Primary disseminated Hydatid disease of the vertebral body and paraspinal region

Volume 1 | Issue 2 | Sep – Dec 2016 | Page 52-54 | Tyagi S K, Mediratta Sunit


Authors : Tyagi S K [1], Mediratta Sunit [1]

[1] Department of Neurosurgery, Indraprastha Apollo Hospital, Sarita Vihar, Mathura Road, New Delhi.

Address of Correspondence
Dr Sunit Mediratta
Department of Neurosurgery, Indraprastha Apollo Hospital,
Sarita Vihar, New Delhi-110076.
Email: sunit_medi@yahoo.com


Abstract

Introduction: Hydatid disease is caused by parasitic infestation by tapeworm of the genus echinococcus. Although any organ can be involved, hydatid disease involving vertebral body and paraspinal soft tissue is a rare occurrence even in endemic areas. Liver is the most commonly involved organ followed by the lungs and together they constitute about 90% of all hydatid disease involvement. Primary spinal hydatid cysts are rare and account for only 1% of all hydatid disease cases. We present a rare case of disseminated primary hydatid disease involving the vertebral body and extensive extradural paravertebral soft tissue causing cord compression .The patient was treated with surgical decompression of the spine and spinal stabilization was achieved using implants followed by antihelminthic therapy using oral albendazole.
Keywords: Hydatid disease, vertebral body, albendazole, spinal stabilization.


Introduction

Hydatid disease or human echinococcosis is a zoonotic infection caused by the larval forms of the genus Echinococcus [1]. It is endemic in areas where dogs and livestock coexist[2] and is prevalent worldwide .Humans are intermediate or accidental hosts and contract the disease by means of contamination through direct contact with the definitive host or its feces or by ingesting infected food[2].Primary spinal involvement occurs in only 1% of all cases [2,3,4,5]. Extensive spinal involvement proposes a challenge for the treating surgeon and makes it nearly impossible to remove entire cysts in-Toto [6].Intra operative rupture of cyst can lead to anaphylaxis, local recurrence and dissemination of hydatid disease, increasing morbidity. In this report we present a case of primary hydatid disease involving vertebral bodies with extensive extradural paravertebral soft tissue involvement causing cord compression .Patient was treated with surgical decompression and spinal stabilization along with medical therapy.

Case Report

A 40 year old male presented with complaints of low back ache and progressive bilateral lower limb weakness and decreased sensations below the inguinal region of two months duration. One month after onset of the initial symptoms he was unable to walk without support and developed urinary frequency and constipation. On examination, he had spastic paraparesis with power 4-/5 bilaterally. The deep tendon reflexes were brisk in both the lower limbs with extensor Babinski reflex. He had hypoesthesia for all sensations below Dorsal (D)-10 dermatome bilaterally .Local examination of spine did not reveal any deformity, swelling or tenderness. Magnetic resonance imaging (MRI) of the dorsolumbar spine revealed multiple small round to oval well defined lesions in the D11-12 vertebral bodies, disc space, epidural and paraspinal soft tissue. The lesions were hypointense on T1 weighted images and brightly hyperintense on T2 weighted images with bright peripheral contrast enhancement. The involved vertebral bodies were collapsed and along with the epidural lesions caused cord compression [Fig 1].

All his hematological investigations were normal except an erythrocyte sedimentation rate (ESR) of 28 mm/hour and ELISA (Enzyme linked immunosorbant assay) was strongly positive for Echinococcal antigen. Chest x-ray and ultrasound abdomen was normal. He underwent a laminectomy at D11-12 with wide excision of epidural cysts and partial corpectomy of diseased D11-12 vertebral body. Cysts were thin walled pearly white containing clear fluid [Fig 2]. Paraspinal soft tissue lesions were also excised. There was intra operative rupture of the cyst. 3% hypertonic saline was used as scolicidal agent for irrigation of the operative field. Thereafter spinal fusion and stabilization was done using a titanium cage with autologous bone graft placed between D10 and L1 vertebral bodies and D10-L1 fused using titanium pedicle screws and laminar hook [Fig 3]. Post operatively the patient was started on oral Albendazole 10 mg/kg /day for 3 months. Power in both the lower limbs had improved to 4+/5 with complete relief from back pain and subjective improvement in sensations by 50%.

Discussion

Cystic hydatid disease is caused by infection with larval form of the tapeworm Echinococcus granulosus and mostly seen in areas where sheep and cattle are raised. Adult worms mature in the intestine of dog, wolf, and other carnivorous animals (definitive host), and eggs are released in feces [2]. Intermediate hosts such as sheep and cattle ingest the eggs. Human are accidental intermediate hosts and contract the disease by means of contamination through direct contact with the definitive host or its feces or by ingesting food infected with parasite eggs [2]. Oncospheres hatch in duodenum, which penetrate intestine and enter portal circulation [2,5,7].Liver and lungs trap oncospheres that migrate from intestine to the portal circulation which then develop into hydatid cysts. Although liver (75%) and lungs (15%) are the most commonly involved organs, the disease can be seen anywhere in the body [4,8]. Bone is involved in 0.5 to 4% of the cases of hydatid disease [4,9].Primary spinal hydatid cysts account for 1% of all cases of hydatid disease [2,5,10]. The disease usually spreads to the spine by direct extension from pulmonary, abdominal, or pelvic infestation[1].After ingestion the parasite can also reach vertebrae directly through Porto-vertebral shunt by paradoxical flow during transient increase in intraabdominal pressure[9,11,12].Spinal hydatid cysts are located most commonly at the thoracic (52%), followed by the lumbar (37%) and then the cervical and sacral levels (1,3).The parasite cyst generally consist of an inner layer(endocyst) and outer layer(ectocyst).The host defense reaction forms vascularised fibrous capsule(pericyst) which provides nutrition to the parasite. The host defense in bony tissue is marginal and thus outer capsule is usually thin or absent [9].On plain x-rays the cyst is seen as osteolytic lesions with well defined rounded margins without any periosteal reaction. Rarely the cyst can be seen as a calcified rounded mass, however most cysts do not calcify and gradually enlarge over time[9].Computed tomography(CT) scan show well defined hypodense rounded lesion within the marrow, osteolytic lesions, cortical thinning and destruction, bone expansion and extension into adjacent soft tissue.[9,11,13 ].
On MRI imaging the cysts appear as hypointense on T1 weighted images and brightly hyperintense on T2 weighted images, rounded or oval in shape, thin walled with no septations[1,2] and conglomeration of the cysts appear as bunch of grapes. Fluid within the cysts has intensity of cerebrospinal fluid (CSF) with no debris in the lumen [2,6].The lesion shows poor contrast enhancement [1,9] however our case showed bright contrast enhancement around the periphery of the lesion .The MRI appears to be the best pre-operative diagnostic modality which also provides comprehensive information about anatomical relationship to neural and surrounding structures. Diagnosis is difficult to miss when there is a conglomeration of cysts or multiple compartment involvement; however diagnosis is difficult to make in cases with few cysts and single compartment involvement. Differential diagnosis may include Aneurysmal bone cyst, cystic component of giant cell tumor and epidermoid cyst [9].
Definitive diagnosis can be achieved by histopathological examination of the resected tissue. Fine needle aspiration biopsy is an invasive procedure and puncture of a cyst may lead to dissemination and anaphylaxis. [6, 14]
The surgical treatment of spinal hydatid disease should be reserved for symptomatic lesions[9,15].Radical resection of the cyst must be followed by albendazole therapy, however controversy remains regarding the dose and duration of albendazole therapy [6] the mean duration in literature is 3 to 4 months[2,5].
Radical resection in extensive spinal hydatid disease is generally impossible and decompression is the more realistic achievable goal [9].Cyst rupture is very common while resecting from within the vertebral body and can induce anaphylactic reaction along with increase chances of recurrence and dissemination[5,9]. These hazards can be minimized by using steroids during procedure and dissemination can be prevented by injecting the cyst or irrigating the wound in case of spillage with scolicidal agents like hypertonic saline, 0.5% silver nitrate, dilute betadine, glycerin or ethanol [2,3, 9].Chemical sterilization however does not kill all microscopic daughter cysts [9].Some authors also recommend poly-methyl methacrylate reconstruction of the vertebral body defect for its antihelminthic effect [1,9].
The prognosis of patients with spinal hydatid disease has been varied, ranging from complete eradication of disease to multiple recurrences, systemic dissemination and death. Recurrence rates from 30 to 100% have been reported [2,3,5] and investigators in one study suggest that the mean life expectancy after spinal involvement is 5 years [3].


Conclusions

Conglomeration of round to oval lesions with CSF intensity on MRI is nearly definitive of vertebral hydatid disease. Contrary to the reported literature, in our patients, bright peripheral rim enhancement of the cyst wall was seen on MRI. Patients do become pain free and show neurological recovery when treated with resection of the cysts from extensively involved vertebra and paravertebral soft tissue followed by spinal stabilization. We believe that aggressive surgery followed by albendazole therapy offers a chance for a prolonged symptom free survival with this illness, even in cases of extensive spinal hydatid disease.


References 

1. Jain A, Prasad G, Rustagi T, Bhojraj SY. Hydatid disease of spine: Multiple meticulous surgeries and a longterm followup. Indian J Orthop 2014; 48:529-32.
2. Kalkan E, Cengiz SL, Ciçek O, Erdi F, Baysefer A.Primary Spinal Intradural Extramedullary Hydatid Cyst in a Child. J Spinal Cord Med. 2007; 30(3): 297–300.
3. Lath R, Ratnam B.G, Ranjan A. Diagnosis and treatment of multiple hydatid cysts at the craniovertebral junction. J Neurosurg spine. 2007; 6:174–177.
4. Suslu HT, Cecen A, Karaaslan A,et al:Primary Spinal Hydatid Disease.Turkish Neurosurgery 2009,vol: 19,No:2,186-188.
5.Hakan Somay, Erdogan Ayan, Cezmi Cagri Turk, Selin Tural Emon, Mehmet Zafer Berkman. Long-Term Disseminated Recurrence in Spinal Hydatid Cyst. Turkish Neurosurgery 2014; Vol: 24, No: 1, 78-81.
6. Moharamzad Y, Kharazi HH, Shobeiri E, Farzanegan G, Hashemi F, et al:Disseminated intraspinal hydatid disease J Neurosurg Spine8:490-493,2008.
7. Pamir MN, Akalan N, Özgen T, et al: Spinal hydatid cyst. Surg neurol 1984; 21: 53–57.
8. Iliac AT, Kocaoglu M, Zeybek N et al: Extrahepatic abdominal hydatid disease caused by echinococcus granulosus: imaging findings. AJR 2007; 189:337–343.
9. Bron JE,Kemenade FJ,Verhoof OJ, Wuisman PIJ.Long term follow-up of a patient with disseminated spinal hydatidosis. Acta orthop, Belgica 2007; 73: 674-677.
10. Benzagmout M,Kamouni I,Chakour K,Chouni ME: Primary spinal epidural hydatid cyst with intrathoracic extension. Neurosciences 2009; vol.14 (1):81-83.
11. Brian JF,Richez P ,Belliol E etal.Osteoarticular involvement in parasitic diseases; bone echinococcosis. J Radiol 1998; 79:1351-1357.
12. Sener RN,Calli C,Kitis O,Yalman O.Multiple primary spinal- paraspinal hydatid cysts. Eur Radiology 2001; 11:2314-2316.
13. Tuzun M,Hekimoglu B.CT findings in skeletal cystic echinococcosis.Acta Radiol 2002 ;43:533-538.
14. HerreraA,Martinez AA,Rodriguez J:spinal hydatidosis.Spine 2005;30:2439-2444.
15. McManus DP, ZhangW,Li J,BartleyPB.Echinococcosis.Lancet 2003;362:1295-1304.


How to Cite this Article: Tyagi S K, Mediratta S. Primary disseminated Hydatid disease of the vertebral body and paraspinal region. International Journal of Spine Sep-Dec 2016;1(2):51-54.


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Thoracolumbar Spinal Injuries – Evolution of Understanding of fracture Mechanics and Management Options

Volume 1 | Issue 2 | Sep – Dec 2016 | Page 7-8 | Shailesh Hadgaonkar, Ketan Khurjekar


Authors : Shailesh Hadgaonkar [1], Ketan Khurjekar [1]

[1] Sancheti Institute for Orthopaedics &Rehabilitation, Pune, India.

Address of Correspondence
Dr Shailesh Hadgaonkar
Sancheti Institute for Orthopaedics &Rehabilitation, Pune, India
Email: editor.ijspine@gmail.com


Introduction

This symposia on thoracolumbar fractures is aimed at providing an overview to the reader with respect to evolving trends in fracture diagnosis and management.
There has always been controversies in treating thoracolumbar spine injuries with neurological deficit, but as we know the goal of managing these T-L junction injuries is to maintain the sagittal alignment for mechanical stability and to give additional support for rehab and physiotherapy for neurological recovery. The main aim of thoracolumbar fracture surgery is to give structural support to the spinal column for wheelchair mobilization in cases with complete injury and paraplegia. We have found significant improvement in quality of life in patients who were operated for these severe thoraco lumbar spinal injuries. As we all know the most common level of these injuries is T 12 and L1, sustaining from the high velocity trauma. The flexibility at thoraco lumbar junction, the thoracic rib cage ending at the junctional level, coronal alignment of facet joint in thoracic spine and the changes in the lower thoracic facets to less coronal alignment is likely to cause fracture dislocations. Various transitional zone injuries- between T 11- L2 are approximately 50 – 60 % of all injuries. Most common reason for these injuries – are fall from height and high velocity RTA. There is a significant association of other injuries such as chest, abdominal, vascular injuries and also head injuries with these fracture dislocations.
It is paramount to evaluate these patients in detail, thorough clinical and neurological assessment is mandatory. The standard American Spinal Injury Association (ASIA) guidelines should be followed in neurological assessment. Associated relevant investigations as the X-rays and MRI scans will guide for non-operative Vs operative management. Additional modalities such as CT scans and 3D reconstruction is important clinically unstable and high grade T-L injuries. Primary assessment and medical management is important to stabilize the patient before planning the surgery.

Evolution of classification systems :
Various different classification system have evolved from the World War I and II days, as Bohler in 1930 classified T-L fractures into five categories :-
1- Compression fractures
2- Flexion /distraction injuries
3- Extension fractures
4- Rotational injuries
5- Shear fractures
Watson Jones in 1938 classified T-L injuries adding instability to Bohler’s classification. The most important factor in Watson Jones classification was description of Posterior ligamentous complex (PLC) in spine stability, as they felt the integrity of interspinous ligament is most important stability factor.
Nicole in 1949, further classified using anatomical classification with emphasis on interspinous ligament integrity. He described the stability structures as the vertebral body, disc, intervertebral joint, and interspinous ligament. This classification serves as a foundation for subsequent classifications.
Holdsworth in 1963, described Two column theory and he emphasized the spinal stability on posterior ligamentous complex (PLC) stability. Kelly and Whitesides attempted to modify Holdsworth classification, as they specifically mentioned anterior column as solid vertebral body whereas posterior column as posterior elements and neural arch. Also they emphasized the treatment of neurological deficit.
Dennis in 1983, came up with a new concept – Three column theory using the radiological parameters. He provided a new insight in detailing the classification into anterior, middle and posterior column. They described the middle column – osteo-ligamentous complex injury is the primary determinant of mechanical spinal stability.
Mcafee et al described the classification based on CT scans of 100 consecutive patients and divided into 6 groups. This was the most detailed classification system in the 1980’s. They described the height loss of vertebral body, facetal joint subluxation, fragments in the spinal canal, progressive neurological deficit, kyphosis angle because of instability was assessed with the CT scan. As per their criteria translational and flexion/rotational fracture dislocation and posterior ligamentous complex (PLC) injury with kyphosis more than 30 degrees angle should undergo surgery.
In 1994 Mc Cormack classified on load sharing concept, which focuses more on location of the fracture in the vertebral body.
Then in 1994, Magrel et al came up with classification based on evaluation of 1445 cases and classified into 3 types and 53 injury models.
In 2005, Vaccero et al came up with Spine trauma study group – Thoraco Lumbar Injury Classification System (TLICS) which takes a detail note on fracture mechanism, the intact PLC status and the neurological status of the patient.
TLICS points:
Fracture Mechanism
Compression fracture 1
Burst fracture 1
Rotational fracture 3
Splitting 4
Neurological involvement
None 0
Nerve root 2
Medulla spinalis, conus medularis-
– Incomplete 3
– Complete 2
Cauda equina 3
Posterior ligamentous complex
Intact 0
Possibly injured 2
Injured 3

Surgical indication is for cases with 5 points or more, cases with 4 points are between surgical vs non surgical, and cases with 3 or less points are non surgical. It is quite a comprehensive and popular classification in clinical practice and many centers prefer to use this classification worldwide.
Recently AO Spine knowledge forum has proposed a comprehensive modified AO classification based on morphology of fracture, neurology status and description of relevant patient specific modifiers
These classifications signify the growth in our understanding of pahtomechanics of the spine fracture as well as takes into account our growing expertise in the offering better surgical options to the patients.

Management Options:
Various management options are discussed in the current symposia and most of the options are individualised depending on the etiology and extent of fracture. Few general rules are noted below –
– Cases where there is retropulsion up to 40- 50 degrees without neurological deficit with intact PLC we can attempt indirect decompression and distraction in first 5 -6 days after the injury.
– Cases with less angulation and wedging with minimal kyphosis can be dealt with short segment fixation.
– Interlink in long construct always adds-up to the stability. Reduction of the dislocation with various maneuvers always beneficial for sagittal profile.
– Role of steroid is controversial post T-L injury with neurological deficit and is rarely used worldwide.
– Role of minimally invasive spine (MIS) surgery is evolving and needs a longer follow up. MIS surgery helps in reducing the bleeding, morbidity in selective cases.
– There is a significant role of rehabilitation post-surgery, in cases of T-L fractures with neurological deficit. Stem cells are promising in animal and Fish models in research labs and we are very hopeful about the same in humans.
Most of the above options are discussed in details in the symposia and we would encourage the readers to go through the articles. Ultimately the clinical evaluation summed with the radiological parameters will decide the management plan as cases with instability, neurological deficit and progressive neurological worsening cases will need surgical intervention. A lot of cases can be conserved with careful monitoring.
We thank all the authors and contributors for participating in the symposia and invite interested readers to participate as symposium editors or authors. Please write to us by email and provide your suggestions and comments.


How to Cite this Article: Hadgaonkar S, Khurjekar K. Thoracolumbar Spinal Injuries Evolution of Understanding Fracture Mechanics and Management Options . International Journal of Spine Sep-Dec 2016;1(2):7-8.


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Interview with Dr Rajasekaran: Part I

Volume 1 | Issue 2 | Sep – Dec 2016 | Page 3-6 | Prof. S. Rajasekaran


Authors : Prof. S. Rajasekaran 

M.S., DNB., F.R.C.S.(Ed)., M.Ch(Liv)., FACS., F.R.C.S.(Eng)., Ph.D
Chairman, Dept of Orthopaedics, Trauma & Spine Surgery.
Ganga Hospital, Coimbatore.


Prof. S Rajasekaran

One of the most Revered Academicians and most decorated Spine surgeon in India, Dr Rajasekaran has inspired an entire generation of Orthopaedic Surgeons across the country. This interview is an attempt to gain an insight into Dr Rajasekaran as a human being as an academician and as an Orthopaedic Surgeon


This interview with Dr S Rajasekaran (SR) was conducted at Kochi at the venue of IOACON 2016. The interview was conducted by Dr Ketan Khurjekar (KK) and Dr Ashok Shyam (AKS). The purpose of this interview was to know more about the journey of Dr Rajasekaran and also to catch a glimpse of his life and personality. A broader objective is to attract people to excellence in orthopaedics and to have pride in our own people who have done exceptionally well in reaching international acclaim in respective fields. This is part I of the interview and part II will be published in the forthcoming issue.

KK: Today you are at cross roads or rather in middle of world orthopaedic landscape and have experienced so many things. You were the IOA president and know about the national scenario and you are now involved in many international association including SICOT, SRS and AO spine. You are exposed to working in India as well as the western world. What are the differences that you perceive between the two worlds and how can we can attain the next level especially in terms of western world?
SR: Successful persons worldwide share the common trait of being focussed and hardworking. Indians as a rule, we work hard (may be even harder than the west) but the western world works with more focus and planning. We work hard and grow but they plan ahead and work towards the goals. Our growth is a more like an organic growth. We all are better than what we were 10 years ago but most of our growth is unplanned. When you don’t have a planned and targeted growth, you often don’t achieve or reach your greatest potential. For example, say a department did 1000 surgeries a year and 1100 the following year. This represents a growth of 10% and one can be happy about it. But the other way of looking at it is if the growth could have been up to 2000 surgeries? To achieve this type of growth, planning in advance is essential. Once a realistic goals have been set, timely audit, at least every every 3 months and a critical appraisal of performance will help to achieve the targets. Otherwise, performance deficit is common.
We have to realise that time waits for no body and keeps on moving. All of us have only a certain amount of time and certain of amount energy and this has to be channelised and not wasted. So we have to have concentrate our time and energy towards our targets. When you are doing things that you don’t need to do, then there is very little time to do what you really want to do. Every activity that is undertaken that is not in line with the long or short term plan, actually amounts to distraction. So we have to learn to say ‘No’ to things that waste our time.
Goals also have to be very specific rather than vague. Every new year, probably most of us aim to be better surgeons and to do more surgeries. But these will be the goals of every orthopaedic surgeon and is very nonspecific, without concrete plans or strategies. Plans need to be specific, time bound, realistic and tangible. And this makes a very huge difference.
Growth is either organic or planned. Orthopaedic speciality in India is growing by 15 to 18% every year. If one is growing at rate of 15%, you can’t take pride in that as you are riding the general growth of the speciality. So unless the growth is by more than 10% of the general growth we cannot take credit for it. If you are growing less than the national average, then someone else is growing much faster than you. So to be aware of one’s growth and performance in relation to other people around you is important.
It is also important not to assess just the performance but also the ‘performance gap’. Not appreciate ourselves on the performance that we have achieved but look at the highest possible that we could have performed and note if we have achieved it. Most of us our very happy in patting ourselves too easily and very early. This can be a big problem. I think achievers are more tuned toward looking at the performance gap and improving themselves continuously.

AKS: Does that mean we should be a bit discontent?
SR: We should have clarity on this subject. Contentment of mind is something that is spiritual and is needed for your happiness, peace of mind and healthy living. But contentment is a poisonous word when it comes to your work and professional life. People often confuse contentment in life and contentment in professional work. When the elders advocate contentment, they simply mean not to be greedy in life. They didn’t advocate to perform less or be happy with poor performance. Contentment is a good word for your spirit but not so good for your work. We should be contended only in worldly possessions but as far as the excellence in academics and profession is concerned, ‘passion for more’ is necessary. I would say you should have fire in your belly every day in your profession. At any time there is a reduction in passion for excellence, there is going to be stagnation.

KK: How then do we achieve our fullest ability?
SR: I often quote the famous words of Dr APJ Kalam, “Small aim is a crime”. One has to aim to achieve to his fullest capacity, whatever that may be. For this to happen, people with whom you spend time and interact become very important. I am often asked the advantage of being closely involved in international societies and also playing leadership roles in them. The most important benefit, and which I really enjoy is the ability and opportunity to move shoulder to shoulder with other giants in the field. I think this is really true – ‘you are the sum average of the five people you constantly move with’. This is very very important. If you are always interacting with people who are high thinking and who are professionally oriented and who are high achievers, you will be motivated towards higher performance than before. In contrast if one spends time with people who are distracted or poor achievers there is every chance that your performance will come down too. So one’s concept of hard work, happiness, contentment, definition of good life is all defined by people with whom you move with, people whom you look up to and people who look up to you.
There is a saying ‘If you are the best person in the room, then you are in the wrong room’. You have to move to a room where there are better persons than you. If you work with better people than you, then it becomes an incentive to improve your life. So it is vital to choose colleagues and friends who are better than you. It will keep you humble and help you to raise your bar from time to time. This is very important.

KK: We have seen that you are not easily attracted to material positions like luxury cars. I always wonder about this?
SR: At different periods of time in your life, different things impress you and it’s probably a sign of growing up. I was really impressed with jaguar cars when I was in England, specially the olive green car XJ8 model. I have taken many pictures of them with me standing in front of the car. My wife was really tired with this and told me to buy one and get over my obsession with it. I could not afford it at that time and I think that the attraction was increased by my inability to buy the car. That really made the car more attractive. At this stage of life where I can buy any car easily, the attraction has just simply vanished. So one gets over your attractions as you grow up . Your focus in life changes.
Please don’t get me wrong. I am not against worldly pleasures or luxury cars etc. I do love a ‘good life’ and I think that we should indulge ourselves from time to time. Life should not be just a bed of nails and should be sprinkled with worldly pleasures also. But not to a point of distraction. We need to keep the proportion and balance. Sometimes we have to get a luxury car to know that it is the most important thing in life. Sometimes they look more important than what they are until they are acquired. Happiness is basically a personal issue. Does not depend on your worldly possessions. If you are sad, having a BMW does not change things in any way. If you have had a successful day, it doesn’t make any difference whether you are travelling in an ambassador or BMW, you will still feel happy.
Materialistic indulgences from time to time is also important. Don’t need to be a ‘sanysi’ to be an achiever. It is the enthusiasm, inquisitiveness and the energy to do things that is very important.

KK : What is your opinion about hard work and professional stress?
SR: This is another area where there is a lot of confusion amongst the younger generation.
Hard work is completely different and has nothing to do with stress. Hard work is important as it allows you to achieve your dreams and give you professional satisfaction which are very important for happiness. Hard work is necessary for success and you can never be happy if you are unsuccessful in your profession. Productive hard work has never harmed anybody. In fact if we look back in our lives, we always remember fondly the times that we have worked hard and achieved a lot. Every surgeon feels happy when he has more work than less. All of us have to accept that.
But stress is something completely different and has to be avoided. It comes from a variety of factors like poor performance and failures in day to day work. Very frequently the cause of stress is lack of hard work, poor preparation and under performance. Stress also comes from doing a work which you are not passionate about. Stress is not working 15 hours at a job you like. Stress is working even 15 minutes at a job you dislike. a. If you are not passionate about your profession and you are feeling stressed you must look seriously at alternatives. Stress can also come from work place problems, incompatibility with working colleagues and family members, uncontrolled anger, jealousy etc. These issues are more relevant and are cause for poor health than hard work. The reason why worry kills more people than work is that nowadays more people worry than work.

 

In my experience, the most happiest people are the people who are fortunate enough to love what they do and be able to do what they love. They don’t need any further incentive for performing well.
Lastly, it is important to have a ‘wholesome life’. We need some buffers in life and best one is a loving and happy family. If you are struggling in family life, you would be pretty stressed in every area of life. A happy family is probably the most important factor and one needs a good ‘work – life balance’.
– To be continued in Next Issue of IJS


Dr S Rajasekaran
M.S., D.N.B, F.R.C.S(Ed)., F.R.C.S.(Lond))., M.Ch. , FACS, Ph.D.
Dr Rajasekaran is the Chairman of the Department of Orthopaedics & Spine Surgery, Ganga Hospital, Coimbatore, India and Adjunct Professor of Orthopaedic Surgery, The Tamilnadu Medical University.

Dr Rajasekaran holds several administrative and academic positions in Spine Surgery. He is the Current President of the Association of Spine Surgeons of India, President Elect of Indian Orthopaedic Association, President of the World Orthopaedic Concern, UK, President of Computer Assisted Orthopaedic Surgery Society, India, and Founder Chairman of Trauma Section of Asia Pacific Orthopaedic Association. He has also been elected as the Hunterian Professor 2011-12 by the Royal College of Surgeons of England.

Dr Rajasekaran heads one of the largest clinical and research units in Spine Surgery in South Asia. His research interests relate to disc biology and nutrition, Diffusion Tensor Imaging of the Spinal Cord, Genetic basis of disc degeneration and kyphotic deformities in spinal tuberculosis on which he has 151 publications in international journals. He has authored many chapters in Textbooks and is the Chief Editor of a Video Atlas in Spine Surgery and Chief Editor of ASSI Textbook of Spinal Infections & Trauma.

Dr Rajasekaran is the Deputy Editor, SPINE, USA and serves as a Editorial Board Member of European Spine Journal, Journal of Craniovertebral Surgery and Journal of Orthopaedic Science, Japan. He is the recipient of many awards in spine research which include the ISSLS Award for 2004 & 2010, EuroSpine Open Paper Award in 2008, APOA Award in 2007 and Sofamer Danek Award of ISSLS for the years 1996, 2002 and 2006.


How to Cite this Article: Rajasekaran S. Interview with Dr Rajasekaran: Part I. International Journal of Spine Sep-Dec 2016;1(2):3-6.


Prof. S. Rajasekaran
M.S., DNB., F.R.C.S.(Ed)., M.Ch(Liv)., FACS., F.R.C.S.(Eng)., Ph.D
Chairman, Dept of Orthopaedics, Trauma & Spine Surgery.
Ganga Hospital, Coimbatore.


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Management of Pathological vertebral collapse in elderly

Volume 1 | Issue 2 | Sep – Dec 2016 | Page 22-26 | Rajesh Parasnis, Alpesh Thumbadiya, Sachin Pathak, Shantanu Patil


Authors : Rajesh Parasnis [1], Alpesh Thumbadiya [1], Sachin Pathak [1], Shantanu Patil [1]

[1] Oyster and pearl hospital, Pune
[2] Jehangir Hospital, Pune
[3] SRM Medical College, SRM University, Kattankulathur, Tamil Nadu 603203

Address of Correspondence
Dr. Rajesh Parasnis
Department of Spine Surgery, Oyster and pearl hospital, India.
Email : rajeshparasnis@rediffmail.com


Abstract

Pathological vertebral fractures can be due to various reasons and management plans will differ as per the diagnosis. We present our series of patient with pathological fractures along with a management algorithm
Material and Methods: All patients aged more than 60 years presenting with intractable back pain with or without neurological deficit were screened. Of the 532 patients, 274 osteoporotic insufficiency fractures were identified by DEXA scan and excluded from the analysis. 258 patients with vertebral collapse caused by infection or neoplastic conditions were included in study.
Results: 212 patients (82.2%) had a single vertebral lesion followed by 34 (13.2%) at 2 levels and 12 (4.7%) with multiple vertebral levels involved. 161 cases (62.9%) had an infective pathology while the remaining 97 (37.9%) had a neoplastic cause. Needle biopsy was positive in 218 (84.49% ) cases. Repeat biopsy was required in 39 cases where Fine Needle Aspiration Cytology (FNAC) was inconclusive. There were 130 tubercular lesion, 7 atypical tuberculosis, 5 MDR tuberculosis, 13 pyogenic, 2 fungal, 4 hydatid cyst, 24 malignant lesions and 73 metastasis. 60 patients (58 TB spine and 2 pyogenic infection) were managed without surgery and the remainder 197 patients underwent surgical intervention
Conclusion: Pathological fractures can be due to varied etiology and although tuberculosis formed major cohort in our series, neoplastic lesion had to be suspected and tissue biopsy is essential to reach correct diagnosis and management plan
Keywords: Thoracolumbar fractures, pathological fractures, biopsy.


Introduction

Atraumatic vertebral collapse is a common clinical problem, especially in elderly population (1). It includes fractures because of osteoporosis or any other pathological cause. Pathological vertebral fracture in elderly occurs due to infective or neoplastic condition. Spinal column affection by neoplastic lesions include primary (benign or malignant ) or secondary metastasis. 50 to 85% of patients with cancer experience skeletal metastasis, most commonly in the spine (2). Infection of spine occurs due to tuberculosis, atypical tuberculosis, pyogenic, fungal and parasitic infestation (e.g.hydatid cyst). Tuberculosis is most common among them and a major health problem in developing countries. In elderly population because of comorbidity and lower immunity, spinal affection by tuberculosis is high.
The spine has a load-bearing and a neuro-protective function, Any failure of its structural integrity as a result of metastatic or infective vertebral involvement often brings about severe pain and/or paralysis. These symptoms impair the ambulatory ability of the patients and worsen their quality of life. One of the main causes of severe pain or paralysis is pathologic vertebral body collapse caused by an osteolytic lesion. Therefore, prevention and treatment of collapse is a key factor in maintaining the patients’ ambulatory ability especially in morbid elderly population (3,4,5,6). Early diagnosis of such conditions is very important to start with proper treatment.
Diagnosis of pathological vertebral collapse in aged population is usually missed or delayed. Elderly patients presenting with backache and vertebral collapse are a challenge for diagnosis as well as for management. Correct diagnosis may require all blood invastigations and imaging modalities including plain X-rays, ultrasonography (USG), computed tomography (CT), radionuclide bone scan, magnetic resonance imaging (MRI) and PET scan. For conclusive diagnosis one needs to identify the causative organism and know histopathology of the lesion by biopsy. One may need to repeat the biopsy if required before starting any treatment. It is mandatory to do a culture and test the sensitivity to rule out drug resistance in case of spinal tuberculosis. Management depends on multiple factors and requires multidisciplinary approach.
While many studies have investigated osteoporotic vertebral collapse in the elderly, not many have reported on other pathological fractures. We present our series of such patients and propose a treatment and management algorithm.

Methods and Materials

All patients aged more than 60 years presenting with intractable back pain with or without neurological deficit were identified from a data base spanning seven and half years (May 2008 to Nov 2015 ) at a tertiary care hospital. Of the 532 patients, 274 osteoporotic insufficiency fractures were identified by DEXA scan and excluded from the analysis. 258 patients with vertebral collapse caused by infection or neoplastic conditions were included in study. The patients were classified according to age, gender, pathology, levels affected, region involved, neurological deficit, type of biopsy and management protocol. Base line haematological tests included haemogram, liver function test (LFT), renal function test (RFT), CRP, ESR and serum electrophoresis studies. Radiological studies included Xrays of the affected region ( anteroposterior & lateral views ) and MRI were done in all cases. CT scan, Bone scan, PET scan and Bone marrow examination were done in indicated cases. Tissue diagnosis was done by biopsy in all cases for histopathology and/or culture sensitivity. Management protocol was decided according to the pathology and severity of the lesions. All patients were followed up at regular intervals 3 months, 6 months, 12 months and yearly follow up after that.

Results

The cohort included 258 patients (Male 156: Female 102) aged between 60 and 82 years age (mean age 63.4 years). 212 patients (82.2%) had a single vertebral lesion followed by 34 (13.2%) at 2 levels and 12 (4.7%) with multiple vertebral levels involved. 161 cases (62.9%) had an infective pathology while the remaining 97 (37.9%) had a neoplastic cause. Out of 258 patients mean aged 63.4 years ( 60-82 years ), we found 156 male and 102 female patients. Level of involvement was found to be single, double and multiple in 212 (82.17%), 34 (13.17%) and 12 (4.65%) cases respectively. Infective pathology was found in 161(62.89%) and neoplastic cause was found in 97(37.89%) cases. Distribution of pathology and level affected are detailed in Table 1.
Out of 258, 234 patients presented with intractable pain[predominant back pain in 198 (76.74%) and predominant extremity pain in 62 (24.03%) patients ] of mean duration8.2 weeks ( 1- 32weeks). 68 (26.35%) patients presented with neuro deficit( Frankel grade B in 3, C in 14 and D in 51 ). Constitutional symptoms were present in 38 (14.72) patients. Spinal deformity was present in 21 cases.
Biopsy: Diagnosis of pathological vertebral fracture in elderly age group is usually delayed but sometimes it may be wrongly diagnosed or even missed. Tissue diagnosis is mandatory in all cases. Needle biopsy using Jamshidi needle was done in all suspicious vertebral pathology. Biopsy material was sent for gram stain, Ziehl-Nielson stain, Pus culture and sensitivity, and histopathological examination. Acid fast bacteria culture was advised in relevant cases ( not responding to treatment and MDR Tb ). Gene expert study ( PCR ) for tuberculosis was done in last 2 years only. Needle biopsy was positive in 218 ( 84.49% ) cases. Repeat biopsy was required in 39 cases where Fine Needle Aspiration Cytology (FNAC) was inconclusive. Core biopsy was done in all these 39 cases using large bore Jamshidi needle and it showed malignancy in 19 cases and tuberculosis in 20 cases. In 11patients who had an unbiopsied vertebral lesion initially as primary lesion was confirmed, and not responding to chemotherapy or radiotherapy, a subsequent vertebral biopsy was done. 5 of these patients were diagnosed to have a tuberculous lesion. 27 vertebral collapse initially thought to be osteoporotic on radiological imaging ( MRI and DEXA ) but not responding to osteoporotic treatment were reevaluated by biopsy and turned out to be Koch’s spine in 21 cases and neoplastic in 6 cases. 17 patients who were put on AKT for Koch’s spine but not responding were reevaluated by biopsy and report turned out to be malignant lesion.

Management

60 patients (58 TB spine and 2 pyogenic infection) were managed without surgery and the remainder 197 patients underwent surgical intervention. Non surgical management comprised of bed rest, analgesics, bracing, anti microbial regimen according to pathogen in case of infective lesions.
The 58 patients of tubercular spondylitis were treated by ATT, 4 drug regimen ( Rifampicin, Isoniazide, Ethambutol, Pyrazinamide ) for 3 months, 3 drugs for 3 months, 2 drugs for 3 months. In 2 cases of pyogenic osteomyelitis culture sensitivity specific antibiotics were given intravenously for 2-3 weeks followed by orally for 6 weeks. CBC, CRP, ESR, LFT and RFT were done at regular interval to modify the dosage in all these old age patients.
In MDR cases second line drug therapy was administered and monitored by the Infectious disease specialist.
101 infective lesions were managed surgically ( 92 primary and 9 revision ).
53 patients of spinal tuberculosis were operated by posterior decompression and fixation. 28 patients underwent surgery by posterolateral extrapleural approach and anteroposterior reconstruction. 13 patients were operated by anterior approach for decompression and reconstruction. 7 patients required a combined surgery and reconstruction by anterior and posterior approaches.
All 97 neoplastic vertebral lesions required surgical intervention. Out of 24 primary malignant lesions 3 (out of 7) solitary plasmacytoma were removed enblock, rest all 21 cases were managed by intralesional removal of tumor mass. Pre operative embolisation was done in all vascular tumors ( Solitar plasmacytoma and spindle cell sarcoma ). 1 multiple myeloma and 2 implant related complications required revision surgery.
Out of 73 metastatic vertebral lesions, Vertebroplasty was done in 29 patients, kyphoplasty was done in 6 cases and surgery was done in 38 cases. En block removal was done in 4 patients while in rest 34 cases intralesional removal of tumor was done. Pre operative embolisation was done in all 38 operated cases. 7 cervical and 9 thoracolumbar lesions were operated by anterior approach, 13 thoracolumbar and lumbar lesions were operated by posterior approach, while 9 cases of thoracolumbar and lumbar lesions were dealt by combination of both anterior as well as posterior approach. All 38 operated cases of vertebral metastases were stabilized by at least 2 levels above and 2 levels below with cementation of involved vertebra in posterior approach and anterior reconstruction using cage with autograft.
Chemotherapy and/or radiotherapy was administered according to neoplastic pathology. Post operatively all malignant cases were put on bisphosphonate therapy.
Complications: 4 out of 197 surgically operated elderly morbid patients died in the perioperative period.
Neurological and / or functional improvement was seen in 185 operated cases. Frankel grade B 3 patients improved to grade C in 1 and grade d in 2 cases. Frankel grade c 14 cases showed no improvement in 3 cases, 9 improved to grade D and 2 improved to grade E. Out of 51 Frankel grade D, 4 patients didn’t show much improvement but 37 fully recovered. Operated Koch’s spine all patients showed neurological improvement.
Mean survival time in primary malignancy cases was 36.2 months, while in metastatic cases it was 14.3 months. 7 patients developed recurrence at same level after mean time of 9 months, out of those 2 patients developed paraplegia.

Discussion

Atraumatic vertebral collapse is a common clinical problem, especially in elderly population (1). Osteoporotic vertebral fracture is the major cause in such elderly population. The prevalence of osteoporotic vertebral fractures varied from about 3% in the age group below 60 to about 19% in the 70+ group in women, and from 7.5% to about 20% in men, with an overall prevalence of 11.8% in women and 13.8% in men (7). Among other causes of pathological collapse in the elderly, infective lesions are also common with neoplastic lesions being on the higher side. A fairly high index of suspicion is necessary when dealing with vertebral collapses in the elderly population.
Infection of spine is still a mojor health issue in developing countries. Poor hygiene, poverty, unawareness, poor ventilation along with that other co-morbidities make elderly individual more prone for the infection especially tubercular in developing countries.

With ageing bony trabeculae becomes weak and osteoporotic vertebral collapse become more prevalent. Because the spine has a load-bearing and a nerve-protecting function, failure of its structural integrity as a result of pathological vertebral involvement often brings about severe pain and/or paralysis. These symptoms impair the ambulatory ability of the patients and worsen their quality of life. One of the main causes of severe pain or paralysis is pathologic vertebral body collapse caused by an osteolytic lesion. Therefore, prevention and treatment of collapse is a key factor in maintaining the patients’ ambulatory ability especially in morbid elderly population (3,4,5,6). So early diagnosis of such conditions is very important to start with proper treatment.
Tan DY et al., studied 58 vertebral collapse out of which he found 36 benign vertebral collapses (20 osteoporotic, 7 post-traumatic, 9 infective) and 22 malignant ones (20 metastatic carcinoma, 2 multiple myeloma). In our study we found Infective pathology in 161 (62.89%) [ 13 pyogenic, 130 tubercular, 7 atypical tubercular, 5 MDR tubercular, 2 fungal, 4 hydatid cyst ] and neoplastic lesions in 97 (37.89%) [ 24 primary malignant ( 13 multiple myeloma, 7 solitary plasmacyetoma, 3 lymphoma, 1 spindle cell sarcoma ) and 73 metastases ].The most frequent spinal metastases (60%) are from breast, lung, or prostate cancer (15).

Any elderly patient presenting with intractable back pain especially at night, weight loss and other constitutional symptoms without any history of trivial injury then think of pathological vertebral lesion. Any vertebral collapse detected on a radiograph must initially undergo MRI and routine blood investigations, followed by a DEXA scan to rule out osteoporosis. Even though DEXA scan is indicating osteoporosis it doesn’t always rule out infection or malignancy. In our study we found 27 patients with osteoporotic vertebral collapse, who didn’t respond to osteoporotic treatment and later on confirmed by biopsy as malignancy in 6 cases and infection in 21 cases.
Typical spinal tuberculosis affects the continuous vertebral levels and causes narrowing of the adjacent disc space and bone destruction (8). However, Atypical tuberculous spondylitis shows spondylitis without discitis, isolated central lesion in single vertebral body, non-contiguous skip vertebral body lesions, isolated posterior vertebral elements involvement and isolated intraspinal canal lesions. Atypical form of spinal tuberculosis is difficult to distinguish from malignancy, leading to misdiagnosis and inadequate treatment. Pyogenic and fungal spondylitis, sarcoidosis, metastasis and lymphoma are the close differential diagnosis for tuberculous spondylitis (10, 11).
Differentiating tuberculous spondylitis from these conditions is very important since the line of management completely differs and also early intervention helps in minimizing the residual spinal deformity and permanent neurological deficits (12). Tan DY et al. stated that features which pointed to malignant cause were hypointense marrow on T1-weighted images, marrow enhancement after intravenous contrast, greater than 50% marrow involvement and involvement of posterior elements. Of the vertebral collapses due to infection, 78% showed end-plate disruption(14). Image guided biopsy is very helpful for early diagnosis and prompt intervention if the clinical and imaging findings are not very helpful arriving diagnosis, especially with the atypical presentations (13).
Biopsy: Diagnosis of pathological vertebral fracture in elderly age group is usually delayed but sometimes it may be wrongly diagnosed or even missed. Tissue diagnosis is mandatory in all cases. Needle biopsy is the procedure of choice in definitive diagnosis of pathologic lesions of the spine (17). Needle biopsy is positive in 65% for lytic lesions, incisional biopsy is useful in 85% of blastic lesion while excisional biopsy is positive in >85% for posterior lesions and benign tumors. The percentage of positive results of biopsy are higher in metastases than primary tumors. The cystic and sclerotic vertebral tumors have less positive results. Transpedicular biopsy with Jamshidi needle has better success rate than FNAB in such lesions.
Once tissue diagnosis is done by biopsy then one should go ahead with other investigations such as CRP, ESR, Procalcitonin for infective pathology. For Neoplastic lesions one should do specific tumor markers and screening of whole body to rule out metastases elsewhere.
All Patients with spinal tuberculosis are started on antituberculosis treatment as Tuberculous spondylodiscitis is primary medical problem. Surgery reserved only for the patients with complications or potential complications (9). Only the patients who had lost neurological power to Frankel grade A,B,C,D or with sphincter involvement were advised surgery. 11 patients who did not show good response to ATT after 3 months were also operated. 17 patients who had progressive kyphosis and instability due to more than 2 vertebral level involvement were also advised surgery. Operative management gives satisfactory results in elderly patients with tuberculous spondylodiscitis (21). Single level involvement of spinal tuberculosis can be very well dealt by posterior approach only ( Transpedicular decompression, 2 level above and 2 level below fixation and shortening). The posterior approach provides adequate exposure for decompression and rigid fixation, providing satisfactory clinical and radiological outcomes (21).
2 level involvement requires pasterolateral extraplueral approach for decompression and reconstruction ( 3 or 4 level above and below ). In case of more than 2 levels are involved one should think of anterior or anterior and posterior approach for thorough decompression and stabilization of segment involved.
The pathological fractures due to neoplastic inlvolvement require a thorough check up to determine the general condition of the patient, staging and grading of the tumor, life expectancy , anticipated hospital and ICU stay etc. The indications for surgery for primary lesions are neurological deficit, instability, intratctable pain, radioresistant tumor and not sensitive to chemotherapy. The metastatic lesion may need surgery for severe pain, progressive neurogical deficit, instability affecting ambulatory ability or solitary metastases where in complete excision may be advocated.
The decision of surgery in malignant or metastatic lesion is taken only if the general condition allows the patient to recover without significant postoperative morbidity or ICU stay.
Vertebroplasty or kyphoplasty is the modality used in such inoperable painful collapse. Transpedicle body augmenter Vertebroplasty proved to be safe and effective in reducing pain andimproving functional status of patients with spinal tumor (18). Percutaneous Vertebroplasty (PVP) can be an effective treatment for metastatic spinal tumors in patients even with posterior wall deficiency (16).
Takayuki Yamashita stated that palliative surgery benefited half of the patients with metastatic spinal tumor, with a greater probability of benefit found in persons with a higher total revised Tokuhashi score (score 9–15) and/or primary cancers with longer survival times (19).
The modified Tokuhashi scoring system is used to decide the operability of the tumor.
The type of surgery and approach is decided depending upon primary or metastasis, extent of involvement of vertebra (Tomita classification) and expected morbidity of the surgery. The response of the tumor to radiotherapy and chemotherapy is also an important factor in management. David W. Polly et al concluded that there is a strong recommendation for posterior or posterolateral approach from T2 through T5. For the T6–L5 regions of the spine we recommend either anterior, posterior, or combined anterior and posterior surgery depending on the clinical presentation, surgeon and patient preference (20).

Hormonal treatment and immunotherapy may play an important role in certain tumors like Ca breast, ovary. In some inoperable tumors management to control pain is very important.
The pathological fractures in elderly can be managed by the following algorithms.


References

1. Cicala D, Briganti F, Casale L, et al. Atraumatic vertebral compression fractures: differential diagnosis between benignosteoporotic and malignant fractures by MRI. MusculoskeletSurg 2013;97(Suppl. 2):169–79.
2. Asdourian PL. Metastatic disease of the spine. In: Bridwell KH, DeWald RL, eds. The Textbook of Spinal Surgery. Philadelphia, JB Lippincott, 1991:1187-242. [Context Link]
3. Cybulski GR. Method of surgical stabilization for metastatic disease of the spine. Neurosurgery 1989;25:240-52. Buy Now Bibliographic Links [Context Link]
4. Hammerberg KW. Surgical treatment of metastatic spine disease. Spine 1992;17:1148-53. [Context Link]
5. Sundaresan N, Galicich JH, Lane JM. Harrington rod stabilization for pathological fractures of the spine. J Neurosurg 1984;60:282-6.Bibliographic Links [Context Link]
6. Matsubayashi T, Koga H, Nishiyama Y, et al. The reparative process of metastatic bone lesions after radiotherapy. Japan J ClinOncol 1981;11(Suppl):253. [Context Link]
7. Svanhild Waterloo, Luai A Ahmed et al. Prevalence of vertebral fractures in women and men in the population-based Tromsø Study. BMC Musculoskeletal Disorders 2012, 13:3
8. Naim-Ur-Rahman, El-Bakry A, Jamjoom A, et al. Atypical forms of spinal tuberculosis: case report and review of the literature. Surg Neurol. 1999;51(6):602- 07.
9. Rasouli MR, Mirkoohi M, Vaccaro AR, Yarandi KK, Rahimi-Movaghar V. Spinal Tuberculosis: Diagnosis and Management. Asian Spine J. 2012;6(4):294–308.
10. Jung NY, Jee WH, Ha KY, Park CK, Byun JY. Discrimination of tuberculous spondylitis from pyogenic spondylitis on MRI. AJR Am J Roentgenol. 2004;182(6):1405-10.
11. Khattry N, Thulkar S, Das A, Alan Khan S, Bakhshi S. Spinal tuberculosis mimicking malignancy: Atypical imaging features. Indian J Paediatr. 2007;74(3):297-8. PMID: 17401273.
12. Moore SL, Rafii M. Imaging of musculoskeletal and spinal tuberculosis. RadiolClin North Am. 2001;39(2):329-42.
13. Momjian R, George M. Atypical Imaging Features of Tuberculous Spondylitis: Case Report with Literature Review. J Radiol Case Rep. 2014;8(11):1–14.
14. Tan DY , Tsou IY , Chee TS. Differentiation of malignant vertebral collapse from osteoporotic and other benign causes using magnetic resonance imaging. Annals of the Academy of Medicine, Singapore [2002, 31(1):8-14]
15. Max Aebi. Spinal metastasis in the elderly .Eur Spine J (2003) 12 (Suppl. 2) : S202–S213
16. Hongpu Sun et al Safety of percutaneous vertebroplasty for the treatment of metastatic spinal tumors in patients with posterior wall defects. Eur Spine J (2015) 24:1768–1777
17. J. Tehranzadeh, C. Tao & C. A. Browning (2007) Percutaneous Needle Biopsy of the Spine, Acta Radiologica, 48:8, 860-868.
18. Anna F-Y. Li, Kung-Chia Li, Fang-Yuan Chang and Ching-Hsiang Hsieh. Preliminary Report of Transpedicle Body Augmenter Vertebroplasty in Painful Vertebral Tumors. SPINE Volume 31, Number 21, pp E805–E812 ©2006.
19. Takayuki Yamashita, Yoichi Aota et al Changes in Physical Function After Palliative Surgery for Metastatic Spinal Tumor Association of the Revised Tokuhashi Score With Neurologic Recovery. SPINE Volume 33, Number 21, pp 2341–2346 ©2008
20. David W. Polly, Jr, Dean Chou et al. An Analysis of Decision Making and Treatment in Thoracolumbar Metastases. SPINE Volume 34, Number 22S, pp S118–S127 ©2009.
21. Manish Kothari, Kunal Shah, Agnivesh Tikoo, Abhay Nene. Short to Mid-Term Term Surgical Outcome Study with Posterior Only Approach on Tuberculous Spondylodiscitis in an Elderly Population. Asian Spine J 2016;10(2):258-266.


How to Cite this Article: Parasnis R, Thumbadiya A, Pathak S, Patil S. Management of Pathological vertebral collapse in elderly. International Journal of Spine Sep-Dec 2016;1(2):22-26.


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Taking IJS Ahead

Volume 1 | Issue 2 | Sep – Dec 2016 | Page 1-2 | Ketan Khurjekar [1], Shailesh Hadgaonkar [1], Ashok Shyam [1,2]


Authors : Ketan Khurjekar [1], Shailesh Hadgaonkar [1], Ashok Shyam [1],[2]

[1] Sancheti Institute for Orthopaedics &Rehabilitation, Pune, India
[2] Indian Orthopaedic Research Group, Thane, India

Address of Correspondence
IJS Editorial Officie
A-203, Manthan Apts, Shreesh CHS, Hajuri Road, Thane [W]
Maharashtra, India.
Email: editor.ijspine@gmail.com


International Journal of Spine has made its mark from the release of first issue and in the second issue we have tried to make it better. As mentioned in the first editorial IJS has two main focus points, Research as well as Education. Currently most of the journals are focussed on research based articles and almost 90% of their publication is original articles. IJs is planned to take a different route where we wish to include equal amount of educational material in the journal.
Every issue of IJS is planned to contain a symposia on a specific topic. These symposia are solicited from leading spine surgeons in the field and are formatted in form of a review article which is easy to read. We encourage authors to include case based scenarios in the review which become much easier to relate to a clinician unlike articles full of statistics. The symposium are created in such a way that even small topics related to the scope of symposia are given adequate space and not become part of foot note. This approach will help general orthopaedic surgeons also who wish to refresh their knowledge and update themselves in the field of spine surgery. This will be especially useful to students who can get collection of articles on single topic written by best authors at one place. We will continue this trend of symposia in all future issue of IJS and invite suggestions from our readers for the topic of symposia. We also invite interested surgeons who wish to be symposium editors to contact the editorial office.
Short narrative reviews and literature updates also form the education element in IJS. One narrative review is published in this issue and from next issue the literature updates will start. It will include summary of most important articles and research that are published in other spine journals and are of practical importance to our readers. Original research articles and case reports will continue to be published in the journal but with strict review guidelines and will follow all ethical standards
From this issue we have started a new feature called ‘Interview’. IJS intends to interview the role models in field of spine surgery, especially people who inspire us to achieve excellence. The aim is to know them better and to understand their though process. We can learn many things from them even outside orthopaedics and this aspect comes out beautifully in the current interview of Dr S Rajasekaran. He was gracious enough to give us his precious time and share with us his knowledge and principles that he follows in his life. We believe this interview will inspire many and everyone will learn something valuable from it. The interview was almost two hours long and in this issue we could include only the part of the interview. The second part will be published in the forthcoming issue. We wish to continue this feature and will be interviewing many more stalwarts in the field of Spine surgery.
IJS is receiving more and more submissions each day and we wish to continue publishing good quality articles. We will appreciate any suggestions of comments, please write to us by email to editor.ijspine@gmail.com.

Dr. Ketan Khurjekar | Dr. Shailesh Hadgaonkar | Dr. Ashok Shyam


How to Cite this Article: Khurjekar K, Hadgaonkar S, Shyam A. Taking IJS Ahead. International Journal of Spine Sep – Dec 2016;1(2):1-2.

1


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Positive Sagittal Balance and Management Strategies in Adult Spinal Deformities

Volume 1 | Issue 1 | Apr – June 2016 | Page 33-38|Charanjit Singh Dhillon1


Authors :Charanjit Singh Dhillon[1]

[1] MIOT Center for Spine Surgery, MIOT International, Chennai

Address of Correspondence
Dr Charanjit Singh Dhillon. MS, DNB, FNB Spine, D-Ortho,
Director MIOT Center for Spine Surgery, MIOT International, Chennai. India
Email: drdhillonc@hotmail.com


Abstract

Human Spine has adapted a curved morphology to compensate for the upright posture. Normally these curves are sagittally balanced and a vertical line drawn from the center of the C7 vertebral body (the C7 plumb line) passes within a few millimeters of the posterior-superior corner of S1. A positive sagittal balance occurs when the C7 plumb line falls anterior to the posterior-superior corner of the S1 endplate. The extent of imbalance is measured as centimeters of deviation of the C7 plumb line (also known as Sagittal vertical axis- SVA) from the posterior-superior corner of the S1 endplate[4](Figure 2). Negative sagittal balance is much less common in clinical practice and rarely warrants surgical attention. In this article we shall deal with only positive sagittal balance which is encountered more often. The article covers the diagnosis and also details of surgical management. In absence of effective conservative measures, the patient seeking surgical remedies are on rise. Selecting the appropriate surgical technique to achieve spinal balance is crucial to success.
Keywords: Positive Sagittal Balance, Smith-Petersen Osteotomy, Pedicle Subtraction Osteotomy, Vertebral Column Resection


Introduction
Ever since man has assumed an erect posture and bipedal gait, a series of morphological changes have taken place in the homosapien vertebral column to adapt to this new challenge of upright posture. One of the most distinctive adaptive changes seen in human spinal column has been the assumption of a gentle ‘S’ curve in sagittal plane with thoracic kyphosis [TK] interposed between cervical and lumbar lordosis [LL]. These curves work like a coiled spring to absorb shock, maintain an upright balance and allow the spine to withstand great amounts of stress than what a straight column would otherwise absorb. At the same time it still allows for a wide range of movements in the cervical and the lumbar region to optimize the use of extremities while still maintaining an upright stance with the head centered over the pelvis and finally over both feet. In most individuals with a disease free and deformity free sagittally balanced spine, a vertical line drawn from the center of the C7 vertebral body (the C7 plumb line) passes within a few millimeters of the posterior-superior corner of S1[1] (Fig. 1).

Figure 1 and 2

This is the most ergonomically favorable position for the spine to maintain an erect posture in the most energy-efficient manner. However, with progressively larger deviations from this ideal position, the endeavor to remain upright increases exponentially, thereby warranting greater muscular effort and energy to maintain standing balance[2]. By convention, positive sagittal balance occurs when the C7 plumb line falls anterior to the posterior-superior corner of the S1 endplate. Conversely, negative sagittal balance occurs when the C7 plumb line falls posterior to this point[3]. The extent of imbalance is measured as centimeters of deviation of the C7 plumb line (also known as Sagittal vertical axis- SVA) from the posterior-superior corner of the S1 endplate[4](Fig. 2). Negative sagittal balance is much less common in clinical practice and rarely warrants surgical attention. In this article we shall deal with only positive sagittal balance which is encountered more often.

Causes
Positive sagittal imbalance can occur due to destruction of the vertebral body by trauma, tumor or infection. It may also result from loss of LL as a consequence of multilevel degenerative disc disease, ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis or osteoporosis[5]. Secondary causes include iatrogenic flat back syndrome resulting from failure of restoration of the appropriate LL according to the patient’s Pelvic incidence[PI]. Rarely, sagittal imbalance may be seen following spinal fusion surgery through an area of pseudarthrosis or through a degenerated segment adjacent to a previous fusion. In the past the use of distraction instrumentations such as the Harrington rods was the frequent cause of iatrogenic flat back syndrome[6]. Positive sagittal imbalance due to congenital deformities is outside the preview of this symposium on adult deformities.

Compensation
Barrey et al. [7] described three stages of compensatory mechanisms corresponding to the severity of the sagittal imbalance: balanced, balanced with compensatory mechanisms and imbalanced spine. In the initial stages when positive sagittal imbalance begins, the pelvis retroversion takes place in an attempt to push the C7 plumb line backwards behind the femoral heads resulting in extension of the hips[7-9]. At this stage the PI determines the global capacity of pelvis retroversion and consequent compensatory capability. In patients with higher PI the pelvis can tilt more and compensate better than patients with a low PI[10]. The full body is now balanced but it is a compensated balance, which is less efficient[11]. At the same time the posterior spinal muscles act as a posterior tension band (trying to restore some LL) pulling the adjacent segments of the lower dorsal spine into hyperextension. In young patients with flexible spines this hyperextension leads to reduction of TK. Spine hyperextension is an energy consuming process that generates increase of stresses on posterior structures resulting in risk of retrolisthesis, facet joints overstress and even sometimes isthmic lysis (Fig. 3) [11]. When pelvis retroversion and spine hyperextension are not enough to keep the C7 plumb line behind the femoral heads, the only solution to keep the gravity line between the two feet is to bend the knees. This process needs good psoas and quadriceps muscles activity, which is again energy consuming and not an efficient situation. When the knee flexion also fails to keep the C7 plumb line behind the femoral heads, a stage of decompensation (imbalance) is reached and an external aid (e.g., crutches, walker) is often required to maintain upright posture[11].

Figure 3

Imaging Studies
Standard full-length anteroposterior and lateral radiographs should be performed in all patients with suspected sagittal imbalance. Horton et al[12] reported the ‘clavicle position’ in which the patient stands with both hips and knees fully extended, the elbows fully flexed, the wrists flexed with the hands in a relaxed fist placed into the supraclavicular fossa without any external support as the best patient position for the study of sagittal deformity. Sagittal imbalance is basically determined by the C7 plumb line offset from the posterior-superior corner of S1 (Fig. 2). An offset >2.5 cm anteriorly or posteriorly is considered to be abnormal[13]. Different components such as TK, LL and PI are also measured to define the overall sagittal balance[14]. Dynamic lateral radiographs with the spine in full flexion and full extension helps to assess the mobility of discs in the kyphotic segment and hence plan appropriate surgical management. Alternately, some surgeons use traction views to assess spine mobility.

Management
Nonsurgical Management
Symptomatic patients with sagittal imbalance are often unresponsive to nonsurgical treatment. Physical therapy programs, bracing, facet joint injections, selective nerve root blocks and epidural steroid injections[15] are often ineffective in decompensated patients.

Surgical Management
Surgery is the mainstay of treatment for patients with sagittal deformity[15]. Indications include failure of nonsurgical treatment, kyphosis progression, significant back pain, radicular symptoms and exhaustion due to effort to maintain upright stance. The goals of surgery are to achieve a solid fusion with a balanced spine in both sagittal and coronal planes, relieve pain, and prevent progression of imbalance. Several studies have shown that adequate restoration of sagittal plane alignment is necessary to significantly improve clinical outcome and avoid pseudarthrosis[16,17]. Prior to surgery, the patient should be evaluated for risk factors such as pulmonary and cardiac disease, osteoporosis, smoking, and malnutrition. Careful consideration should be given to especially elderly patients due to higher incidence of pseudarthrosis and complications[17,18]. Relative contraindications to major spinal reconstructive surgery include psychiatric disease, uncontrolled diabetes, osteoporosis, substantial cardiopulmonary disease, and poor family or social support[19]. Flexibility of the spine should be assessed radiologically using long-cassette standing and supine AP and lateral radiographs and lateral dynamic flexion and extension radiographs. Patients’ standing sagittal imbalance may decrease in supine or prone position due to mobile segments. Bridwell[20] classified spinal deformities into three categories based on curve flexibility: totally flexible, partially flexible through mobile segments, and fixed deformity with no correction in the recumbent position. Flexible deformities can be addressed with anterior-posterior or posterior only surgery not requiring any osteotomy[6]. Sagittal balance is improved by lengthening the anterior column, either through an anterior or a posterior approach, using cages, structural allograft or autograft. The posterior column is then shortened with laminectomies (when there is evidence of stenosis), facetectomies and fusion with compression instrumentation to correct kyphosis. Fixed deformities can be managed by anterior-only, combined anterior and posterior or posterior-only approaches. Spinal osteotomies like the Smith-Petersen osteotomy[SPO], pedicle subtraction osteotomy [PSO], and vertebral column resection[VCR] are often employed to correct the stiff apical kyphotic segment. The amount of correction needed determines the type of osteotomy warranted (Fig. 4). With recent advances in instrumentation and techniques, posterior-only approaches have become more popular. Numerous studies support the safety and efficacy of a posterior-only approach for the treatment of most spinal deformities[21,22]. Fusion across the L5-S1 junction is mandatory in the presence of lumbosacral pathology, such as postlaminectomy defects, lumbar spinal stenosis, oblique take-off of L5, and L5-S1 disc degeneration to reduce the risk of pseudoathrosis and loss of fixation[22].

Figure 4

Smith-Petersen Osteotomy [SPO]
In 1945, Smith-Petersen and associates[23] were the first to describe a posterior osteotomy for correction of fixed sagittal deformity in patients with rheumatoid arthritis. In 1946, La Chapelle[24] described a modification of Smith-Petersen’s technique by adding an anterior release in a case of ankylosing spondylitis. The use of this osteotomy for the treatment of flat back deformity was first reported by Moe and Denis in 1977[25]. In 1984 Ponte[26] described multiple chevron osteotomies with spinal instrumentation in a patient with Scheuermann’s disease.

The surgical technique involves removal of all the posterior ligaments (supraspinous, interspinous, and ligamentum flavum) and facets to produce a posterior release. Dissection is then performed laterally to decompress the nerve roots. The lamina is beveled to allow sufficient room for the dura and nerve roots after closure of the osteotomy. The osteotomy hinges at the posterior border of the vertebral body and creates hyperextension by closing the posterior elements and opening the anterior elements providing sagittal plane realignment. Posterior segmental pedicle screw instrumentation is used to maintain closure of the osteotomy (Fig. 5). It should be emphasized that either a mobile disc or an anterior release is required to allow lengthening of the anterior column.

Figure 5 and 6
The SPO should be considered for patients with C7 plumb line that is less than 7 cm positive[27]. Amount of correction provided by a single SPO is in the range of 4-10° depending on the disc height and the mobility of the disc. One degree of correction is usually achieved per millimeter of bone resected posteriorly[27]. The SPO is technically easier and safer than other osteotomies offering a reduction in operative time, blood loss and risk of neurological complications, although rupture of the great vessels has been reported following anterior-column lengthening in an unfortunate case[23].For the patient requiring 10° to 20° of lordosis or 6-8 cm of correction of the C7 plumb line, it is more appropriate to perform multiple SPOs than one PSO, unless the fixed deformity is fused anteriorly[27].

Pedicle-Subtraction osteotomy [PSO]
In 1963, Scudese and Calabro[28] were the first to describe a monosegmental intravertebral closing wedge posterior osteotomy of the lumbar spine. Later, Thomasen[29] reported on 11 patients with ankylosing spondylitis treated with posterior closing wedge osteotomies. In the same year, Heining et al[30] described an eggshell osteotomy as a variant of the PSO. The PSO is performed by removing the posterior elements and both pedicles, performing a transpedicular V shaped wedge osteotomy of the vertebral body, and closing the osteotomy by hinging on the anterior cortex (Fig. 6) achieving bone-on-bone contact in the posterior, middle, and anterior columns[31]. Central canal enlargement is critical to avoid neurologic injury during closure of the osteotomy. Posterior segmental pedicle screw instrumentation is used to maintain the correction. Instrumentation of at least three vertebral levels above and below the osteotomy is recommended[32]. The PSO has the advantage of obtaining correction through all the three spinal columns, while the posterior and middle columns shorten, this osteotomy does not lengthen the anterior column avoiding stretch on the major vessels and viscera anterior to the spine[33]. An average of 30º to 40º correction can be achieved with one level PSO[34]. The ideal candidates for a PSO are patients with a fixed sagittal imbalance of more than 10 cm and those patients who have circumferential fusion along multiple segments, which would contradict multiple SPOs(Fig. 7)[27].

Figure 7

Although PSOs are more technically demanding and more prone to complications than SPOs, PSOs provide satisfactory clinical and radiologic outcomes in long-term follow-up. Kim et al[34] in a series of 35 PSOs reported their good results with 87% patient satisfaction and 69% restoration of function after more than 5 years of follow-up. Cho et al[35] compared one level of PSO with three levels of SPOs in their study and reported that an average total kyphosis correction was 31.7º for PSO group and the improvement in the sagittal imbalance (11.2 ± 7.2 cm) was much better than multiple SPOs. Blood loss was significantly higher in PSO group but there was no statistical difference between one level PSO and three levels of SPO groups with respect to operating times. Regarding neurological complications, Buchowski et al[36] reported a postoperative immediate neurological deficit rate of 11.1% which subsequently reduced to 2.8% during follow up. Deficits were mostly unilateral and never proximal to osteotomy site, often did not correspond to the level of osteotomy, and surprisingly were not detected by neuromonitoring[36].

Figure 8

Vertebral Column Resection [VCR]
VCR was first described in 1922 by MacLennan[37] as a combined anterior and posterior procedure and was popularized by Bradford and Tribus[38] as a method of correcting severe coronal deformity and combined coronal and sagittal deformity. It is indicated in rigid severe deformities of the spine such as congenital kyphosis, rigid multiplanar deformities, sharp angulated deformities, posttraumatic deformities and spondyloptosis. The VCR technique is a challenging procedure involving the complete resection of the posterior elements and the vertebral body including adjacent discs of one or more levels (Fig. 8) providing controlled manipulation of both the anterior and posterior columns simultaneously. It can be performed using either combined anterior and posterior approaches or a posterior-only approach[39]. Of all the spinal osteotomies, VCR provides the greatest amount of correction. Suk et al[40] reported a correction of 61.9o in the coronal plane and 45.2o in the sagittal plane in their series of 70 patients after VCR. In their series of 35 patients, Lenke[41] reported major curve improvements of 55o in global kyphosis cases, 58o in angular kyphosis cases and 54o in kyphoscoliosis cases after VCR. Vertebral column resection through a posterior-only [PVCR] approach has become popular in the recent years. Suk[40] and Lenke[41] popularized the use of PVCR for severe deformities of the spinal column. PVCR enables simultaneous manipulation and control of both anterior and posterior spinal columns and thus provides better correction than other types of osteotomies. It is a single procedure compared to combined anterior and posterior VCR, reducing the total operating time and the amount of blood loss and also avoiding opening of the thoracic cage and pleura. Avoiding anterior surgery may be very beneficial for patients with severe pulmonary function compromise because of severe thoracic deformity[27]. Inspite of all advantages, PVCR is a technically demanding procedure. One major concern with PVCR is the potential for neurologic complications, which may result from direct neurologic injury during bone resection or deformity correction. Neurologic complications may also result from subluxation of the spinal column, dural buckling and compression of the spinal cord by residual bone or soft tissues in the canal after correction[27]. Suk[40] reported a 34.3% overall rate of complications and a 17.1% rate of neurological complications. Lenke[41] reported a similar 40% overall rate of complications and an 11.4% rate for neurological complications. Hamzaoglu[39] reported neurological complications of 7.84%.

Figure 9


Conclusions

With rising life expectancy the number of patients seeking consultation for pain due to sagittal imbalance is increasing. In the absence of effective conservative measures, the patient seeking surgical remedies are on rise. Selecting the appropriate surgical technique to achieve spinal balance is crucial to success. SPO, PSO and VCR all play an important role in the armamentarium of the spine deformity surgeon. However, each of these procedures are technically demanding and carries a certain amount of risks. Appropriate preoperative optimization of the patient as well as preoperative surgical planning are critical in order to avoid potential complications. Surgical achievement of the ideal spinopelvic alignment parameters is the desired goal. Nevertheless, even a partial improvement in these parameters is very likely to translate into substantial clinical benefits.


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How to Cite this Article: Dhillon CS. Positive sagittal balance and management strategies in adult Spinal deformities. International Journal of Spine Apr – June 2016;2(1):33-38 .

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