[Show abstract][Hide abstract] ABSTRACT: Retrospective clinical series.
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.
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.
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.
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.
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.
Asian spine journal 12/2014; 8(6):711-9. DOI:10.4184/asj.2014.8.6.711
[Show abstract][Hide abstract] ABSTRACT: Hemophilic pseudotumor involving the spine is extremely uncommon and presents a challenging problem. Preoperative planning, angiography, intra and perioperative monitoring with factor VIII cover and postoperative care for hemophilic pseudotumor is vital. Recognition of the artery of Adamkiewicz in the thoracolumbar junction helps to avoid intraoperative neurological injury. We report the case of a 26-year-old male patient with hemophilia A, who presented with a massive pseudotumor involving the first lumbar vertebra and the left iliopsoas. Preoperative angiography revealed the artery of Adamkiewicz arising from the left first lumbar segmental artery. Excision of pseudotumor was successfully carried out with additional spinal stabilization. At 2 years followup, there was no recurrence and the patient was well stabilized with a satisfactory functional status. Surgical excision gives satisfactory outcome in such cases.
Indian Journal of Orthopaedics 11/2014; 48(6):617-20. DOI:10.4103/0019-5413.144238 · 0.62 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Spinal hydatid cyst is a rare occurrence in non endemic countries. We present a case of recurrent lumbar hydatid disease in a 21-year-old male who following initial treatment had a good functional outcome and healing for 8 years, following which he came back with complaints of low back ache and neurological deficit. Patient underwent a second surgery with global debridement of L3-L5 vertebrae followed by medical management for two years. He had a good surgical outcome with recovery from the neurological deficit. Patient has returned to his routine activities and is being reviewed every year; there is no evidence of recurrence in the past 3 years. To the best of our knowledge recurrence after 8 years of initial treatment, followed by good clinical and radiological outcome for 3 years after surgery and treatment of the recurrence has not been reported in literature.
Asian spine journal 03/2013; 7(1):39-43. DOI:10.4184/asj.2013.7.1.39
[Show abstract][Hide abstract] ABSTRACT: Chondrosarcomas are malignant cartilage forming tumours. They form the second most common primary malignant tumour involving the vertebral axis. We present a rare presentation of a secondary chondrosarcoma from the spinous process of lumbar vertebra and discussed its management. The main emphasis is on the rare presentation and the need for awareness and suspicion of the pathology.
Asian spine journal 12/2012; 6(4):279-83. DOI:10.4184/asj.2012.6.4.279
[Show abstract][Hide abstract] ABSTRACT: AIM: To present the magnetic resonance imaging (MRI) findings of 10 patients with histopathologically proven tuberculous spondylitis (TS) presenting as vertebra plana (VP) on radiographs. MATERIAL AND METHODS: Radiographs of 451 adult TS patients were reviewed. In this consecutive series, there were 11 patients who presented as VP. MRI of 10 of these patients was available for review. RESULTS: VP-like collapse of a single vertebral body of the dorsal spine with preserved endplates and disc was seen in all cases. Epidural, pre- and para-vertebral soft tissue was found in all patients. Epidural soft tissue presenting on sagittal images as a convexity of the posterior longitudinal ligament was also found in all the signal of which was different from the involved vertebra on axial images. All patients showed posterior element involvement, which was characterized by preserved cortical outline without expansion. CONCLUSION: TS presenting with VP-like collapse of the bone is rare, accounting for 2.4% of the cases in the present series. MRI may show a collapsed vertebra with preserved endplates and disc. MRI findings that are suggestive of TS include: (1) signal intensity of the epidural soft-tissue mass on axial images, which is different from the vertebral body; (2) presence of a thin, T2-weighted hypointense capsule of the para-vertebral soft tissue; (3) posterior element involvement characterized by intact hypointense cortical outline without expansion; and (4) involvement of the costovertebral joint.
[Show abstract][Hide abstract] ABSTRACT: Exostosis of the rib with neural foraminal extension as a cause of spinal cord compression and scoliosis has to the best of our knowledge not been reported. We describe a young male with hereditary multiple exostosis who presented with a spastic gait, lower limb weakness and a deformity of the upper back. Radiographic imaging revealed a lesion arising from the left second rib which was encroaching the spinal canal and a scoliotic deformity of the upper thoracic spine. Through a single T shaped posterior approach he underwent a decompressive laminectomy of T1 and T2 vertebra and excision of the lesion. The diagnosis of osteochondroma was confirmed by histopathological studies. He was followed up at one year when his neurological condition had returned to normal however the scoliosis had increased.
Asian spine journal 09/2012; 6(3):207-10. DOI:10.4184/asj.2012.6.3.207
[Show abstract][Hide abstract] ABSTRACT: Retrospective clinical series.
To assess whether titanium cages are an effective alternative to tricortical iliac crest bone graft for anterior column reconstruction in patients with active pyogenic and tuberculous spondylodiscitis.
The use of metal cages for anterior column reconstruction in patients with active spinal infections, though described, is not without controversy.
Seventy patients with either tuberculous or pyogenic vertebral osteomyelitis underwent a single staged anterior debridement, reconstruction of the anterior column with titanium mesh cage and adjuvant posterior instrumentation. The lumbar spine was the predominant level of involvement. Medical co-morbidities were seen in 18 (25.7%) patients. A significant neurological deficit was seen in 32 (45.7%) patients. At follow up patients were assessed for healing of disease, bony fuson, and clinical outcome was assessed using Macnab's criteria.
Final follow up was done on 64 (91.4%) patients at a mean average of 25 months (range, 12 to 110 months). Pathologic organisms could be identified in 42 (60%) patients. Forty two (60%) patients had histopathological findings consistent with tuberculosis. Thirty of 32 (93.7%) patients showed neurological recovery. The surgical wound healed uneventfully in 67 (95.7%) patients. Bony fusion was seen in 60 (93.7%) patients. At final follow up healing of infection was seen in all patients. As per Macnab's criteria 61 (95.3%) patients reported a good to excellent outcome.
Inspite of the theoretical risks, titanium cages are a suitable alternative to autologous tricortical iliac crest bone graft in patients with active spinal infections.
Asian spine journal 09/2011; 5(3):155-61. DOI:10.4184/asj.2011.5.3.155
[Show abstract][Hide abstract] ABSTRACT: The outcome of open Lisfranc injuries has been reported infrequently. Should these injuries be managed as closed injuries and is their outcome different?
We undertook a retrospective study of high-energy, open Lisfranc injuries treated between 1999 and 2005. The types of dislocation, the associated injuries to the same foot, the radiologic and functional outcome, and the complications were studied. There were 22 patients. Five patients died. One had amputation. Of the remaining 16 patients, 13 men were followed up at a mean of 56 months (range, 29-88 months). The average age was 36 years (range, 7-55 years).
According to the modified Hardcastle classification, type B2 injury was the commonest. Ten patients had additional forefoot or midfoot injury. All patients were treated with debridement, open reduction, and multiple Kirschner (K) wire fixation. All injuries were Gustilo Anderson type IIIa or IIIb. Nine patients had split skin graft for soft tissue cover. Mean time taken for wound healing was 16 days (range, 10-30 days). Ten patients (77%) had fracture comminution. Eight patients had anatomic reduction, whereas five had nonanatomic reduction. Ten of 13 (77%) patients had at least one spontaneous tarsometatarsal joint fusion. The mean American Orthopaedic Foot and Ankle Society score was 82 (range, 59-100). Nonanatomic reduction, osteomyelitis, deformity of toes, planus foot, and mild discomfort on prolonged walking were the unfavorable outcomes present.
In open Lisfranc injuries, multiple K wire fixation should be considered especially in the presence of comminution and soft tissue loss. Although anatomic reduction is always not obtained, the treatment principles should include adequate debridement, maintaining alignment with multiple K wires, and obtaining early soft tissue cover. There is a high incidence of fusion across tarsometatarsal joints.
The Journal of trauma 03/2011; 70(3):710-6. DOI:10.1097/TA.0b013e3181f02ab9 · 2.96 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Retrospective case series.
To report the clinical features, diagnostic dilemmas and management options of 11 immunologically normal patients with salmonella spondylodiscitis.
Majority of existing data on salmonella spondylodiscitis in the immunologically normal patient is from anecdotal case report.
From 1995 to 2008, 11 patients with salmonella spondylodiscitis proven by positive culture, biopsy, and Widal test were included. One patient died, and the average follow-up of the remaining 10 patients was 36 months (12-122 months). Five (50%) patients had a documented history of typhoid fever. Intravenous antibiotics for 2 weeks and oral antibiotics for at least 10 weeks were given to all patients. Indications for surgical intervention were unrelenting pain and osseous instability. Clinical outcome was evaluated according to Macnab criteria.
Salmonella typhi was cultured in 4 and S. Paratyphi in 5 patients. No organism was identified in 2 patients, on whom the diagnosis was performed by a characteristic history, high Widal titers, and a positive biopsy. Widal titers were positive for all patients (Average + 1360). Five patients were managed with antibiotics only, 1 with surgical debridement and uninstrumented fusion and 4 with single-stage debridement, anterior fusion, and posterior instrumentation. Healing of disease with a good to excellent outcome was seen in all patients.
Salmonella and tuberculous spondylitis must be differentiated as they both have similar epidemiological and clinicoradiologic presentations. Prodromal gastrointestinal symptoms are usually not present. The diagnosis rests largely on the recovery of the organism by appropriate culture techniques. However, when this is not apparent the Widal test, in the setting of a suggestive history and radiograph, may be used as a diagnosis tool. Though antibiotics are the mainstay of treatment, surgical debridement with the use of instrumentation may be indicated in selected patients.
[Show abstract][Hide abstract] ABSTRACT: We describe a previously healthy, non-leukaemic young male presenting with neurological deficit and a pathological dislocation of D8 over D9 vertebra. The magnetic resonance imaging showed an enhancing soft tissue tumour. His basic laboratory workup as well as a bone marrow biopsy was normal. Through a single midline posterior approach, he underwent a decompressive laminectomy of D8 and D9 vertebra, anterior column reconstruction with a meshed titanium cage and posterior pedicle screw instrumentation. The histological diagnosis of granulocytic sarcoma was confirmed by appropriate immuno-histochemical studies. He received postoperative radiotherapy following which his wound dehiscesed and the tumour fungated and spread to his left thigh. He declined chemotherapy and unfortunately expired 9 months later. This case is presented to draw attention to the unusual presentation and to stress that granulocytic sarcoma should be kept in mind when making the differential diagnosis in patients with signs of spinal cord compression even in non-leukaemic individuals.
[Show abstract][Hide abstract] ABSTRACT: Posterior spinal surgical approach to achieve a retropleural/ retroperitoneal corpectomy with circumferential spinal cord decompression following subtotal vertebrectomy, posterior instrumentation and interbody spacer placement under compression as well as kyphosis correction with spinal column shortening.
Infective, traumatic or neoplastic lesions of the vertebral body that lead to vertebral body destruction, instability and neurologic deficit. Need for immediate postoperative loading stability to permit ambulation and rehabilitation.
Multiple contiguous vertebral disease. Instances where the graft bed preparation and stable interbody spacer placement may be suboptimal due to the limited access offered by this approach.
Posterior midline exposure two to three levels above and below lesion, dissection at level of lesion extended bilaterally exposing transverse processes, costotransverse articulations and medial 5-8 cm of ribs. Placement of pedicle screws at proximal and distal levels; in case of osteoporotic bone augment screws with cement. Bilateral costotransversectomy at one or more levels to drain prevertebral abscess and expose diseased vertebral bodies. After temporary stabilization, laminectomy and corpectomy are carried out from both sides to permit circumferential decompression. A temporary rod is placed on the contralateral side in the position of deformity to prevent any inadvertent translatory movements during the subsequent surgical step. After completion of the procedure an appropriately contoured rod is placed. The interbody spacer is positioned. Kyphosis correction by spinal column shortening and compression along the posterior implant is performed.
By day 3 ambulation and rehabilitation are initiated.
22 patients were operated in the last 8 years with tuberculosis (18 patients - twelve paraplegics), osteoporotic fractures (two patients), congenital kyphosis and Ewing's sarcoma (one patient each). All patients were followed up at 3, 6, 9, and 12 months and then annually. At each followup, clinical, hematologic and radiologic parameters were assessed. All interbody grafts and cages incorporated without significant loss of correction. Ten of twelve tuberculous paraplegics recovered. No patient had postoperative infection, interbody spacer- or implant-related complications.
[Show abstract][Hide abstract] ABSTRACT: We describe an adult patient with traumatic, nonunion of ulna sustained at 11 years of age who presented with wrist deformity. The possible pathogenesis, differential diagnoses and its successful management are described. A 23-year- old right hand dominant male presented with a progressive wrist deformity of his right upper limb. At 11 years of age, he sustained an isolated open fracture of the right forearm. He had nonoperative treatment. He had 60 degrees of ulnar deviation at wrist. He had no pain in the wrist or elbow. He was able to do all activities using his right upper limb. Radiograph revealed a nonunion of ulna in mid-shaft. The radius was bowed. Radiographs at the time of injury revealed a displaced both bones forearm fracture in mid-shaft. He underwent open reduction, internal fixation of ulna with bone grafting and a corrective osteotomy of the radius. The contracted Extensor carpi ulnaris was Z lengthened. Seven months postoperative, both the nonunion of ulna and radius osteotomy were consolidated. The wrist had no deformity. He had returned to preoperative activity level. Though nonunion is rare in pediatric forearm fractures, asymmetric bone and soft tissue growth can lead to deformities even in the absence of physeal injury. In addition to the standard treatment of nonunion, maintenance of the relative lengths of radius and ulna is essential, to obtain optimum function.
Archives of Orthopaedic and Trauma Surgery 08/2008; 128(7):717-22. DOI:10.1007/s00402-008-0644-4 · 1.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Telangiectatic osteosarcoma (TOS) of the spine is rare accounting for only 0.08% of all primary osteosarcomas. Though a well described radio-pathological entity it is not often thought of as a cause of paraplegia. We describe the clinical, radiological and pathological features and discuss the treatment options of telangiectatic osteosarcoma of the dorsal spine presenting in a young man. The diagnostic pitfalls are discussed emphasising the fact that the diagnosis of TOS of the spine requires not only a multi modal approach of appropriate radiological and pathological tests but also an awareness of this condition.
[Show abstract][Hide abstract] ABSTRACT: To assess the role of preoperative embolisation in benign bone tumour excision.
3 men and 3 women aged 19 to 35 (mean 23) years with either a giant cell tumour or an aneurysmal bone cyst in limb girdle sites underwent preoperative embolisation a day prior to wide local excision by the same surgeon. Tumour size, blood loss, wound healing, infection, and tumour recurrence were assessed.
The mean total blood loss was 391 (range, 100-980) ml. No blood transfusion was needed. No patient had any surgery- or embolisation-associated complication. No tumour recurred within a minimum 5-year follow-up. All patients had satisfactory limb function.
Preoperative embolisation is useful in the management of vascular and aggressive bone tumours located at limb girdle sites where a tourniquet cannot be used.
Journal of orthopaedic surgery (Hong Kong) 05/2008; 16(1):80-3.
[Show abstract][Hide abstract] ABSTRACT: Anterior debridement, grafting of the defect and posterior instrumentation as a single-stage procedure is a controversial method of managing pyogenic vertebral osteomyelitis. Between 1994 and 2005, 37 patients underwent this procedure at our hospital, of which two died and three had inadequate follow-up. The remaining 32 were reviewed for a mean of 36 months (12 to 66). Their mean age was 48 years (17 to 68). A significant pre-operative neurological deficit was present in 13 patients (41%). The mean duration of surgery was 285 minutes (240 to 360) and the mean blood loss was 900 ml (300 to 1600). Pyogenic organisms were isolated in 21 patients (66%). All patients began to mobilise on the second post-operative day. The mean hospital stay was 13.6 days (10 to 20). Appropriate antibiotics were administered for 10 to 12 weeks. Early wound infection occurred in four patients (12.5%), and late infection in two (6.3%). At final follow-up, the infection had resolved in all patients, neurological recovery was seen in ten of 13 (76.9%) and interbody fusion had occurred in 30 (94%). The clinical outcome was excellent or good in 30 patients according to Macnab's criteria. This surgical protocol can be used to good effect in patients with pyogenic vertebral osteomyelitis when combined with appropriate antibiotic therapy.
The Bone & Joint Journal 10/2007; 89(9):1201-5. DOI:10.1302/0301-620X.89B9.18776 · 2.80 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We describe here the management of eleven patients with fracture neck of femur. Excepting one patient all had severe haemophilia A. Nine patients were less than 50 years of age. Eight out of eleven patients had fracture after trivial trauma. Nine patients had closed reduction and one patient open reduction. The patient with non union had a Valgus osteotomy. All fractures united. The average time to union was 11 weeks (range:8-16). We followed either a low dose intermittent or a low dose continuous infusion factor support protocol for the management of these patients. The median dose of factor support was 252 u/kg (range: 136-580). The average duration of factor support was 9 days (range: 7-10). Two patients had aggravation of pre existing knee stiffness following post operative immobilisation. No other major complication was observed in this cohort of patients. To conclude, management of fracture neck of femur in patients with haemophilia is no different from general population if an adequate haemostasis is achieved.