Neurological Recovery Pattern in Cervical Spondylotic Myelopathy after Anterior Surgery: A Prospective Study with Literature Review

Naveen Pandita,Sanjeev Gupta,Prince Raina,Abhishek Srivastava,Aamir Yaqoob Hakak,Omeshwar Singh,Mohd. Azhar-ud-din Darokhan,Mohd. Farooq Butt 대한척추외과학회 2019 Asian Spine Journal Vol.13 No.3

Study Design: Prospective clinical study. Purpose: The present study aimed to examine the neurological recovery pattern in cervical spondylotic myelopathy (CSM) after anterior cervical decompression and compare it with the existing reports in the literature. Overview of Literature: Neurological recovery and regression of myelopathy symptoms is an important factor that determines the outcomes of surgical decompression. The present findings contribute to the literature on the pattern of neurological recovery and patient prognosis with respect to the resolution of myelopathy symptoms after surgery. Methods: This prospective study was conducted in Government Medical College in Jammu, North India between November 2012 and October 2014, a total of 30 consecutive patients with CSM were included and treated with anterior decompression and stabilization. They were prospectively followed up for 1 year and were evaluated for their neurological recovery pattern. The postoperative outcome was evaluated using the modified Japanese Orthopaedic Association (mJOA) score. The recovery rate was calculated using Hirabayashi’s method. The JOA score was assessed before the operation and postoperatively at 1 week, 2 weeks, 1 month, 3 months, 4 months, 6 months, and 1 year. Results: The postoperative mJOA score was 0 in the 1st month, 12.90±3.57 in the 3rd month, 13.50±3.55 in the 4th month, 14.63±3.62 in the 6th month, and 14.9±3.24 at the final follow-up of 1 year. The average recovery rate during the 1st month follow-up was 0%, and that during the 3rd month follow-up was 12.91% with a range of 0%–50%. The average recovery rate during the 4th month was 32.5%, with a range of 0%–60%, while that during the 6th month was 72.83%, with a range of 0%–100%. The average recovery rate during the final follow-up of 1 year was 54.3%. Conclusions: Neurological recovery after surgical decompression starts from the 3rd postoperative month and progresses until the 6th postoperative month; thereafter, it gradually plateaus over the subsequent 6 months until it steadies. Symptom duration is an important factor that requires consideration while determining postoperative neurological recovery.

Evaluation of Challenges in Diagnosis of Spontaneous Subacute Pyogenic Spondylodiscitis in Immunocompetent Patients: Experiences from a Tertiary Care Center

Naveen Pandita,Souvik Paul,Gagandeep Yadav,Roop Bhushan Kalia,Pankaj Kandwal 대한척추외과학회 2019 Asian Spine Journal Vol.13 No.4

Study Design: Prospective clinical study. Purpose: We evaluated the challenges faced during diagnosis and management of patients with subacute pyogenic discitis and discussed various clues in clinical history, radiologic and hematologic parameters of these patients that helped in establishing their diagnosis. Overview of Literature: Present literature available shows that in patients with subacute spondylodiscitis and infection with less virulent organisms, the clinical picture often is confusing and the initial radiologic and hematologic studies do not contribute much toward establishing the diagnosis. Methods: Demographic pattern, predisposing factors, clinical presentation, comorbidities, microbiology, treatment, neurologic recovery, and complications of 11 patients were prospectively reviewed regarding their contribution toward the conformation of diagnosis of subacute pyogenic discitis. Results: Mean age at presentation was 46.0 years with average preoperative Oswestry Disability Index and Visual Analog Scale scores of 83.4 and 7.18, respectively. Mean follow-up duration was 12.0 months. The most common site of infection was the lumbar spine, followed by the thoracic spine (n=1). Infective organisms were isolated in only 45% of cases. Staphylococcus aureus was the most common causative organism isolated. Conclusions: Diagnosing subacute spondylodiscitis in a patient presenting with subacute low backache poses a diagnostic challenge. Clinical and radiologic picture are deceiving, and bacteriologic results often are negative, further complicating the picture. A detailed medical history along with clinical, radiologic, and biochemical parameters prevents missing the diagnosis. Serial serum C-reactive protein and alkaline phosphatases were more reliable blood parameters in cases of subacute presentation.

Asymptomatic Construct Failure after Metastatic Spine Tumor Surgery: A New Entity or a Continuum with Symptomatic Failure?

Kumar Naresh,Patel Ravish,Tan Barry Wei Loong,Tan Jiong Hao,Pandita Naveen,Sonawane Dhiraj,Lopez Keith Gerard,Wai Khin Lay,Hey Hwee Weng Dennis,Kumar Aravind,Liu Gabriel Ka-Po 대한척추외과학회 2021 Asian Spine Journal Vol.15 No.5

Study Design: Retrospective cohort study. Purpose: To study the incidence, onset, underlying mechanism, clinical course, and factors leading to asymptomatic construct failure (AsCF) after metastatic spinal tumor surgery (MSTS). Overview of Literature: The reported incidence rates for implant and/or construct failure after MSTS are low (1.9%–16%) and based on clinical presentations and revisions required for symptomatic failures (SFs). AsCF after MSTS has not been reported. Methods: We conducted a retrospective analysis of 288 patients (246 for final analysis) who underwent MSTS between 2005–2015. Data collected were demographics and peri/postoperative clinical and radiological features. Early and late radiological AsCF were defined as presentation before and after 3 months, respec­tively. We analyzed patients with AsCF for risk factors and survival duration by performing competing risk regression analyses where AsCF was the event of interest, with SF and death as competing events. Results: We observed AsCF in 41/246 patients (16.7%). The mean time to onset of AsCF after MSTS was 2 months (range, 1–9 months). Median survival of patients with AsCF was 20 and 41 months for early and late failures, respectively. Early AsCF accounted for 80.5% of cases, while late AsCF accounted for 19.5%. The commonest radiologically detectable AsCF mecha­nism was angular deformity (increase in kyphus) in 29 patients. Increasing age (p<0.02) and primary breast (13/41, 31.7%) (p<0.01) tumors were associated with higher AsCF rates. There was a non-significant trend towards AsCF in patients with a spinal instability neoplastic score ≥7, instrumentation across junctional regions, and construct lengths of 6–9 levels. None of the patients with AsCF underwent revision surgery. Conclusions: AsCF after MSTS is a distinct entity. Most patients with early AsCF did not require intervention. Patients who survived and maintained ambulation for longer periods had late failure. Increasing age and tumors with a bet­ter prognosis have a higher likelihood of developing AsCF. AsCF is not necessarily an indication for aggressive/urgent intervention.

Symptomatic Construct Failure after Metastatic Spine Tumor Surgery

Kumar Naresh,Patel Ravish,Tan Jiong Hao,Song Joshua,Pandita Naveen,Hey Dennis Hwee Weng,Lau Leok Lim,Liu Gabriel Ka-Po,Thambiah Joseph,Wong Hee-Kit 대한척추외과학회 2021 Asian Spine Journal Vol.15 No.4

Study Design: Retrospective cohort study.Purpose: To evaluate the incidence and presentation of symptomatic failures (SFs) after metastatic spine tumor surgery (MSTS). To identify the associated risk factors. To categorize SFs based on the management in these patients.Overview of Literature: Few studies have reported on the incidence (1.9%–16%) and risk factors of SF after MSTS. It is unclear whether all SFs, occurring in MSTS-patients, result in revision surgery.Methods: We conducted a retrospective analysis on 288 patients (246 for final analysis) who underwent MSTS between 2005–2015. Data collected were demographics and peri/postoperative clinical and radiological features. Early and late radiological SF were defined as presentation before and after 3 months from index surgery, respectively. Univariate and multivariate models of competing risk regression analysis were designed to determine the risk factors for SF with death as a competing event.Results: We observed 14 SFs (5.7%) in 246 patients; 10 (4.1%) underwent revision surgery. Median survival was 13.4 months. The mean age was 58.8 years (range, 21–87 years); 48.4% were women. The median time to failure was 5 months (range, 1–60 months). Patients with SF were categorized into three groups: (1) SF when the primary implant was revised (n=5, 35.7%); (2) peri-construct progression of disease requiring extension (n=5, 35.7%); and (3) SFs that did not warrant revision (n=4, 28.5%). Four patients (28.5%) presented with early failure. SF commonly occurred at the implant-bone interface (9/14) and all patients had a spinal instability neoplastic score (SINS) >7. Thirteen patients (92.8%) who developed failure had fixation spanning junctional regions. Multivariate competing risk regression showed that preoperative Eastern Cooperative Oncology Group score was a significant risk factor for implant failure (adjusted sub-hazard ratio, 7.0; 95% confidence interval, 1.63–30.07; p<0.0009).Conclusions: The incidence of SF (5.7%) was low in patients undergoing MSTS although these patients did not undergo spinal fusion. Preoperative ambulators involved a 7 times higher risk of failure than non-ambulators. Preoperative SINS >7 and fixations spanning junctional regions were associated with SF. Majority of construct failures occurred at the implant-bone interface.

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.