be considered as a diagnostic possibility in persons with SCI who are more prone to infections. The management includes aggressive debridement and circumferential fusion along with appropriate medications to control the infection.

Fifth Lumbar L5 Perineural Cyst with Unusual Radiculopathy: Traction Plexopathy

Perineural cysts are cystic dilations and are frequently seen in relation to the lumbosacral spine. We describe a case of a fifth lumbar (L5) perineural cyst with unusual radicular symptoms and discuss the possible role of traction plexopathy caused by the cyst. A 38-year-old male presented with a longstanding history of back pain and right side thigh pain. This pain radiated from the buttocks to the lateral and anterior aspect of the thigh. He described the pain as pins and needles/burning with no significant relief with medications or rest. Imaging of the lumbar spine revealed a cystic lesion on the right side involving the L5 nerve root in the foraminal region. He failed conservative treatment and elected to have the cyst removed even with a guarded prognosis. A wide L5 laminectomy was performed. Due to the size of the cyst which was causing traction on the exiting L5 nerve root, the L5 pedicle was excised in order to delineate the cyst and to prevent any iatrogenic injury to the root. The patient had the dramatic improvement in his radicular pain immediately after the surgery and continues to be pain-free at his latest three-year follow-up. This case highlights the unusual pain pattern distribution from a perineural cyst possibly secondary to traction effect of the tumor.

Sclerosing Epithelioid Fibrosarcoma of the Coccyx: A Case Report and Review of Literature

Coccydynia in adult patients is not uncommon and is frequently neglected. Coccydynia is mostly associated with fall on buttocks. In long-standing cases, coccydynia can be debilitating. Rarely coccydynia can be due to more sinister causes and surgeons should be aware of all differential diagnosis. We present a case of an elderly female who presented with a complaint of pain over coccyx which was not subsiding with conventional treatment methods. Biopsy was done and a diagnosis of sclerosing epitheloid fibrosarcoma was made. We describe an unusual case of coccydynia secondary to this tumour with the histopathology finding and surgical management.

Aortic Rupture During Surgical Management of Tubercular Spondylodiscitis

Aortic rupture is a rare but possible complication during spine surgery. It may manifest as severe intraoperative hemorrhage or present in a delayed manner after the formation of an aneurysm or an arteriovenous fistula. Though it is commonly encountered during anterior surgeries involving the surgical field close to the thoracic or abdominal aorta, it can also occur during a posterior surgery. Aortic injury could be associated with surgeries ranging from the commonly performed pedicle screw instrumentation to a complex three-column osteotomy. It can also occur, as in the reported case, while performing complex procedures in the presence of a pre-existing aneurysm or aortic adhesions due to coexisting infectious or inflammatory pathologies. The treatment options for such aortic ruptures range from open repair to endovascular stenting techniques. We discuss a case of an aortic rupture that occurred during a posterior vertebral column resection (PVCR) procedure performed on a 58-year-old female with spastic paraparesis secondary to tuberculous spondylodiscitis and the lessons learnt.

A New Search Algorithm for Reducing the Incidence of Missing Cottonoids in the Operating Theater

Study Design Retrospective study. Purpose Missing cottonoids during and after spinal surgery is a persistent problem and account for the most commonly retained surgical instruments (RSIs) noticed during a final cottonoid count. The aim of this study was to enumerate risk factors and describe the sequence to look out for misplaced cottonoids during spinal surgery and provide an algorithm for resolving the problem. Overview of Literature There are only a few case reports on RSIs among various surgical branches. The data is inconclusive and there is little evidence in the literature that relates to spinal surgery. Methods This retrospective study was conducted at Indian Spinal Injuries Centre. The data was collected from hospital records ranging from January 2013 to December 2017. The surgical cases in which cottonoid counts were inconsistent during or after the procedure were included in the study. The case files along with operating theater records were thoroughly screened for selecting those in which there was confirmed evidence of such an event. Results There were 7,059 spinal surgeries performed during the study period. Fifteen cases of miscounts were recorded with an incidence of one in every 471 cases. Cottonoids were most commonly lost under the shoes of the surgeon or assistants. In two instances, cottonoids were found in the surgical field and trapped in the interbody cage site. Based on these locations, a systematic search algorithm was created Conclusions This study enumerates RSI risk factors in spinal surgical procedures and describes steps that can be followed to account for any missing cottonoids. The incidence of missing cottonoids can be decreased using a goal-oriented approach and ensuring that surgical teams work in collaboration.

Bladder Recovery Patterns in Patients with Complete Cauda Equina Syndrome: A Single-Center Study

Study Design Retrospective case series. Purpose Cauda equina syndrome (CES) is associated with etiologies such as lumbar disc herniation (LDH) and lumbar canal stenosis (LCS). CES has a prevalence of 2% among patients with LDH and exhibits variable outcomes, even with early surgery. Few studies have explored the factors influencing the prognosis in terms of bladder function. Therefore, we aimed to assess the factors contributing to bladder recovery and propose a simplified bladder recovery classification. Overview of Literature Few reports have described the prognostic clinical factors for bladder recovery following CES. Moreover, limited data are available regarding a meaningful bladder recovery status classification useful in clinical settings. Methods A single-center retrospective study was conducted (April 2012 to April 2015). Patients with CES secondary to LDH or LCS were included. The retrieved data were evaluated for variables such as demographics, symptom duration, neurological symptoms, bladder symptoms, and surgery duration. The variable bladder function outcome during discharge and at follow-up was recorded. All subjects were followed up for at least 2 years. A simplified bladder recovery classification was proposed. Statistical analyses were performed to study the correlation between patient variables and bladder function outcome. Results Overall, 39 patients were included in the study. Majority of the subjects were males (79.8%) with an average age of 44.4 years. CES secondary to LDH was most commonly seen (89.7%). Perianal sensation (PAS) showed a significant correlation with neurological recovery. In the absence of PAS, bladder function did not recover. Voluntary anal contraction (VAC) was affected in all study subjects. Conclusions Intactness of PAS was the only significant prognostic variable. Decreased or absent VAC was the most sensitive diagnostic marker of CES. We also proposed a simplified bladder recovery classification for recovery prognosis.