Morphometric Study of C1 Pedicle and Feasibility Evaluation of C1 Pedicle Screw Placement with a Novel Clinically Relevant Radiological Classification in an Indian Population

Abhishek Srivastava,Rajat Mahajan,Ankur Nanda,Geetanjali Nanda,Nirajana Mishra,Vijayant Kanagaraju,Sahil Batra,Harvinder Singh Chhabra 대한척추외과학회 2017 Asian Spine Journal Vol.11 No.5

Study Design: A retrospective computed tomography (CT)‒based morphometric study of 84 C1pedicles in an Indian population focusing on critical morphometric dimensions vis-a-vis C1 pedicle screw placement Purpose: To determine the feasibility of C1 pedicle screw placement in an Indian population and propose a novel classification system for the same. Overview of Literature: At present, C1 pedicle screws are rarely used, and very few studies have focused on the feasibility of pedicle screw placement in terms of racial, gender, and ethnic variations in anatomical structures. There are no CT-based data on C1 pedicles that assess the feasibility of pedicle screw placement in the Indian population. Methods: We measured C1 pedicle diameter on CT coronal scan images of 42 adult patients. Extramedullary height (EMH) and intramedullary height (IMH) were measured. We examined the differences between the right and left atlas pedicles and compared measures between males and females. These data were analyzed using significance tests. Based on the results, we propose a novel classification system, which we believe will help in determining the feasibility of C1 pedicle screw placement. Results: Forty-two adult patients (84 pedicles) were examined. Average EMH and IMH were 4.48±0.91 and 0.86±0.77, respectively. Approximately, 32% of the C1 pedicles had bone thicknesses of <4 mm, 49% had IMH of <1 mm, and 38% had no pedicles. The average thickness in women was 4.21±0.93 mm, which was significantly thinner than that in men (4.73±0.81 mm, p =0.004). Right and left pedicles were not significantly different. Conclusions: Our data indicate that approximately one-third of the Indian population may not be suitable candidates for C1 pedicle screw placement. Caution should be exercised while placing type 1B and type 2 pedicles based on our proposed classification system.

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

Abhinandan Reddy,Rajat Mahajan,Tarush Rustagi,Shakti A. Goel,Murari L. Bansal,Harvinder Singh Chhabra 대한척추외과학회 2019 Asian Spine Journal Vol.13 No.1

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.

Computed Tomography-Based Occipital Condyle Morphometry in an Indian Population to Assess the Feasibility of Condylar Screws for Occipitocervical Fusion

Abhishek Srivastava,Geetanjali Nanda,Rajat Mahajan,Ankur Nanda,Nirajana Mishra,Srinivasa Karmaran,Sahil Batra,Harvinder Singh Chhabra 대한척추외과학회 2017 Asian Spine Journal Vol.11 No.6

Study Design: A retrospective computed tomography (CT)-based morphometric study of 82 occipital condyles in the Indian population, focusing on critical morphometric dimensions with relation to placing condylar screws Purpose: This study focused on determining the feasibility of placing occipital condylar screws in an Indian population using CT anatomical morphometric data. Overview of Literature: The occipital condylar screw is a novel technique being explored as one of the options in occipitocervical stabilization. Sex and ethnic variations in anatomical structures may restrict the feasibility of this technique in some populations. To the best of our knowledge, there are no CT-based data on an Indian population that assess the feasibility of occipital condylar screws. Methods: We measured the dimensions of 82 occipital condyles in 41 adults on coronal, sagittal, and axial reconstructed CT images. The differences were noted between the right and left sides and also between males and females. Statistical analysis was performed using the t -test, with a p- value of <0.05 considered significant. Results: Mean sagittal length and height were 17.2±1.7 mm and 9.1±1.5 mm, respectively. Mean condylar angle/screw angle was 38.0°±5.5° from midline, with mean condylar length and width of 19.6±2.6 mm and 9.5±1.0 mm, respectively. Average coronal height on the anterior and posterior hypoglossal canal was 10.8±1.4 mm and 9.0±1.4 mm, respectively. The values in females were significantly lower than those in males, except for screw angle and condylar width. Based on Lin et al.’s proposed criteria, eight of 82 condyles were not suitable for condylar screws. Conclusions: Preliminary CT morphometry data of the occipital condyle shows that condylar screws are anatomically feasible in a large portion of the Indian population. However, because a small number of population may not be suitable for this technique, meticulous study of preoperative anatomy using detailed CT data is advised.

Use of Topical Tranexamic Acid to Reduce Blood Loss in Single-Level Transforaminal Lumbar Interbody Fusion

Mallepally Abhinandan Reddy,Mahajan Rajat,Rustagi Tarush,Goel Shakti Amar,Das Kalidutta,Chhabra Harvinder Singh 대한척추외과학회 2020 Asian Spine Journal Vol.14 No.5

Study Design: Nonrandomized, prospective, and case-controlled study.Purpose: To evaluate the efficacy and cost-effectiveness of topically applied tranexamic acid (TXA) during different phases of spine surgery.Overview of Literature: Perioperative blood loss is the leading cause of postoperative anemia associated with prolonged stays in hospital and long recovery times. The direct and indirect costs involved pose a significant economic challenge in developing countries. There is no consensus for topical use of tranexamic acid in spine surgery.Methods: Patients requiring a single-level TLIF were divided into 2 groups. In the TXA group (n=75), the wound surface was soaked with TXA (1 g in 100 mL saline solution) for 3 minutes after exposure, after decompression, and before wound closure, and in the control group (n=175) using only saline. Intraoperative blood loss drain volume was recorded on each of the first 2 days immediately after surgery. An estimated cost analysis was made on the basis of the length of hospital stay and the blood transfusion.Results: IBL for the control group was 783.33±332.71 mL and for intervention group 410.57±189.72 mL (p <0.001). The operative time for control group was 3.24±0.38 hours and for intervention group 2.99±0.79 hours (p <0.695). Hemovac drainage on days 1 and 2 for control group was 167.10±53.83 mL and 99.33±37.5 mL, respectively, and for intervention group 107.03±44.37 mL and 53.38±21.99 mL, respectively (p <0.001). The length of stay was significantly shorter in the intervention group (4.8±1.1 days) compared to control group (7.0±2.3 days). The cost of treatment in the intervention group was US dollar (USD) 4,552.57±1,222.6 compared with that in the control group USD 6,529.9±1,505.04.Conclusions: Topical TXA is a viable, cost-effective method of decreasing perioperative blood loss in major spine surgery with fewer overall complications than other methods. Further studies are required to find the ideal dosage and timing.

Feasibility of Sub-Axial Cervical Laminar Screws, Including C7, in the Indian Population: A Study on 50 Patients Using Computed Tomography-Based Morphometry Measurements

Abhishek Srivastava,Geetanjali Nanda,Rajat Mahajan,Ankur Nanda,Sahil Batra,Nirajana Mishra,Naveen Pandita,Harvinder Singh Chhabra 대한척추외과학회 2019 Asian Spine Journal Vol.13 No.1

Study Design: Observational study of computed tomography (CT) data. Purpose: We performed a CT-based radiographic analysis of sub-axial cervical lamina in the Indian population to assess the feasibility of laminar screws. Overview of Literature: Morphometric studies have been performed for populations of various ethnic groups, but none exist for Indian populations. Methods: Cervical spine CT scans of 50 adults with a minimum slice thickness of <2 mm (0.5–2 mm) were obtained from the database of a single center in northern India. Measurements (e.g., length, thickness, and height) were taken in millimeters along the axial, coronal, and sagittal planes. Three measurements were made to assess laminar anatomy, namely, the translaminar/screw length, laminar thickness, and sagittal laminar height. Results: The final sample comprised 500 laminae in 50 patients, resulting in 1,500 measurements. The mean translaminar lengths of the C3, C4, C5, C6, and C7 laminae were 19.48 mm, 19.60 mm, 19.61 mm, 20.49 mm, and 22.85 mm, respectively. The mean thicknesses of these cervical laminae were 3.12 mm, 2.62 mm, 2.56 mm, 3.47 mm, and 5.20 mm, respectively. The mean sagittal heights of these laminae were 9.38 mm, 9.80 mm, 10.12 mm, 11.31 mm, and 13.84 mm, respectively. Except for the C7 vertebrae, all other levels had a success rate of <10% in the Indian population using the criteria of a laminar height of at least 9 mm and thickness of 4.5 mm. Limited success was achieved at the C5, C6, and C3 levels. Conclusions: To the best of our knowledge, the present study is the only series on the feasibility of laminar screws in the sub-axial cervical spine in the Indian population. We found that Indian patients have smaller anatomical dimensions and thus, are not suitable for laminar screws in the sub-axial cervical spine, barring C7, which is contrary to findings for populations in western and south Asian countries.

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

Ashok Pedabelle Reddy,Rajat Mahajan,Tarush Rustagi,Harvinder Singh Chhabra 대한척추외과학회 2018 Asian Spine Journal Vol.12 No.6

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.

Magnetic Resonance Imaging and GeneXpert: A Rapid and Accurate Diagnostic Tool for the Management of Tuberculosis of the Spine

Ayush Sharma,Harvinder Singh Chhabra,Rajat Mahajan,Tarun Chabra,Sahil Batra 대한척추외과학회 2016 Asian Spine Journal Vol.10 No.5

Study Design: Retrospective study. Purpose: The aim of this study was to analyze various diagnostic tools, including GeneXpert, for the management of tuberculosis of the spine. Overview of Literature: Traditional diagnostic methods of microscopy, histology, and culture have low sensitivity and specificity for the management of tuberculosis of the spine. Methods: Of the 262 treated cases of spinal tuberculosis, data on 1 year follow-up was available for 217 cases. Of these, only 145 cases with a confirmed diagnosis were selected for retrospective analysis. Results: In 145 of the 217 patients (66.80%), diagnosis was confirmed on the basis of a culture. Of the 145 patients with a confirmed diagnosis, 98 (66.20%) patients were diagnosed on the basis of clinical presentation, whereas 123 (84.8%) exhibited a typical magnetic resonance imaging (MRI) picture. In 99 surgically treated patients, the diagnosis was confirmed on the basis of an intraoperative tissue biopsy. Among the 46 patients treated conservatively, 35 underwent a transpedicular biopsy, 4 patients underwent computed tomography-guided biopsy, 6 patients were diagnosed on the basis of material obtained from a cold abscess, and 1 patient underwent an open biopsy. The sensitivity of the culture for the detection of Mycobacterium tuberculosis was 66.80% (145/217) in our patients. Among the cases in which GeneXpert was used, the sensitivity for the detection of Mycobacterium tuberculosis was 93.4% (43/46). Moreover, the sensitivity of GeneXpert to detect rifampicin resistance was 100% (7/7) in our study. Conclusions: Majority of the patients with tuberculosis of the spine can be diagnosed on the basis of a typical radiological presentation via MRI. In our study, 84.8% cases exhibited typical MRI findings. For patients presenting with atypical MRI features, a rapid and accurate diagnosis is possible by combining GeneXpert with MRI. The combined use of MRI and GeneXpert is a rapid and highly sensitive tool to diagnose tuberculosis and rifampicin resistance in patients with tuberculosis of the spine. Furthermore, we achieved a 97.9% sensitivity for the detection of Mycobacterium tuberculosis and 100% sensitivity for the detection of rifampicin resistance in our study.