Does the Surgical Reduction of High Grade Spondylolisthesis Restore Spino-Pelvic Alignment? An Analysis of 35 Patients

Amritanand Rohit,Arockiaraj Justin,David Kenny S.,Krishnan Venkatesh 대한척추외과학회 2021 Asian Spine Journal Vol.15 No.5

Study Design: Retrospective case series. Purpose: This study aimed to analyze how the sagittal spinopelvic alignment is influenced by an attempted surgical reduction of the L5–S1 segment in patients with high-grade spondylolisthesis (HGS). Overview of Literature: Conventional treatment strategies stress the importance of achieving fusion across the lumbosacral junction in patients with HGS. The role of reduction in this subset of patients is controversial. Methods: This is a retrospective case series of 35 patients with Meyerding grades III, IV, or V spondylolisthesis who underwent surgical treatment in our institution. Before and after surgery, we took standing lateral radiographs from L1 vertebra to pelvis, including the femoral heads, and measured the slip grade, pelvic incidence, sacral slope, pelvic tilt, lumbosacral angle, and lumbar lordosis. Patients were subdivided into “balanced” and “unbalanced” pelvis groups. To determine the effect and correlation of reduction on these spinopelvic parameters, we statistically compared the pre- and postoperative measurements. Results: The average follow-up was 9 months (range, 3–169 months). Slip grade improved from an average 74.0%±13.2% to 30.0%±14.0% (p<0.001), and lumbosacral angle reduced from an average 32.0°±11.6° to 6.0°±0.6° (p<0.001). Although the pelvic tilt was reduced, this was not significant. There was a modest negative correlation between the reduction in slip grade and the increase in sacral slope (r=−0.3, p=0.06). At follow-up, five patients improved, from an unbalanced pelvis to a balanced pelvis. Fusion occurred in 33 patients (95%). Conclusions: Surgical reduction of HGS restores the lumbosacral alignment. However, a similar trend is not noted with the pelvic parameters.

Treatment Strategy and Outcomes in Patients with Hematogenous Culture-Negative Pyogenic Vertebral Osteomyelitis

Gouse Mohamad,Rohit Amritanand,Kenny Samuel David,Venkatesh Krishnan,Justin Arockiaraj 대한척추외과학회 2019 Asian Spine Journal Vol.13 No.1

Study Design: Retrospective case series. Purpose: The aim of this study was to analyze functional and radiological outcomes in patients with culture-negative pyogenic vertebral osteomyelitis (PVO). Overview of Literature: There were only few literature available for these group of patients. Methods: Patients with biopsy-positive but culture-negative PVO were included. We analyzed records for data on demography, comorbidities, coexisting infections, neurological status, prior antibiotic therapy, pre- and postoperative erythrocyte sedimentation rate, C-reactive protein levels, and Oswestry Disability Index, and Japanese Orthopedics Association scores. Results: Sixty-one patients were included, of which data of 45 patients were available for follow-up. The patients were predominantly males (71%), with a mean age of 53.2 years. Seventy-seven percent patients had comorbidities. Echocardiography, blood culture, and urine culture were performed on 8%, 24%, and 18% of patients, respectively. Thirty-one percent patients had neurological deficits. Computed tomography-guided biopsy was performed on 67% patients. Fifty-two percent patients were treated surgically, and 48% were treated non-surgically. Nineteen percent patients were treated according to the results of cultures from other foci, and the rest were treated empirically. For the initial 2 weeks, all patients were treated with intravenous antibiotics empirically or based on culture from other foci. This treatment was followed by 10 weeks of oral cloxacillin/cephalexin for gram-positive organisms or ciprofloxacin for gram-negative organisms. The mean follow-up time was 18 months (range, 12–120 months). All patients had improvement in Japanese Orthopedics Association, Oswestry Disability Index, and Visual Analog Scale scores (p <0.001). Conclusions: Treatment with empirical antibiotics for 12 weeks with watchful clinical and radiological follow-up yields good resolution of the disease. Further multicenter clinical research needs to be performed for obtaining an algorithmic treatment plan for these patients.

Symptomatic Solitary Osteochondroma of the Subaxial Cervical Spine in a 52-Year-Old Patient

Vijay Sekharappa,Rohit Amritanand,Venkatesh Krishnan,Kenny Samuel David 대한척추외과학회 2014 Asian Spine Journal Vol.8 No.1

Osteochondromas are the most common benign tumors of the bone. They mostly arise from the appendicular skeleton and present clinically in the second or third decade of life. Ostechondromas arising from the subaxial cervical spine and presenting after the 5th decade of life are extremely rare. We report a 52-year-old male patient who presented with numbness and subjective weakness of left upper and lower limbs and neck pain, and had lobulated bony hard fixed swelling in the right lower cervical paraspinal region. Radiological images revealed a bony swelling arising from C4 and C5 lamina with a cartilaginous cap and intraspinal extension. Excision biopsy with stabilisation of the spine was performed. Histopathalogical examination of the specimen confirmed the diagnosis of osteochondroma. We conclude surgical excision of such rare tumors, including the cartilaginous cap as well as the intraspinal component can reliably produce a good clinical outcome.

Orthopaedics, PostGraduate Institute of Medical Education and Research, Chandigarh, India

Vijay Sekharappa,Rohit Amritanand,Venkatesh Krishnan,Kenny Samuel David 대한척추외과학회 2014 Asian Spine Journal Vol.8 No.1

Study Design: Retrospective analysis of radiological images. Purpose: To determine the prevalence of lumbosacral transition vertebra (LSTV) and to study its significance with respect to clinically significant spinal symptoms, disc degeneration and herniation. Overview of Literature: LSTV is the most common congenital anomaly of the lumbosacral spine. The prevalence has been debated to vary between 7% and 30%, and its relationship to back pain, disc degeneration and herniation has also not been established. Methods: The study involved examining the radiological images of 3 groups of patients. Group A consisted of kidney urinary bladder (KUB) X-rays of patients attending urology outpatient clinic. Group B consisted of X-rays with or without magnetic resonance images (MRIs) of patients at-tending a spine outpatient clinic, and group C consisted of X-rays and MRI of patients who had undergone surgery for lumbar disc herniation. One thousand patients meeting the inclusion criteria were selected to be in each group. LSTV was classified by Castellvi’s classification and disc degeneration was assessed by Pfirrmann’s grading on MRI scans. Results: The prevalence of LSTV among urology outpatients, spine outpatients and discectomy patients was 8.1%, 14%, and 16.9% respectively. LSTV patients showed a higher Pfirrmann’s grade of degeneration of the last mobile disc. Results were found to be significant statistically. Conclusions: The prevalence of LSTV in spinal outpatients and discectomy patients was significantly higher as compared to those attending the urology outpatient clinic. There was a definite causal relationship between the transitional vertebra and the degeneration of the disc immediately cephalad to it.

Recurrent Lumbar Disc Herniation: Results of Revision Surgery and Assessment of Factors that May Affect the Outcome. A Non-Concurrent Prospective Study

Mohammed Ibrahim,Justin Arockiaraj,Rohit Amritanand,Krishnan Venkatesh,Kenny Samuel David 대한척추외과학회 2015 Asian Spine Journal Vol.9 No.5

Study Design: Non-concurrent prospective study. Purpose: To determine the functional outcome after open ‘fragment’ discectomy for recurrent lumbar disc herniation, and to analyze the factors that may affect the outcome. Overview of Literature: Literature search revealed only four studies where the factors affecting the outcome of a revision surgery for recurrent disc herniation have been evaluated. None of these studies analyzed for diabetes, disc degeneration and facet arthropathy. We have analyzed these features, in addition to the demographic and clinical factors. Methods: Thirty-four patients who underwent the procedure were followed up for an average period of 27.1 months. The Japanese Orthopaedic Association (JOA) score and Oswestry disability index (ODI) were used to assess the functional outcome. Age, gender, smoking, diabetic status, duration of recurrent symptoms, the side of leg pain, level and type of disc herniation, degree of disc degeneration on magnetic resonance imaging, and facet joint arthritis before first and second surgeries, were analyzed as factors affecting the outcome. Results: The average Hirabayashi improvement in JOA was 56.4%. The mean preoperative ODI was 74.5% and the mean ODI at final follow-up was 32.2%, the difference being statistically significant (p <0.01). Patients with diabetes, all of whom had poor long term glycemic control, were found to have a poor outcome in terms of ODI improvement (p =0.03). Conclusions: Open fragment discectomy is a safe and effective surgical technique for the treatment of recurrent disc herniation. However, patients with uncontrolled diabetes may have a less favorable outcome.

Composite Grip Strength as a Marker of Outcome in Patients Surgically Treated for Degenerative Cervical Myelopathy

Paul Arun John,Amritanand Rohit,Margabandhu Prabakaran,Karuppusami Reka,David Kenny Samuel,Krishnan Venkatesh 대한척추외과학회 2021 Asian Spine Journal Vol.15 No.5

Study Design: Retrospective case series. Purpose: This study aimed to examine the efficacy of composite grip strength as a marker of surgical outcome in patients with moderate to severe degenerative cervical myelopathy. Overview of Literature: Degenerative cervical myelopathy causes loss of dexterity, muscle strength, and sensations in the hand. The impact of surgical management on improvement in composite grip strength has received scant attention. Methods: This retrospective study was performed on degenerative cervical myelopathy patients with a complete composite grip strength assessment between January 2013 to January 2019. The Biometrics E-link hand kit was used for the assessment. The following parameters were measured: maximum grip strength, sustained grip strength, three-jaw pinch, maximum key pinch, and sustained key pinch. The pre- and postoperative functional status was assessed using the Nurick grade and the modified Japanese Orthopaedic Association (mJOA) score. Results: A total of 40 patients were included in the study. The mean patient age was 51.9 years. The mean preoperative Nurick grade was 3.5 and the mJOA score was 10.9. The anterior approach was used in 25 patients, and the posterior approach was used in 15 patients. Four patients developed complications. Degenerative cervical myelopathy resulted in decreased handgrip and pinch strength as compared to normative Indian data. There was a significant improvement in the postoperative composite grip strength for all five parameters. There was no differential improvement between the anterior and posterior surgical groups. The improvement in the composite grip strength correlated with the improvement in functional scores. Conclusions: Composite grip strength analysis is an objective method for assessing the impact of degenerative cervical myelopathy on grip strength and monitoring the postoperative improvement. Decompressive surgery resulted in global improvement in all the parameters of composite grip strength.

Role of Biochemical Nutritional Parameters as Predictors of Postoperative Morbidity in Major Spine Surgeries

Sugumar Deepak,Arockiaraj Justin,Amritanand Rohit,David Kenny S.,Krishnan Venkatesh 대한척추외과학회 2021 Asian Spine Journal Vol.15 No.4

Study Design: Prospective cohort study.Purpose: To evaluate the association between nutritional parameters related to postoperative surgical site infections and duration of hospital stay and intensive care unit (ICU) stay in patients undergoing major spine surgery.Overview of Literature: Malnutrition is highly prevalent in surgical patients. Malnourished patients are considered to be at higher risk for postoperative morbidity and mortality due to impaired wound healing, delayed inflammation, impaired fibroblast proliferation, and collagen synthesis. Decreased lymphocyte count also impairs the ability of the immune system to eradicate or prevent infection, which predisposes these patients to infections. However, this association between malnutrition and postoperative morbidity is not consistent across studies, thus necessitating further investigation.Methods: The values of serum albumin, prealbumin, total lymphocyte counts, and transferrin were documented preoperatively and postoperatively on day 5 for all patients undergoing major spine surgery (surgery involving instrumentation of at least three motion segments). In addition, patients’ surgical wound healing status, duration of hospital stay, and duration of ICU stay in the postoperative period were documented. Finally, the statistical correlation between the nutritional markers and these complications was determined.Results: Low postoperative prealbumin levels was significantly associated with increased complication rates. ICU stay demonstrated a statistically significant association with low postoperative albumin, prealbumin, and transferrin levels. Similarly, we observed that low postoperative albumin and prealbumin levels could significantly predict the need for prolonged hospital stay in patients undergoing major spine surgery.Conclusions: The magnitude of the decrease in nutritional status due to surgery with respect to albumin and prealbumin levels is a significant (p<0.05) predictor of wound-related complications, rather than a single nutritional parameter evaluated at a point of time.

Non-Caseating Granulomatous Infective Spondylitis: Melioidotic Spondylitis

Justin Arockiaraj,Rajiv Karthik,Veena Jeyaraj,Rohit Amritanand,Venkatesh Krishnan,Kenny Samuel David,Gabriel David Sundararaj 대한척추외과학회 2016 Asian Spine Journal Vol.10 No.6

Study Design: Retrospective clinical analysis. Purpose: To delineate the clinical presentation of melioidosis in the spine and to create awareness among healthcare professionals, particularly spine surgeons, regarding the diagnosis and treatment of melioidotic spondylitis. Overview of Literature: Melioidosis is an emerging disease, particularly in developing countries, associated with a high mortality rate. Its causative pathogen, Burkholderia pseudomallei , has been labeled as a bio-terrorism agent. Methods: We performed a retrospective analysis of patients who were culture positive for B. pseudomallei. Assessment of patients was performed using clinical, radiological, and blood parameters. Clinical measures included pain, neurological deficit, and return to work. Radiological measures included plain radiography of the spine and magnetic resonance imaging. Blood tests included erythrocyte sedimentation rate and C-reactive protein levels. Results: Four patients having melioidosis with spondylitis were evaluated. All of them had diabetes mellitus; three had multiple abscesses which required incision and drainage. Their clinical spectrum was similar to that of tuberculous spondylitis; all had back pain and radiology revealed infective spondylodiscitis with prevertebral and paravertebral collections with psoas abscess. Three patients underwent ultrasound-guided drainage of the psoas abscess and one had aspiration of the subcutaneous abscess. Bacteriological cultures showed presence of B. pseudomallei, and histopathology showed non-caseating granulomatous inflammation. All patients were treated with intravenous Ceftazidime for 2 weeks, followed by oral bactrim double strength and Doxycycline for 20 weeks. All patients improved with treatment and were healed at follow up. Conclusions: Melioidosis presents with a clinical spectrum similar to that of tuberculosis. A diagnosis of melioidotic spondylitis should be considered, particularly in patients with diabetes with neutrophilic leukocytosis and clinical-radiological features suggestive of infective spondylodiscitis. Bacteriological culture and histopathology helps in differentiating the two conditions. Health education for healthcare professionals is important for correctly diagnosing this disease.

The Extended Posterior Circumferential Decompression Technique in the Management of Tubercular Spondylitis with and without Paraplegia

Barani Rathinavelu,Justin Arockiaraj,Venkatesh Krishnan,Rohit Amritanand,Gabriel David Sundararaj 대한척추외과학회 2014 Asian Spine Journal Vol.8 No.6

Study Design: Retrospective clinical series. Purpose: To study the clinical, functional and radiological results of patients with tuberculous spondylitis with and without paraplegia, treated surgically using the “Extended Posterior Circumferential Decompression (EPCD)” technique. Overview of Literature: With the increasing possibility of addressing all three columns by a single approach, posterior and posterolateral approaches are gaining acceptance. A single exposure for cases with neurological deficit and kyphotic deformity requiring circumferential decompression, anterior column reconstruction and posterior instrumentation is helpful. Methods: Forty-one patients with dorsal/dorsolumbar/lumbar tubercular spondylitis who were operated using the EPCD approach between 2006 to 2009 were included. Postoperatively, patients were started on nine-month anti-tuberculous treatment. They were serially followed up to thirty-six months and both clinical measures (including pain, neurological status and ambulatory status) and radiological measures (including kyphotic angle correction, loss of correction and healing status) were used for assessment. Results: Disease-healing with bony fusion (interbody fusion) was seen in 97.5% of cases. Average deformity (kyphosis) correction was 54.6% in dorsal spine and 207.3% in lumbar spine. Corresponding loss of correction was 3.6 degrees in dorsal spine and 1.9 degrees in the lumbar spine. Neurological recovery in Frankel B and C paraplegia was 85.7% and 62.5%, respectively. Conclusions: The EPCD approach permits all the advantages of a single or dual session anterior and posterior surgery, with significant benefits in terms of decreased operative time, reduced hospital stay and better kyphotic angle correction.

Early Detection and Analysis of Children with Multidrug-Resistant Tuberculosis of the Spine

Justin Arockiaraj,Magdalenal Robert,Winsley Rose,Rohit Amritanand,Kenny Samuel David,Venkatesh Krishnan 대한척추외과학회 2019 Asian Spine Journal Vol.13 No.1

Study Design: Retrospective case series. Purpose: The aim of the study is to report the clinical characteristics, early diagnosis, management, and outcome of children with multidrug-resistant (MDR) tubercular spondylodiscitis and to assess the early detection of rifampicin resistance using the Xpert MTB/ RIF assay. Overview of Literature: MDR tuberculosis is on the rise, especially in developing countries. The incidence rate of MDR has been reported as 8.9% in children. Methods: A retrospective study of children aged <15 years of age who were diagnosed and treated for MDR tuberculosis of the spine was conducted. Confirmed cases of MDR tuberculosis and patients who had completed at least 18 months of second-line antituberculous treatment (ATT) were included. Children were treated with ATT for 24 months according to drug-susceptibility-test results. Outcome measures included both clinical and radiological measures. Clinical measures included pain, neurological status, and return to school. Radiological measures included kyphosis correction and healing status. Results: Six children with a mean age of 10 years were enrolled. The mean follow-up period was 12 months. All the children had previous history of treatment with first-line ATT, with an average of 13.6 months before presentation. Clinically, 50% (3/6 children) had psoas abscesses and 50% had spinal deformities. Radiologically, 50% (three of six children) had multicentric involvement. Three children underwent surgical decompression; two needed posterior stabilization with pedicle screws posteriorly followed by anterior column reconstruction. Early diagnosis of MDR was achieved in 83.3% (five of six children) with Xpert MTB/RIF assay. A total of 83.3% of the children were cured of the disease. Conclusions: Xpert MTB/RIF assay confers the advantage of early detection, with initiation of MDR drugs within an average of 10.5 days from presentation. The cost of second-line ATT drugs was 30 times higher than that of first-line ATT.