The Journal of Spinal Surgery

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2019 | April-June | Volume 6 | Issue 2

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Original Article

Satyajit Rabha, Andi S Ramesh, Vadivel RR Kumar, Rajalakshmi Rajasegaran

Do Effective Canal Diameter and Atlantodental Interval have a Role in the Assessment of Postoperative Early Clinical and Radiological Status in Craniovertebral Junction Disorders?

[Year:2019] [Month:April-June] [Volume:6] [Number:2] [Pages:5] [Pages No:35 - 39]

Keywords: Atlantoaxial dislocation, Compressive myelopathy, Neck pain, Nurick grade

   DOI: 10.5005/jp-journals-10039-1209  |  Open Access |  How to cite  | 


Introduction: Surgery at the level of the craniovertebral junction (CVJ) is complex and technically challenging due to the presence of vital anatomical structures and complex congenital anomalies. The type of surgical procedure depends on the primary pathology. However, the aim of these surgical procedures is to relieve the compression at the level of the medulla and achieve anatomical stabilization. Objective: The objective of this study was to assess the early postoperative clinical and radiological outcome following stabilization of the CVJ in patients with atlantoaxial dislocation (AAD). Materials and methods: It is a retrospective descriptive study. All consecutively operated patients of AAD having complete clinical and radiological medical records in the institute were included in this study. Patients who had undergone transoral odontoidectomy were excluded. Atlantodental interval more than 3 mm in adults and 5 mm in children was considered as AAD. Three parameters were studied: Nurick grade, atlantodental interval (ADI), and effective canal diameter (ECD) at the level of C1. Clinical and radiological improvement was assessed by the Wilcoxon signed-rank sum test and the paired t test, respectively. A correlation among the duration of symptoms, Nurick grade, and changes in ECD and ADI was assessed by the Pearson correlation coefficient test. Results: Twenty-five patients who had complete clinical and radiological records were included in this study. There was no significant neurological improvement in the immediate (within 7 days) postoperative period. However, statistically significant improvement was observed in ECD and ADI. There was no significant correlation among the duration of symptoms, Nurick grade, and changes in ECD and ADI. Conclusion: ECD and ADI may serve as useful parameters to assess the radiological improvement in the early postoperative period of patients with AAD.


Original Article

Karthick A Krishnamurthy, Rajababu Rapeta

Assessment of the Level of Serum Beta Carotene in Chronic Low Back Pain Patients and its Association with Lumbar Osteophyte Formation

[Year:2019] [Month:April-June] [Volume:6] [Number:2] [Pages:4] [Pages No:40 - 43]

Keywords: Beta carotene, Osteophytes, Spinal osteoarthritis

   DOI: 10.5005/jp-journals-10039-1212  |  Open Access |  How to cite  | 


Aim: To assess the relationship between beta carotene levels, smoking, and alcohol consumption as a risk factor for developing spinal osteoarthritis. Materials and methods: This is a cross-sectional study on 153 patients above 50 years of age with at least 3 months of continuous low back pain. The study period was from August 2015 to March 2017. The demographic data, the amount of alcohol intake, and smoking history were noted. The X-ray of lumbosacral spine (ap and lateral) was taken and Nathan's criteria for osteophyte positivity were applied. Blood samples were sent to biochemistry department for assessing beta carotene levels. Patients with any preexisting pathology of the spine were excluded. Statistical correlation studies were used to assess the significance. Results: Spinal osteoarthritis was more in females and among them 22% had low serum beta carotene. Among the men with osteoarthritis, 32% had low serum beta carotene levels. There was a moderate correlation between beta carotene levels and osteophyte formation. There was strong association between smoking, alcohol intake, and osteophyte formation. The beta carotene levels were found to be low in persons consuming alcohol and persons who smoke. Conclusion: Low serum beta carotene is a risk factor for spinal osteoarthritis, but it can be prevented by adequate dietary supplementation. Smoking and alcohol are independent but avoidable risk factors for developing spinal osteoarthritis.


Original Article

Vinod K Tewari, Neeraj Seth, Devesh Johari, Rakesh Shukla, Hari K Das Gupta

Acupuncture-like TENS (AL-TENS) as a Quantitative Measure for the Feasibility of Intrathecal Sodium Nitroprusside Superfusion in Paraplegics for Physiological Recovery—A Pilot Study (13 Cases)

[Year:2019] [Month:April-June] [Volume:6] [Number:2] [Pages:5] [Pages No:44 - 48]

Keywords: Acupuncture-like TENS, Intrathecal sodium nitroprusside, Paraplegias, The 10,000 fold effect

   DOI: 10.5005/jp-journals-10039-1214  |  Open Access |  How to cite  | 


Background and introduction: Intrathecal sodium nitroprusside (ITSNP) has shown marked recovery in various causes of paraplegias after proper surgical decompression of the spinal cord and stabilization of vertebra. Until now, we were unable to predict paraplegias’ recovery post-ITSNP bedside effectively, either by clinical or by any investigatory modality (somato sensory-evoked potential (SSEP) and motor-evoked potential (MEP)).1 We present our work on the grading system and predictability for paraplegics using acupuncture-like TENS (AL-TENS) with ITSNP in various thoracolumbosacral cases. AL-TENS causes pain relief by well-known gate theory at the spinal cord by activating A-alpha nerve fibers which activates A-delta fibers for muscle spindle, and then pain fibers are inhibited by Renshaw cells at the spinal cord. The present work uses this cascade of various transmissions of nerves via a normal or damaged (complete or partial) spinal cord and utilizing this pathway to predict the feasibility of ITSNP in paraplegics. Our hypothesis works on this fact that the various nerves passing through the spinal cord and toward the brain can be utilized to use the quantitative measure for spinal cord injured patients and their recovery. Aims/study design: The aim of the study is to prognosticate the post-ITSNP effect by AL-TENS in thoracolumbosacral paraplegia cases in the pre-ITSNP phase, a prospective study. Materials and methods: Thirteen paraplegia patients (11 male patients and 3 females, and 3 complete paraplegias and 10 partial paraplegias) with zone of partial preservation (ZPP) cases were considered in whom pre-ITSNP-AL-TENS and post-ITSNP-TENS have been done. The mean time for superfusion was 9.69 months. ITSNP was administered at a dosage of 0.2 mg/kg body weight at the L3/4 level using a 20G LP needle. Pre- and post-ITSNP was monitored by AL-TENS. Results: Post-ITSNP-AL-TENS showed 23.84% benefit overall and 23.32% in American Spinal Injury Association (ASIA) grading in thoracolumbosacral paraplegia cases. Complete paraplegia cases did not show any change while partial paraplegias (with ZPP) showed 31% recovery in post-ITSNP-TENS and 33.34% in ASIA grading. Thus, AL-TENS showed a favorable modality to predict the ITSNP feasibility in thoracolumbosacral paraplegia cases. If pre- ITSNP-TENS showed 8 mAmp or more, there will be no response to ITSNP. This effect of post-ITSNP-TENS has increased to 34.96% after 24 hours. After 1 week, it became 39.19% and after 21 days, it had reached 44.16%. Conclusion: ITSNP with the help of TENS done in paraplegic cases helped us to prognosticate the future outcome.


Original Article

Shashivadhanan Sundaravadhanan

Percutaneous Axial Presacral Lumbar Interbody Fusion: A Preliminary Case Series (Three Cases)

[Year:2019] [Month:April-June] [Volume:6] [Number:2] [Pages:4] [Pages No:49 - 52]

Keywords: Interbody fusion, Percutaneous, Presacral axial lumbar

   DOI: 10.5005/jp-journals-10039-1215  |  Open Access |  How to cite  | 


Introduction: Traditional surgical management of lumbosacral spondylolisthesis is technically challenging and is associated with significant complications. The combination of percutaneous pedicle screw reduction and an axial presacral approach for lumbosacral discectomy and fusion offers an alternative procedure for the surgical management of low-grade lumbosacral spondylolisthesis. In an attempt to alleviate many of the limitations of previous lumbar fusion techniques, a presacral approach to the lumbosacral junction has been investigated. This study attempts to analyze the feasibility and efficacy of percutaneous 360° axial lumbar interbody fusion (AxiaLIF) as a standard procedure for lumbar fusion. Materials and methods: A total of three patients were evaluated in this study. The AxiaLIF system (TranS1, Inc., Wilmington, NC) was used for this new fusion technique which combines a minimally invasive technique with a novel corridor approach. Results were compared preoperatively and following the surgery at 3 and 6 months. Observation: There was a significant improvement in the pain scores. No complications were recorded and Magnetic Resonance Imaging revealed satisfactory implant placement with no neural compromise. Conclusion: The AxiaLIF is a feasible procedure which will require long term studies before it can be validated as a standard technique for lumbar fusion.


Original Article

Sreenath Kuniyil, Bijukrishnan Rajagopalawarrier, Vijayan Peettakkandy

A Study Comparing Open and Minimally Invasive Surgery for One- or Two-level Thoracolumbar Intradural Extramedullary (IDEM) Spine Tumors

[Year:2019] [Month:April-June] [Volume:6] [Number:2] [Pages:7] [Pages No:53 - 59]

Keywords: Intradural extramedullary, Minimally invasive, Spine tumors

   DOI: 10.5005/jp-journals-10039-1216  |  Open Access |  How to cite  | 


Background: The era of modern minimally invasive spine (MIS) surgery begins in the early 1990s with the report of the first case of tubular discectomy. Later, intradural tumor excision was reported in 2006. But most of us are still reluctant in accepting this new corridor due to lack of studies from India. Aim: The aim of this study is to compare various aspects of minimally invasive resection of one- or two-spinal level thoracolumbar intradural extramedullary (IDEM) tumors with conventional open surgery. Materials and methods: This study was conducted in patients admitted with a diagnosis of IDEM spinal tumor during the period of January 2016 January 2019. We compared 19 cases of one- or two-spinal level thoracolumbar IDEM tumors operated through MIS with 19 similar cases operated through open surgery. Results: The mean intraoperative blood loss was 115 mL in the MIS group and 530 mL in the open group and the duration of surgery was 229.74 minutes for the MIS group and 230.26 minutes for the open group. The mean C arm exposure was 6.04 in the MIS group and 2.63 in the open group. Ten cases in the MIS group and eight cases in the open group were operated in one spinal level and 9 in the MIS group and 11 in the open group were operated in two spinal levels. One patient in both groups developed cerebrospinal fluid (CSF) leak and one patient in the MIS group and two patients in the open group had a postoperative wound infection. The mean postoperative pain score was 2 in the MIS group and 3.58 in the open group (assessed by the visual analog scale). Sensory and motor symptoms improved in all cases in both groups. The mean hospital stay was 5.16 days in the MIS group and 8.42 days in the open group. The mean size of incision was 2.73 in the MIS group and 8.18 in the open group. The patient satisfaction index (PSI 1–4) in terms of overall satisfaction was 1 (68.4%) and 2 (31.6%) in the MIS group and 1 (47.4%), 2 (31.6%), and 3 (21.1%) in the open group. Conclusion: We conclude that MIS procedures are a safe and better alternative for one- or two-level thoracolumbar IDEM spinal tumors but its usefulness in tumors with more than two-level needs further studies.



Ali M Maziad

Can Delayed Surgical Decompression and Stabilization of Neglected Subaxial Cervical Trauma Provide Satisfactory Functional Outcomes? A Case Study

[Year:2019] [Month:April-June] [Volume:6] [Number:2] [Pages:5] [Pages No:60 - 64]

Keywords: Anterior cervical fusion, Cervical corpectomy, Cervical trauma, Myelopathy

   DOI: 10.5005/jp-journals-10039-1217  |  Open Access |  How to cite  | 


Aim: This article aims to describe the case of a 22-year-old male with neglected subaxial cervical trauma involving C6 and C7 vertebrae, associated with spinal cord injury/transection, who received delayed surgical treatment, however, achieved a relatively satisfactory functional outcome. Background: The patient sustained motor vehicle accident (MVA) at a rural area in a developing country with limited access to advanced diagnostic facilities or trained medical providers. Thus, leading to delayed diagnosis and conservative treatment of subaxial cervical dislocation with associated spinal cord injury and quadriplegia. Procedure: Two months after injury, following transfer to a tertiary center, a single-stage anterior cervical corpectomy and fusion was performed. The surgery was uneventful. Outcomes: Complete anterior spinal cord decompression was achieved with good fixation. The patient was discharged 2 days after surgery. At 1 year follow-up, upper extremity function of both upper limbs was restored; however, limited nonfunctional improvement of the lower extremity was noted. Scientific message: Spinal decompression and stabilization can lead to better functional outcomes in traumatic spinal cord injuries even if delayed due to lack of facilities. Anterior-only decompression and fixation with a proper technique are sufficient in single-level corpectomy.



Manish Beniwal, Indiradevi Bhagavatula, Amit Padwal

Management of Endovascular Intervention Complication in Spinal Vascular Malformation—Report of Two Cases

[Year:2019] [Month:April-June] [Volume:6] [Number:2] [Pages:4] [Pages No:65 - 68]

Keywords: Complication, Intervention, Laminectomy, NBCA, Onyx

   DOI: 10.5005/jp-journals-10039-1210  |  Open Access |  How to cite  | 


Aim: Management of cases of spinal vascular malformation, complicated by vessel injury during catheterization. Background: Vascular abnormalities of the spinal cord are rare group of spinal cord disease and complex angioarchitecture of these lesions makes its treatment both by surgical or radiological intervention technically demanding. Case description: We report two cases of spinal vascular malformation, complicated by vessel injury during catheterization. In case 1, extravasation of embolic material and blood could be documented by the digital subtraction angiogram (DSA), the patient developed progressive sensorimotor deficits after the next 48 hours, whereas in case 2, the patient developed immediate postprocedural weakness in both lower limbs and postprocedural computed tomography (CT) showed glue material in the spinal canal. Both the patients underwent decompressive laminectomy and showed improvement in motor power. Conclusion: Following intervention, if the patient develops weakness, it is generally thought to be due to ischemia, and not due to extravasated material (glue + hematoma). When imaging shows the mass effect due to this complication, the patient should undergo decompression instead of taking a pessimistic attitude of not doing anything due to supposedly arterial ischemia and infarct.



Mehul N Modi, Samir Dhami, Jigesh Vaidya, Jignesh Patel, Nirmal Choraria

Traumatic C2 Fracture in a 10-month-old Infant: Controversies and Hurdles in Management

[Year:2019] [Month:April-June] [Volume:6] [Number:2] [Pages:3] [Pages No:69 - 71]

Keywords: C2 fracture, Infant, Management, Quadriparesis

   DOI: 10.5005/jp-journals-10039-1211  |  Open Access |  How to cite  | 


Cervical spine injuries (CSIs) in children are relatively rare, representing only about 2% of all spinal trauma.1 The pattern, severity, and level of these injuries are age dependent. Evaluation and management of CSIs in children are difficult. Neurological deficits in young children are uncommon with good potential for recovery; however, it carries potential risk of catastrophic permanent neurological disability. We describe a rare case of C2 fracture due to high speed road traffic accident in a 10-month-old child. The child underwent posterior C1–C2 fixation and required prolonged ventilatory support, but was ultimately able to survive with improving residual hemiparesis.



Vinu V Gopal

History of Neurospinal Surgery in Kerala

[Year:2019] [Month:April-June] [Volume:6] [Number:2] [Pages:4] [Pages No:72 - 75]

   DOI: 10.5005/jp-journals-10039-1218  |  Open Access |  How to cite  | 


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