A Randomized Control Trial Comparing Local Autografts and Allografts in Single Level Anterior Cervical Discectomy and Fusion Using a StandAlone Cage

Kanna Rishi Mugesh,Perambuduri Ashok Sri,Shetty Ajoy Prasad,Rajasekaran Shanmuganathan 대한척추외과학회 2021 Asian Spine Journal Vol.15 No.6

Study Design: Randomized controlled trial. Purpose: To compare the functional and radiological outcomes of anterior cervical discectomy and fusion (ACDF) using local graft and allograft Overview of Literature: The choice of bone grafts for ACDF varies among different types: iliac crest, allograft, and substitutes. Availability, cost, and donor site morbidity are potential disadvantages. Local osteophyte grafts are then advantageous and shows to have good fusion. Methods: We randomly sampled participants requiring a single level ACDF for degenerative conditions (n=27) between allograft (n=13) and local graft (n=14) groups. Follow-up of patients occurred at 6 weeks, 3 months, 6 months, and 1 year using Numerical Pain Rating Scale (NPRS) scores for arm and neck pain, Neck Disability Index (NDI), 2-item Short Form Health Survey (SF-12), and lateral disk height. We then assessed radiological fusion using computed tomography (CT) scan at 12 months, and graded as F- (no fusion), F (fusion seen through the cage), F+ (fusion seen through the cage, with bridging bone at one lateral edge), and F++ (fusion seen through cage with bridging bone bilaterally). Results: There were no significant differences in the age, sex, duration of intervention, blood loss, and hospital stay between the two groups (p>0.05). Both groups showed significant improvements in all functional outcome scores including NPRS for arm and neck pain, NDI, and SF-12 at each visit (p<0.01). We observed a marked improvement in disk height in both groups (p<0.05), but at 1 year of follow-up, there was a significant though slight subsidence (p=0.47). CT at 1 year showed no non-unions. We recorded F, F+, and F++ grades of fusion in 23.2%, 38.4%, and 38.4% in allograft group and 28.6%, 42.8%, and 28.6% in local graft group, respectively, though no significant differences observed (p=0.73). Conclusions: Marginal osteophytes are effective as graft inside cages for ACDF, since they provide similar radiological outcomes, and equivalent improvements in functional outcomes, as compared to allografts.

Prevalence, Patterns, and Genetic Association Analysis of Modic Vertebral Endplate Changes

Rishi Mugesh Kanna,Rajasekaran Shanmuganathan,Veera Ranjani Rajagopalan,Senthil Natesan,Raveendran Muthuraja,Kenneth Man Chee Cheung,Danny Chan,Patrick Yu Ping Kao,Anita Yee,Ajoy Prasad Shetty 대한척추외과학회 2017 Asian Spine Journal Vol.11 No.4

Study Design: A prospective genetic association study. Purpose: The etiology of Modic changes (MCs) is unclear. Recently, the role of genetic factors in the etiology of MCs has been evaluated. However, studies with a larger patient subset are lacking, and candidate genes involved in other disc degeneration phenotypes have not been evaluated. We studied the prevalence of MCs and genetic association of 41 candidate genes in a large Indian cohort. Overview of Literature: MCs are vertebral endplate signal changes predominantly observed in the lumbar spine. A significant association between MCs and lumbar disc degeneration and nonspecific low back pain has been described, with the etiopathogenesis implicating various mechanical, infective, and biochemical factors. Methods: We studied 809 patients using 1.5-T magnetic resonance imaging to determine the prevalence, patterns, distribution, and type of lumbar MCs. Genetic association analysis of 71 single nucleotide polymorphisms (SNPs) of 41 candidate genes was performed based on the presence or absence of MCs. SNPs were genotyped using the Sequenome platform, and an association test was performed using PLINK software. Results: The mean age of the study population (n=809) was 36.7±10.8 years. Based on the presence of MCs, the cohort was divided into 702 controls and 107 cases (prevalence, 13%). MCs were more commonly present in the lower (149/251, 59.4%) than in the upper (102/251, 40.6%) endplates. L4–5 endplates were the most commonly affected levels (30.7%). Type 2 MCs were the most commonly observed pattern (n=206, 82%). The rs2228570 SNP of VDR (p =0.02) and rs17099008 SNP of MMP20 (p =0.03) were significantly associated with MCs. Conclusions: Genetic polymorphisms of SNPs of VDR and MMP20 were significantly associated with MCs. Understanding the etiopathogenetic mechanisms of MCs is important for planning preventive and therapeutic strategies.

Classification and Management Algorithm for Postoperative Wound Complications Following Transforaminal Lumbar Interbody Fusion

Kanna Rishi Mugesh,Renjith Karukayil Ramakrishnan,Shetty Ajoy Prasad,Rajasekaran Shanmuganathan 대한척추외과학회 2020 Asian Spine Journal Vol.14 No.5

Study Design: Retrospective study.Purpose: Postoperative wound complications occurring after transforaminal lumbar interbody fusion (TLIF) are unique, as they can involve different tissue zones (subcutaneous, subfascial, osseous, peri-implant, and disc). Overview of Literature: Management of postoperative infections occurring after TLIF remains controversial in the context of retention or removal of implants.Methods: A total of 1,279 consecutive patients (1,520 segments) who underwent TLIF with a minimum follow-up of 1 year were analyzed. Patients with wound complications were classified anatomically into the following five types: type 1, suprafascial necrosis; type 2, wound dehiscence; type 3, pus around screws and rods; type 4, bone marrow edema; and type 5, pus in the disc space. Details pertaining to clinicoradiological and laboratory findings and management were also recorded.Results: Of the 62 patients (4.8%) with wound complications, there were seven patients in type 1, 35 in type 2, 10 in type 3, four in type 4, and six in type 5. Patients in types 1 and 2 manifested delayed wound healing and were systemically well. In type 1, five patients were managed with resuturing and two were managed conservatively. In type 2, all patients had wound gaping and were managed by debridement, whereas three patients required vacuum-assisted closure. Patients in type 3 had severe back pain and fever, with demonstrable pus around the screw site. Tissue culture identified organisms in 90% of the patients. Patients in type 4 presented with increasing back pain, and magnetic resonance imaging revealed vertebral bone marrow edema. Those in type 5 had severe back pain and fever, with demonstrable pus in the disc space. Patients in types 3–5 required debridement, implant revision/retention, and long-term antibiotics.Conclusions: The new anatomical classification of surgical site infections could help grade the severity of infection and provide tangible treatment guidelines, resulting in better infection clearance and patient outcomes.

Patterns of Traumatic Spinal Injuries in the Developing World: A Five-Year Longitudinal Review

Kanna Rishi Mugesh,Peddireddy Sreeharsha,Shetty Ajoy Prasad,Rajasekaran Shanmuganathan 대한척추외과학회 2022 Asian Spine Journal Vol.16 No.5

Study Design: Retrospective review.Purpose: A 5-year longitudinal study documenting and comparing patterns of traumatic spinal injuries (TSIs) observed in developing countries.Overview of Literature: Current knowledge of the patterns and epidemiology of TSI are based on evidence from developed countries and there is a lack of data from developing countries to enable a comparison of information to formulate healthcare policies.Methods: A review of case records of all patients treated at a tertiary level trauma center over a 5-year period (2015–2019) was performed. Epidemiological, clinical, and radiological data were analyzed.Results: The incidence of spinal trauma was 6.2% (2,065/33,072) among all trauma patients. Among these 2,065 patients, the mean age was 43.4±16.3 years and 77.3% (n=1,596) were aged 21–60 years. The major cause of injury was falls (52.1%, n=1,069) and 49.8% were high-energy falls (>10 feet [=3.048 m]). In patients with TSI due to falls, injuries occurred at the workplace (n=376), home (n=309), trees (n=151), wells (n=77), and electric poles (n=57). Road traffic accidents contributed to 42% (n=862) of TSIs and predominantly affected motorcyclists (52%, n=467). Around half (53.5%, n=1,005) of all patients were in the lower socioeconomic strata. The most common injury level was thoracic region (37.2%, n=769). Spinal cord injury (SCI) occurred in 49% (n=1,011) of patients and 49.7% (n=1,028) had injuries associated with other organs.Conclusions: Our study indicated different demographic patterns and epidemiological features of TSI compared with the Western literature, including a preponderance of young male patients, falls from heights, motorcycle accidents, and a larger percentage of SCI. The high number of falls at workplace indicates a lack of knowledge among the public and policy makers about safety measures.

Impact of Acute Lumbar Disk Herniation on Sexual Function in Male Patients

Panneerselvam Keerthivasan,Kanna Rishi Mugesh,Shetty Ajoy Prasad,Rajasekaran Shanmuganathan 대한척추외과학회 2022 Asian Spine Journal Vol.16 No.4

Study Design: Prospective observational study.Purpose: In this study, we determined the effects of lumbar disk herniation (LDH) on male sexual activity and whether surgical intervention improved any related sexual dysfunction.Overview of Literature: The impact of surgery on sexual activity has been extensively studied in arthroplasty, uro-gynecological surgery, and stroke, but there are relatively few studies on spine surgery, and none involve an Asian population to the best of our knowledge.Methods: We evaluated sexually active male patients (n=22, 40.8±6.8 years) admitted for microdiscectomy with a questionnaire for assessing sexual function before and 8 weeks after surgery. The questionnaire included the Oswestry Disability Index, Hospital Anxiety Depression Score, and Brief Sexual Function Inventory (BSFI), as well as questions about perceived sexual dysfunction (frequency, performance, satisfaction).Results: The average preoperative Visual Analog Scale (VAS) score was 4.36±2.59 (n=18) for low back pain (LBP) and 6.81±2.1 (n=22) for leg pain. The mean preoperative BSFI score was 27.8±11.2. Among the five BSFI components, sexual drive was reduced in 63.0% of patients, while erection and ejaculation were affected in 40.9% and 31.8%, respectively. The VAS score for LBP had a negative correlation with the preoperative BSFI score (<i>p</i> <0.03). After LDH onset, 54.5% of patients noted a decrease in frequency, and 77.2% described a decrease in desire and satisfaction. At 8 weeks after surgery, the mean BSFI score significantly improved to 33.23 (<i>p</i> =0.002). Sexual drive was normal in 77.7% of patients, and erection and ejaculation were normal in 77.7% and 91.0%, respectively. Overall, 59.1% had resumed sexual intercourse within 6 weeks of surgery.Conclusions: LDH resulted in sexual dysfunction in up to 77% of patients, which significantly improved after surgery. By 6 weeks, the majority had resumed sexual activity without undue discomfort. Therefore, this study supports counseling for patients with LDH about sexual function.

Circumferential Fusion through All-Posterior Approach in Andersson Lesion

Sreekanth Reddy Rajoli,Rishi Mugesh Kanna,Siddharth N. Aiyer,Ajoy Prasad Shetty,Shanmuganathan Rajasekaran 대한척추외과학회 2017 Asian Spine Journal Vol.11 No.3

Study Design: Retrospective case series. Purpose: To assess safety and efficacy of single stage, posterior stabilisation and anterior cage reconstruction through the transforaminal or lateral extra-cavitary route for Andersson lesions. Overview of Literature: Pseudoarthrosis in ankylosing spondylitis (Andersson lesion, AL) can cause progressive kyphosis and neurological deficit. Management involves early recognition and surgical stabilisation in patients with instability. However, the need and safety of anterior reconstruction of the vertebral body defect remains unclear. Methods: Twenty consecutive patients with AL whom presented with instability back pain and or neurological deficit were managed by single stage posterior approach with long segment pedicle screw fixation and anterior vertebral reconstruction. Radiological evaluation included- the regional kyphotic angle, measurement of anterior defect in computed tomography (CT) scan and the spinal cord status in magnetic resonance imaging. Radiological outcomes were assessed for fusion and kyphosis correction. Functional outcomes were assessed with visual analogue scale (VAS), ankylosing spondylitis quality of life (ASQoL) and Oswestry disability index (ODI). Results: The mean age of the patients was 50.1 years (male, 18; female, 2). The levels affected include thoracolumbar (n=12), lower thoracic (n=5) and lumbar (n=3) regions. The mean level of fixation was 6.2±2.4 vertebrae. The mean anterior column defect was 1.6±0.6 cm. The mean surgical duration, blood loss and hospital stay were 112 minutes, 452 mL and 6.2 days, respectively. The mean followup was 2.1 years. At final follow up, VAS for back pain improved from 8.2 to 2.4 while ODI improved from 62.7 to 18.5 (p <0.05) and ASQoL improved from 14.3±2.08 to 7.90±1.48 (p <0.05). All patients had achieved radiological union at a mean 7.2±4.6 months. The mean regional kyphotic angle was 27° preoperatively, 16.7° postoperatively and 18.1° at the final follow-up. Conclusions: Posterior stabilisation and anterior reconstruction with cage through an all-posterior approach is safe and can achieve good results in Andersson lesions.

The Effectiveness of Noninvasive Positive Pressure Ventilation in Subarachnoid Pleural Fistula: A Case Report and Literature Review

Dilip Chand Raja Soundararajan,Ajoy Prasad Shetty,Rishi Mugesh Kanna,,S Rajasekaran 대한척추신경외과학회 2018 Neurospine Vol.15 No.4

Subarachnoid pleural fistula (SPF) is an aberrant communication between the pleural cavity and subarachnoid space, resulting in uncontrolled cerebrospinal fluid drainage. The negative pressure of the pleural cavity creates a continuous suctioning effect, thereby impeding the spontaneous closure of these fistulas. Dural tears or punctures in cardiothoracic procedures, spinal operations, and trauma are known to cause such abnormal communications. Failure to recognize this entity may result in sudden neurological or respiratory complications. Hence, a high index of suspicion is required for early diagnosis and prompt management. Noninvasive positive pressure ventilation has been described to be effective in managing such fistulas, thus mitigating the high morbidity associated with exploratory surgery for primary repair. Herein, we describe the typical presentation of SPF and the clinical course, treatment, and follow-up of a patient who sustained SPF following anterior thoracic spinal surgery.

Analysis of Spinopelvic Parameters with L5 as the New Sacrum after Fusion in High-Grade Spondylolisthesis: A Possible Explanation for Satisfactory Results with In-Situ Fusion

Shanmuganathan Rajasekaran,Gurudip Das,Siddharth Narasimhan Aiyer,Rishi Mugesh Kanna,Ajoy Prasad Shetty 대한척추외과학회 2018 Asian Spine Journal Vol.12 No.1

Study Design: Retrospective case series. Purpose: To correlate functional outcomes with spinopelvic parameters in patients with high-grade spondylolisthesis (HGS) treated with instrumented in-situ surgery or reduction and fusion Overview of Literature: Satisfactory functional outcomes are reported with reduction and in-situ fusion strategies in HGS. However, reasons for this are unclear. We hypothesize that following lumbosacral fusion, the L5 becomes part of the sacrum, which improves spinopelvic parameters, resulting in equivalent functional outcomes in both surgical methods. Methods: Twenty-six patients undergoing HGS (reduction group A, 13; in-situ group B, 13) were clinically evaluated using the Os- westry Disability Index (ODI), short form-12 (SF-12), and Visual Analogue Scale (VAS) scores. Spinopelvic parameters, including pelvic incidence, pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), lumbosacral kyphosis (LSK) angle, and sacrofemoral distance (SFD) were measured preoperatively from S1 and postoperatively from L5 as the new sacrum at 1 year follow-up. Sagittal alignment was assessed using the sagittal vertical axis. Results: Both groups were comparable in terms of age, sex, severity of slip, and preoperative spinopelvic parameters (p >0.05). Postoperative VAS, SF-12, and ODI scores significantly improved in both groups (p <0.05). Compared with preoperative values, the mean postoperative PT, SFD, and LSK significantly changed in both groups. In reduction group, PT changed from 26.98° to 10.78°, SFD from 61.24 to 33.56 mm, and LSK from 74.76° to 109.61° (p <0.05). In in-situ fusion group PT changed from 26.78° to 11.08°, SFD from 62.9 to 36.99 mm, and LSK from 67.23° to 113.38° (p <0.05 for all). In both groups, SS and LL did not change significantly (p >0.05). Conclusions: After fusion, the L5 becomes the new sacrum and influences spinopelvic parameters to change favorably. This possibly explains why reduction and in-situ fusion achieve equivalent functional outcomes in HGS.

Morphometric Evaluation of Occipital Condyles: Defining Optimal Trajectories and Safe Screw Lengths for Occipital Condyle-Based Occipitocervical Fixation in Indian Population

Aju Bosco,Prakash Venugopal,Prakash Venugopal,Rajasekaran Shanmuganathan,Rishi Mugesh Kanna 대한척추외과학회 2018 Asian Spine Journal Vol.12 No.2

Study Design: Computed tomographic (CT) morphometric analysis. Purpose: To assess the feasibility and safety of occipital condyle (OC)-based occipitocervical fixation (OCF) in Indians and to define anatomical zones and screw lengths for safe screw placement. Overview of Literature: Limitations of occipital squama-based OCF has led to development of two novel OC-based OCF techniques. Methods: Morphometric analysis was performed on the OCs of 70 Indian adults. The feasibility of placing a 3.5-mm-diameter screw into OCs was investigated. Safe trajectories and screw lengths for OC screws and C0–C1 transarticular screws without hypoglossal canal or atlantooccipital joint compromise were estimated. Results: The average screw length and safe sagittal and medial angulations for OC screws were 19.9±2.3 mm, ≤6.4°±2.4° cranially, and 31.1°±3° medially, respectively. An OC screw could not be accommodated by 27% of the population. The safe sagittal angles and screw lengths for C0–C1 transarticular screw insertion (48.9°±5.7° cranial, 26.7±2.9 mm for junctional entry technique; 36.7°±4.6° cranial, 31.6±2.7 mm for caudal C1 arch entry technique, respectively) were significantly different than those in other populations. The risk of vertebral artery injury was high for the caudal C1 arch entry technique. Screw placement was uncertain in 48% of Indians due to the presence of aberrant anatomy. Conclusions: There were significant differences in the metrics of OC-based OCF between Indian and other populations. Because of the smaller occipital squama dimensions in Indians, OC-based OCF techniques may have a higher application rate and could be a viable alternative/salvage option in selected cases. Preoperative CT, including three-dimensional-CT-angiography (to delineate vertebral artery course), is imperative to avoid complications resulting from aberrant bony and vascular anatomy. Our data can serve as a valuable reference guide in placing these screws safely under fluoroscopic guidance.

Factors Influencing Postoperative Urinary Retention Following Elective Posterior Lumbar Spine Surgery: A Prospective Study

Siddharth Narasimhan Aiyer,Ajit Kumar,Ajoy Prasad Shetty,Rishi Mugesh Kanna,Shanmuganath Rajasekaran 대한척추외과학회 2018 Asian Spine Journal Vol.12 No.6

Study Design: Prospective observational study. Purpose: To determine the incidence of postoperative urinary retention (POUR) in patients undergoing elective posterior lumbar spine surgery and identify the risk factors associated with the development of POUR. Overview of Literature: POUR following surgery can lead to detrusor dysfunction, urinary tract infections, prolonged hospital stay, and a higher treatment cost; however, the risk factors for POUR in spine surgery remain unclear. Methods: A prospective, consecutive analysis was conducted on patients undergoing elective posterior lumbar surgery in the form of lumbar discectomy, lumbar decompression, and single-level lumbar fusions during a 6-month period. Patients with spine trauma, preoperative neurological deficit, previous urinary disturbance/symptoms, multiple-level fusion, and preoperative catheterization were excluded from the study. Potential patient- and surgery-dependent risk factors for the development of POUR were assessed. Univariate analysis and a multiple logistical regression analysis were performed. Results: A total of 687 patients underwent posterior lumbar spine surgery during the study period; among these, 370 patients were included in the final analysis. Sixty-one patients developed POUR, with an incidence of 16.48%. Significant risk factors for POUR were older age, higher body mass index (BMI), surgery duration, intraoperative fluid administration, lumbar fusion versus discectomy/ decompression, and higher postoperative pain scores (p <0.05 for all). Sex, diabetes, and the type of inhalational agent used during anesthesia were not significantly associated with POUR. Multiple logistical regression analysis, including age, BMI, surgery duration, intraoperative fluid administration, fusion surgery, and postoperative pain scores demonstrated a predictive value of 92% for the study population and 97% for the POUR group. Conclusions: POUR was associated with older age, higher BMI, longer surgery duration, a larger volume of intraoperative fluid administration, and higher postoperative pain scores. The contribution of postoperative pain scores in the multiple regression analysis was a significant predictor of POUR.