Efficacy of Transforaminal Steroid Block for Pain Relief Due to Recurrent Lumbar Disc Herniation in Previously Operated Case of lumbar Discectomy

Volume 8 | Issue 1 | January-June 2023 | Page: 02-07 | Chandrasen Chaughule, Nitin Bhalerao, Anjaney Karangutkar, Jay Date, Sanket Tanpure, Srishti Tiwari

DOI: https://doi.org/10.13107/ijs.2023.v08.i01.44

Authors: Chandrasen Chaughule [1], Nitin Bhalerao [1], Anjaney Karangutkar [1], Jay Date [1], Sanket Tanpure [1], Srishti Tiwari [2]

[1] Department of Orthopaedics, Dr. Vikhe Patil Medical College, Ahmednagar, Maharashtra, India.
[2] Department of Anaesthesia, Dr. Vikhe Patil Medical College, Ahmednagar, Maharashtra, India.

Address of Correspondence
Dr. Chandrasen Chaughule,
Assistant Professor, Department of Orthopaedics, Dr. Vikhe Patil Medical College, Ahmednagar, Maharashtra, India.
E-mail: csfever10@gmail.com


Background: lower Back discomfort as a result of a herniated disc is quite prevalent worldwide, frequently resulting in missed work days and significant changes in affect and motivation. Recurrent lumbar disc herniation is one of the most common problem faced after a lumbar discectomy, most frequently seen among male gender, tall-heighted individuals, heavy workers, obese and smokers. Analgesic and anti-inflammatory medication is the initial course of treatment. But in the majority of instances, it progresses slowly and calls for surgical intervention or minimally invasive treatments like steroid injections.
Aims and Objectives: The purpose of this study is to determine whether transforaminal steroid block can be attempted before surgery for pain relief in cases of recurrent herniated lumbar disc with failed conservative management having intractable radicular pain.
Materials & Methods: Use of transforaminal selective nerve root block (SNRB) in single level recurrent lumbar disc herniation patients was studied. 40 patients with single lumbar disc herniation, operated with discectomy were studied irrespective of age and sex. All patients were injected with a combination of long acting steroid suspension with local anaesthetic (Bupivacaine-plain) near the affected nerve root via cambins triangle approach and the results were analysed.
Result: Those graded mild, were pain free for up to an average of 5.5 months and those graded moderate had 3.3 months of relief. Patients suffering from extensive disc prolapse had immediate post procedural relief but not in long term. 47.5% patients have had a pain free interval upto 6 months.
Conclusion: Transforaminal SNRB is an excellent alternative for pain relief in patients with recurrent lumbar disc herniation having failed conservative management with intractable lumbar radicular pain. It was also found to be a cost effective alternative and relatively less invasive, with almost no complication.
Keywords: Selective nerve root block, Disc prolapse, Recurrent lumbar disc herniation.



Recurrent lumbar disc herniation is defined as intervertebral disc herniation at the same level with a pain-free interval of more than six months, regardless of ipsilateral or contralateral herniation. There are several frequent pathologies of the spine, with a lifetime prevalence of 5–18%. In some circumstances, it resolves on its own or with the help of analgesic, anti-inflammatory, and physiotherapeutic therapy; nevertheless, it can also progress chronically with serious negative effects on the mind, society, economy, and quality of life. Transforaminal injections of small doses of steroids have lately been used to alleviate lower back pain, however the condition can become chronic and have severe negative effects on the quality of life. Recently, lower back discomfort brought on by a herniated disc has been successfully treated with transformational injection of modest quantities of steroids [1-6].
In both the cervical and lumbar areas, selective nerve root block (SNRB) is used to treat radicular pain brought on by a specific damaged nerve root [7-9]. Therapeutic efficacy needs to be discussed despite claims that it has a low degree of specificity as a diagnostic tool [10-11]. This modality is being used commonly for those with or without significant surgical spinal lesions [12]. Mechanical lesions include various stages of disc prolapse as in ligamentum flavum hypertrophy, facet hypertrophy and degenerative osteophytes causing foraminal stenosis, all leading to the nerve root irritation [13]. Transforaminal nerve root block has proven to be quite a specific procedure with excellent outcomes in cases of lumbar disc herniation. Being a pain-relieving interventional procedure, it also falls in the purview of different medical care specialists, including spine surgeons, radiologists, anaesthesiologists, and pain physicians, and thus the inclusion criteria and as a result, different studies have quite diverse inclusion requirements and patient evaluation standards. Patients in non-manual job (“white collared”) had a poor outcome with SNRB although studies have revealed a higher incidence of LDH in young, male patients engaged in severe manual labour, although the relationship between this finding and the results of LDH treatment is unclear. Significantly greater in patients with low work satisfaction and high stress employment, particularly those with jobs that required them to meet regular time-based deadlines. It has been demonstrated that obesity and a higher BMI are linked to recurrent LDH. Other risk factors are smoking, diabetes, etc. Another theory for the cause of the nerve root pain is an inflammatory reaction to an exposed nucleus pulpous [13]. The idea behind this method is to inject a steroid into the nerve root to minimise inflammation, which will lessen pain intensity. For their anti-inflammatory effects, these medications work through a variety of substrates by inhibiting phospholipase A2 which plays a significant role in the cascade and the pathophysiology of pain. Experimental models demonstrated that betamethasone might decrease the expression of substance P thus leading us to a possible role in pain mediating pathway. In addition, methylprednisolone has demonstrated effects leading to a decrease in edema and venous congestion with reduction of ischemia and pain. However, the actual disease causing the stimulation of the nerve roots is still unknown, thus recurrence is anticipated.
Our goal is to investigate the prognosis following a single dosage of SNRB over the damaged lumbar nerve roots to see its efficacy in reduction of pain in case of recurrent lumbar disc herniation.

Materials and methods
Patients were chosen based on different factors regardless of age and sex. Screening with MRI was done in all patients for identifying the lesion. Only those patients with intervertebral disc lesions affecting a particular lumbar nerve root, who were previously operated were selected for the study. Patients with more of back pain than radicular pain were to be excluded as a part of study also those having symptoms of bilateral and more than one nerve root involvement and those having neuro deficit. Patients’ MRI were graded according to MSU classification for herniated disc [14].
Inclusion criteria. : Patients previously operated for lumbar disc herniation (Endoscopic/ Microscopic) having a unilateral disc prolapse on same or the adjacent side or level, not responding to conservative modalities for more than 3 months and destined to have a revision surgery were included in study. (Fig. 1, 2)

Before the operation, all patients completed the Roland Morris Disability Questionnaire (RMDQ) for back pain, and their results were recorded [15]. Numeric rating scale (NRS) for pain was used to grade pre-procedural pain on doing SLR [16]. Procedure took not more than 15 minutes. The patients which were selected had underwent a micro or open lumbar discectomy, followed by a conservative management plan that included rest and physical therapy but did not help the patients’ symptoms. Since there were no patients in our sample with pathology at any levels other than L4-L5 and L5-S1, L5 and S1 were our target nerve roots. No case of far lateral or foraminal disc prolapse were present, affecting l4 at L4-L5 or L5 at L5-S1. The procedure to direct L5 and S1 nerve root is different. (Fig. 3, 4)

Although there are discrepancies in the position of the C-arm and the direction of exposure change, this procedure is always done under C-Arm control. In the prone position, the patient’s lumbosacral spine is examined. The area has been set up and covered. An antero-posterior (AP) view of the lumbosacral junction is possible with the C-Arm in this posture. Identification of the L5 pedicle on that side in an AP C-Arm picture is required in order to target the damaged L5 nerve root. Normally, the L5 nerve leaves the body below and at the L5 pedicle. The L5 nerve usually exits just inferior to L5 pedicle. Adequate local anaesthetic was infiltrated under the skin 3–4 cm lateral to the inferior border of L5 pedicle where we usually enter. A 20-gauge spinal needle was introduced and directed to a point few millimetres below and lateral to the L5 pedicle where the nerve is usually found. If there is resistance by bony lamina, the needle is walked over the bony lamina to reach the desired point via kambin’s triangle approach. The first dorsal sacral foramen must be clearly visible in order to target the S1 nerve root, hence the C-Arm must be tilted perpendicular to the sacrum. Here the first dorsal foramen, where S1 leaves, is the intended location for the needle. We were very careful not to handle the needle aggressively. The patients were warned about the paraesthesia that would be felt along the path of their radicular pain when the needle would hit the nerve. This is done to stop the needle from injuring the nerve. (Table 1)

Sometimes, when it was difficult to induce paraesthesia, a lateral view was taken to validate the needle’s position. As soon as paraesthesia is elicited, needle is slightly withdrawn and 0.5 ml of an iodine based radiopaque dye is injected to confirm the position of needle [17]. Then a combination of 80 mg of triamcinolone-based suspension with local anaesthetic was injected over the affected nerve root. Post procedural paraesthesia due to local anaesthetic effect is expected. Numeric rating of pain using NRS on doing SLRT was used to analyse immediate effect of this procedure. The majority of patients were discharged on the same day of the treatment and advised to relax and refrain from strenuous activity for the first two days. They were instructed to check in after two days if their symptoms remained the same or one week later if they felt better. Patients were assessed with the Roland Morris Disability questionnaire for back pain, and their results were recorded every week also In the first month following the treatment and then monthly up to 6 months. Those with unchanged symptoms and recurrence went for a subsequent revision surgery and remaining patients were warned about recurrence of symptoms. (Fig. 4, 5)

Roland Morris Disability Questionnaire (RMDQ)

When performing straight leg raises on the afflicted side before the procedure, the mean NRS pain score was 8. The mean pre-procedure Roland Morris Disability questionnaire score was 23, and L5 nerve root was targeted in 32 patients (80%) who had L4 L5 intervertebral disc prolapse. L5 S1 disc prolapse affected 8 patients (20%), where S1 nerve root was involved. after the procedure on doing straight leg raising on the test on the involved side, the mean numbering rating of pain was reduced to 4 which was result of local anaesthetic effect. NRS assessment on doing SLR was done on 2nd day after the procedure for 4 patients who returned with similar pain. It was determined to be one point less or the same as pre procedure status. As per the protocol every patient was to be re-examined after one week and were given the Roland Morris Disability questionnaire for back pain and the score was recorded. At one week, the average RMDQ score was 10.35, which pointed to improvement. Revision surgery was suggested for those who experienced full recurrence in consecutive follow-ups and had RMDQ scores higher than 20. These patients were those who were deemed to be severe and in whom surgery was recommended but they were reluctant to go for surgery. After the first week, all of these patients experienced a near complete recurrence with an RMDQ score of 22 or above. They were informed of their unsatisfactory outcome further they all decided to have surgery. On excluding those 4 patients with recurrence our sample reduced to 36 patients (90%) with a mean RMDQ score of 8.1 by 2 weeks and 6.2 by 3 weeks. Review at one month had 5 patients with RMDQ scores more than 20. As a result they were omitted from study group and thus, reducing our sample size to 31 patients (77.5%). average RMDQ score of the revised study group was 7.8 by 1 month. Next follow up was by 2 months which had 6 patients with RMDQ scores more than 20. They were excluded and our group reduced to 25 patients (62.5%) with mean RMDQ score of 6.8. of the remaining sample size four patients started experiencing symptoms again at 3 months thus, reducing our group to 21 (52.5%). Mean RMDQ score of the remaining 21 was 9. By 4 months, 2 more patients had RMDQ score more than 20. Hence our group reduced to 19 patients (47.5%) with mean 4-month RMDQ score of 8.4. Thus, with a mean RMDQ score of 8.4 after 4 months, our cohort was decreased to 19 patients (47.5%). The average RMDQ score for these 19 patients at 5 months was 11.8; at 6 months, it was 13. After 6 months, patients with non-surgical radiological lesions were offered the option of receiving a second dose of SNRB, and all of them chose to do so. They were informed of our findings and prognosis.

Analysing results showed that 90% patients had improvement by 2 weeks which reduced to 77.5% by 1 month (Table 2). Sequential follow-up showed a consistent decline in the number of patients reporting alleviation. By two months, only 62.5% of patients reported relief, which fell to 52.5% by three months and to 52.5% by four months. Finally, only 47.5% of patients were still pain free at six months, returning gradually to their pre-procedural condition. The final 47.5% of patients had a mild bulging disc to one side. According to our description based on MSU Classification, those graded mild had 5.5 months relief and that graded moderate had 3.3 months relief. Except for the immediate post-procedural relief, those with significant disc prolapse for whom surgery is recommended did not experience any relief.

Lumbar radiculopathy secondary to a recurrent lumbar disc herniation is quite a challenging scenario in orthopaedic clinic. Patients who present with this complaints have an increasing trend. When treating these patients conservatively, results can vary greatly. The majority of patients who previously had a spine surgery initially reject surgery. Such people require a treatment that will at least temporarily reduce their agony. For these patients, SNRB is a critical treatment component. Also considering the morbidity and problems with revision lumbar spine surgery Transforaminal nerve root block has proved to be quite a specific procedure for pain relief with excellent outcomes in cases of recurrent lumbar disc herniation. Being a pain-relieving interventional procedure, it also falls in the purview of different medical care specialists, including spine surgeons, radiologists, anaesthesiologists, and pain physicians, and as a result the inclusion criteria and Patient evaluation differs greatly between trial. The prognosis for these people varies depending on the specific condition still causing the inflammation of the nerve root. Many authors have used methyl prednisolone-based preparations for this purpose [18]. Manchikanti et al demonstrated Transforaminal injections of local anaesthetic with or without steroids might be an effective therapy for patients with disc herniation. However present evidence illustrates the lack of superiority of steroids compared with local anesthetic at 2-year follow-up [22].

Patients with sedentary jobs fared poorly with SNRB. While studies have shown a higher incidence of Recurrent LDH in young, male patients engaging in heavy manual labour, their relationship with regard to the outcomes of LDH management has not been made clear. Studies have also shown that the incidence of LDH was significantly higher in patients who had high-stress jobs, particularly patients whose jobs required them to meet frequent time-based deadlines and patients with lower job satisfaction.
Morgan-Hough et al demonstrated, compared to extruded or sequestrated discs, a confined disc protrusion was almost three times more likely to require revision surgery. In comparison to patients with extruded or sequestrated discs, those with initial protrusions had a much higher straight leg rise and a lower prevalence of favorable neurological symptoms. Since these patients are three times more likely to need revision surgery, they should be excluded from care clinically and treated with a more zealous conservative approach emphasizing need for conservative management in lumbar disc herniations [23].
Study conducted by Kim J et al showed to have a comparison of nerve blocks and surgery that focused on radiological data, which was not previously proposed. According to the study’s findings, patients with disc herniations in the L4-5 that are longer than 6.31 mm may be candidates for surgery, whereas those with disc herniations less than 6.23 mm may benefit from nerve blocks. The threshold values for the radiological variables at 12 months exhibited nearly moderate discriminating power. However the study has limitations even if it is still promising. The study’s patient population was rather small, especially among the elderly, and it was retrospective in nature. Therefore, additional research involving more patients will be required before suggested cut-off values and may be used generally [24].
While performing the procedure the needle should not be handled roughly when the treatment is being performed because we only expect to lightly contact the nerve root. The majority of publications advice against doing this to avoid needle-induced problems, however none occurred in our study [17–20]. Using a quantitative pain rating scale, we assessed pain both before and after the procedure. Since focusing on the functional outcome was our main goal, we chose to employ the Roland Morris Disability Questionnaire. When the patient is unable to attend a follow-up appointment, this strategy can be helpful. according to questionnaire the severity of the prolapse was proportional to number of yes answers by the patient Based on the examination of serial questionnaire score 21, clinical improvement over time can be rated. Early response could not predict the effect after two weeks, as mentioned by a select few other writers. This quick relief may serve as a diagnostic tool to establish that the affected root is the obstructed root and has to be decompressed. It refers to how much relief the patient will get if that specific nerve root is surgically decompressed. Similar outcomes were obtained for those with mild and moderate prolapse, giving the majority of our patient’s time to consider their next course of treatment in case their pain reappears.
To the best of our knowledge, despite the lack of standardised guidelines, the goal of this study is to show how well steroid nerve root block works in treating recurrent lumbar disc herniation. Future large-scale randomised control studies should be conducted for a proper understanding

Numerous factors like tobacco chewing smoking, Lifestyle, obesity, intraoperative technique, and biomechanical factors may lead to occurrence of recurrent disc disease. Steroid nerve tansforaminal root block proved to be an excellent alternative for pain relief in patients with unilateral recurrent lumbar disc herniation, having failed conservative management complaining of intractable radicular pain with unilateral positive straight leg raise test. Considering the morbidity and complications as well as challenges with Revision Lumbar spine Surgery, It seemed a relatively less invasive with almost no complication. Although, the effect is typically unpredictable in its duration of course of pain free interval majority of patients yet it gains a valuable pain free interval in those patients with mild and moderate pathology. Also it proved to be a Cost effective, day care procedure with minimal morbidity with almost no complications.


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How to Cite this Article: Chaughule C, Bhalerao N, Karangutkar A, Date J, Tanpure S, Tiwari S | Efficacy of Transforaminal Steroid Block for Pain Relief Due to Recurrent Lumbar Disc Herniation in Previously Operated Case of lumbar Discectomy | International Journal of Spine | January-June 2023; 8(1): 02-07.

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Titles, Money Or Academics: What Drives the Orthopaedic Surgeon in India- Tracing the Happiness and Productivity of Indian Orthopaedic Surgeons

Volume 7 | Issue 2 | July-December 2022 | Page: 07-13 | Saijyot Raut, Tushar Agrawal, Rajendra Sakhrekar

DOI: https://doi.org/10.13107/ijs.2022.v07i02.38

Authors: Saijyot Raut [1, 2], Tushar Agrawal [3, 4], Rajendra Sakhrekar [5, 6]

[1] One Spine Clinic, Mumbai, Maharashtra, India.
[2] Department of Orthopaedics, SL Raheja Hospital, Mumbai, Maharashtra, India.
[3] Department of Orthopaedics, Aastha Hospital, Mumbai, Maharashtra, India.
[4] Department of Orthopaedics, MGM Hospital, Navi Mumbai, Maharashtra, India.
[5] Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, ON, Canada.
[6] Division of Orthopaedic Surgery, University of Toronto, Toronto, Canada.

Address of Correspondence
Dr. Rajendra Sakhrekar
Division of Orthopaedic Surgery, University of Toronto, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, Canada M5G 1X8.
E-mail: raj.sakhrekar@gmail.com


Background- Happiness and productivity are two interlinked parameters. Orthopaedic surgery is physically demanding, and often Orthopaedic surgeons need to work for long unpredictable hours. In this study, the factor impacting the happiness and success of Orthopaedic surgeons will be delineated. Moreover, we will try to address different characteristic features of Orthopaedic practice at different geographical locations of the country.
Material and methods- This is a randomized cross-sectional survey that was conducted among practicing Orthopaedic surgeons from Tier 1, Tier 2, and Tier 3 cities of India. We hypothesized that an annual income of Indian Rupees Four Lakhs would be likely to contribute positively to an Orthopaedic surgeon’s productivity. Additionally, we hypothesized that surgeons involved in research, teaching, and conferences would be more likely to be satisfied with their personal and professional life. Participants were selected through random sampling and a questionnaire was sent to them that explored the personal and professional happiness of the participants. This questionnaire was made by four surgeons from differing backgrounds with respect to age, training, city of practice and area of interest and was subsequently reviewed by four peers. The questionnaire contains a total of 18 questions that covered a wide range of characteristics including age, marital status, practice characteristics, quality of life, calorie intake, exercise frequency, burnout, career satisfaction, and monetary satisfaction.
Result- A total of 298 participants were responded in the survey. Among these participants 135 (45.3%) were from Mumbai, 86 (28.86%) were from Bangalore and 77 (25.84%) were from UP. The happiness quotient of Orthopaedic surgeons was shown to be significantly associated with the city where they practiced (p-value= 0.004), age of the surgeons (p-value=0.001), the setup of postgraduate training (P-value=0.004), and the frequency of physical exercise (P-value=0.019). Among the respondents 71.81% were found to have completed their training from a government hospital and 79.05% were found to be happy in their present life. However no statistically significant difference in happiness was observed between surgeons who had undergone training abroad and those that hadn’t among the respondents. It was also reported that surgeons associated with teaching institutions expected a lower salary and this association was also found to be statistically significant (P Value=0.038).
Conclusion- This study reported that practice in a Tier 1 city, age greater than 60 years, post-graduate training in a government institute, higher frequency of physical exercise (thrice a week to daily), the consciousness of daily caloric intake, and an involvement in the organization and management of major conferences and other academic and research activities were some of the factors that contributed to the happiness of Orthopaedic surgeons in India.
Keywords: Happiness, Orthopaedic surgeon, Age, Productivity, Exercise


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2. Klein G, Hussain N, Sprague S, Mehlman C, Dogbey G, Bhandari M. Characteristics of highly successful orthopedic surgeons: a survey of orthopedic chairs and editors. Can J Surg. 2013 Jun 1;56(3):192–8.
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5. Kp W, Ak K-P, Jyl O. Orthopaedic Resident Burnout: A Literature Review on Vulnerability, Risk Factors, Consequences and Management Strategies. Malays Orthop J. 2019 Jul 1;13(2):15–9.
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10. Saleh KJ, Quick JC, Conaway M, Sime WE, Martin W, Hurwitz S, et al. The prevalence and severity of burnout among academic orthopaedic departmental leaders. JBJS. 2007;89(4):896–903.
11. Andrews JR. What I have learned about being successful as an orthopedic surgeon. J Shoulder Elbow Surg. 2019 Jan;28(1):203–4.
12. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012; 172: 1377-1385. 2012/08/23.
13. Thomas NK. Resident burnout. JAMA. 2004; 292: 2880-2889. 2004/12/16.
14. Arora M, Diwan AD and Harris IA. Burnout in orthopaedic surgeons: a review. ANZ J Surg. 2013; 83: 512-515. 2013/06/26.
15. Ishak WW, Lederer S, Mandili C, et al. Burnout during residency training: a literature review. J Grad Med Educ. 2009; 1(2): 236-42.
16. Zheng H, Shao H and Zhou Y. Burnout Among Chinese Adult Reconstructive Surgeons: Incidence, Risk Factors, and Relationship With Intraoperative Irritability. J Arthoplasty. 2018; 33: 1253-1257. 2017/12/15.
17. Sargent MC, Sotile W, Sotile MO, et al. Stress and coping among orthopaedic surgery residents and faculty. J Bone Joint Surg Am. 2004; 86-a: 1579-1586. 2004/07/15.
18. Sargent MC, Sotile W, Sotile MO, et al. Managing stress in the orthopaedic family: avoiding burnout, achieving resilience. J Bone Joint Surg Am. 2011; 93: e40. 2011/04/22. DOI: 10.2106/jbjs.j.01252.

How to Cite this Article: Raut S, Agrawal T, Sakhrekar R | Titles, Money or Academics: What Drives the Orthopaedic Surgeon in India- Tracing the Happiness and Productivity of Indian Orthopaedic Surgeons | International Journal of Spine| July-December 2022; 7(2): 07-13| https://doi.org/10.13107/ijs.2022.v07i02.38

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Ewing’s Sarcoma of Spine-Current Concepts and Review of literature

Volume 7 | Issue 2 | July-December 2022 | Page: 14-18 | Rajendra Sakhrekar, Samuel Yoon, Carlo Iorio, Saijyot Raut

DOI: https://doi.org/10.13107/ijs.2022.v07i02.39

Authors: Rajendra Sakhrekar [1, 2], Samuel Yoon [1. 2], Carlo Iorio [1, 2, 3], Saijyot Raut [4, 5], Aditya Raj [6]

[1] Division of Orthopaedic Surgery, The Hospital for Sick Children, 555 University Avenue Toronto, Canada M5G1X8.
[2] Division of Orthopaedic Surgery, University of Toronto, Canada.
[3] Spine Surgery Unit, Department of Surgery, Bambino Gesù Children’s Hospital, Rome, Italy.
[4] One Spine Clinic, Mumbai, Maharashtra, India.
[5] Department of Spine Surgery, SL Raheja Hospital, Mumbai, Maharashtra, India.
[6] Division of Orthopaedic Surgery, Toronto Western Hospital, Canada.

Address of Correspondence
Dr. Rajendra Sakhrekar
Division of Orthopaedic Surgery, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, Canada M5G 1X8 & Division of Orthopaedic Surgery, University of Toronto, Canada.
E-mail: raj.sakhrekar@gmail.com


Introduction- Ewing sarcoma (ES) is a malignant and aggressive bony tumor affecting the most common age group of 5-20 years. It constitutes 10%-15% of all bone sarcomas and is the second most common primary malignant bone tumor after osteosarcoma.
Methods- We undertook a review of the literature on Ewing’s Sarcoma of the spine to evaluate its etiology, clinical presentations, differential diagnosis, imaging modalities, and management with chemotherapy, radiotherapy, and surgical management. PubMed, EMBASE, Google Scholar, and Cochrane key articles were searched. Keywords like ‘Ewing’s Sarcoma’, ‘Spine’, ‘etiology’, ‘treatment’, ‘surgical management’, and ‘en bloc resection’ were used
Discussion- The current management of Ewing’s sarcoma of the spine usually involves three main modalities: combination chemotherapy, surgery, and/or radiotherapy. Recent improvements in combination chemotherapy (vincristine, doxorubicin, cyclophosphamide +/- Ifosfamide, and etoposide) are one of the most significant factors for improving survival. Also, recent advancements in radiotherapy and instrumentation, and fusion techniques in surgical management have also been demonstrated to improve local disease control and overall survival.
Conclusion- Primary Ewing sarcoma of the spine is a rare condition affecting the most common age group of 5-20 years and accounting for 1-3 cases/million/year. About 5 % of cases have spine involvement. Recent improvements in combination chemotherapy have improved the overall survival rates. En block resection and/or radiotherapy have improved local control of the disease.
Keywords: Ewing’s Sarcoma, Spine, etiology, Treatment, Surgical management, En-bloc resection


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13. Kandel R, Coakley N, Werier J, Engel J, Ghert M, Verma S (2013) Surgical Margins and Handling of Soft-Tissue Sarcoma in Extremities: A Clinical Practice Guideline. Current Oncology 20:247–254.
14. Durer S SH (2023) Ewing Sarcoma. StatPearls Publishing.
15. Paulussen M, Craft AW, Lewis I, Hackshaw A, Douglas C, Dunst J, Schuck A, Winkelmann W, Köhler G, Poremba C, Zoubek A, Ladenstein R, van den Berg H, Hunold A, Cassoni A, Spooner D, Grimer R, Whelan J, McTiernan A, Jürgens H (2008) Results of the EICESS-92 Study: Two Randomized Trials of Ewing’s Sarcoma Treatment—Cyclophosphamide Compared With Ifosfamide in Standard-Risk Patients and Assessment of Benefit of Etoposide Added to Standard Treatment in High-Risk Patients. Journal of Clinical Oncology 26:4385–4393.
16. Schuck A, Ahrens S, Paulussen M, Kuhlen M, Könemann S, Rübe C, Winkelmann W, Kotz R, Dunst J, Willich N, Jürgens H (2003) Local therapy in localized Ewing tumors: results of 1058 patients treated in the CESS 81, CESS 86, and EICESS 92 trials. International Journal of Radiation Oncology*Biology*Physics 55:168–177.
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20. Sciubba DM, Okuno SH, Dekutoski MB, Gokaslan ZL (2009) Ewing and Osteogenic Sarcoma. Spine (Phila Pa 1976) 34:S58–S68.
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24. Harrop JS, Schmidt MH, Boriani S, Shaffrey CI (2009) Aggressive “Benign” Primary Spine Neoplasms. Spine (Phila Pa 1976) 34:S39–S47.
25. Sharafuddin MJ HFHPHS el-KGY (1992) Treatment options in primary Ewing’s sarcoma of the spine: report of seven cases and review of the literature. Neurosurgery 610–618.
26. Talac R, Yaszemski MJ, Currier BL, Fuchs B, Dekutoski MB, Kim CW, Sim FH (2002) Relationship Between Surgical Margins and Local Recurrence in Sarcomas of the Spine. Clin Orthop Relat Res 397:127–132.
27. Boriani S ALCACMBSFS (2011) Ewing’s sarcoma of the mobile spine. Eur Rev Med Pharmacol Sci 15:831–839.
28. Hesla AC, Bruland ØS, Jebsen N, Styring E, Eriksson S, Tsagozis P (2019) Ewing sarcoma of the mobile spine; predictive factors for survival, neurological function and local control. A Scandinavian sarcoma group study with a mean follow-up of 12 years. J Bone Oncol 14:100216.

How to Cite this Article: Sakhrekar R, Yoon S, Iorio C, Raut S, Raj A |  Ewing’s Sarcoma of Spine-Current Concepts and Review of literature | International Journal of Spine | July- December 2022; 7(2): 14-18 | https://doi.org/10.13107/ijs.2022.v07i02.39

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Adult Eosinophilic Granuloma of Thoracic Spine

Volume 7 | Issue 2 | July-December 2022 | Page: 27-29 | Vijaya Anand , Krishnakumar R , Ranjima Abraham

DOI: https://doi.org/10.13107/ijs.2022.v07i02.42

Authors: Vijaya Anand [1], Krishnakumar R [1], Ranjima Abraham [2]

[1] Department of Spine Surgery, Medical Trust Hospital, Kochi, India.
[2] Department of Pathology, Medical Trust Hospital, Kochi, India.
Dr. Vijaya Anand
Department of Spine Surgery, Medical Trust Hospital, Kochi, India.
E-mail: drvijayanand24@gmail.com


A rare case report of Adult Eosinophilic Granuloma of the upper thoracic spine involving the vertebral body. A 48-year-old male with chronic pain over the lower neck without neurological involvement. MR imaging shows a lytic lesion over D2 vertebral body. Open biopsy is done; it is consistent with EG. Immunohistochemistry markers are positive for CD1a, S100. Adult Eosinophilic Granuloma is a self-limiting and spontaneous resolution condition in adults. It should be in the list of differential diagnoses for a solitary lytic lesion of the spine in adults.

Keywords: Adult eosinophilic granuloma, Solitary lytic lesion, Langerhans cell histiocytosis


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3. Zheng W, Wu J, Wu Z, Xiao J. Atlantoaxial instability secondary to eosinophilic granuloma of the axis in adults: Long-term follow-up in six cases. Spine J. 2014;14:2701-2709.
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6. Huang W, Yang X, Cao D, et al. Eosinophilic granuloma of spine in adults: a report of 30 cases and outcome. Acta Neurochir (Wien). 2010; 152(7):1129-1137.
7. Lau€enburger MD, Dull ST, Toselli R. Eosinophilic granuloma of the adult spine: A case report and review of the literature. J Spinal Disord 1995; 8: 243 ± 245.
8.Villas C, Martinez-Perric R, Barrios RH, Beguiristain JL. Eosinophilic granuloma of the spine with and without vertebra plana: Long term follow-up of six cases. J Spinal Disord 1993; 6: 260 ± 268.

How to Cite this Article: Anand V, R Krishnakumar, Abraham R | Adult Eosinophilic Granuloma of Thoracic Spine | International Journal of Spine | July-December 2022; 7(2): 27-29 | https://doi.org/10.13107/ijs.2022.v07i02.42

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Spontaneous Cervical Epidural Hematoma Following Anti-Coagulant Medications with Quadriparesis: A Case Report and Narrative Review

Volume 7 | Issue 2 | July-December 2022 | Page: 23-27 | Vijay Kumar Loya, Charanjit Singh Dhillon, T.V. Krishna Narayana, Chetan S. Pophale, Sameen V.K.

DOI: https://doi.org/10.13107/ijs.2022.v07i02.41

Authors: Vijay Kumar Loya [1], Charanjit Singh Dhillon [2], T.V. Krishna Narayana [3], Chetan S. Pophale [2], Sameen V.K [4]

[1] Department of Spine Surgery, Germanten Hospital, Hyderabad, Telangana, India.
[2] Department of Spine Surgery, M.I.O.T International, Chennai, Tamil Nadu, India.
[3] Department of Spine Surgery, Udai Omni Hospital, Hyderabad, Telangana, India.
[4] Department of Spine Surgery, Government Medical College, Kottayam, Kerala, India.

Address of Correspondence
Dr. Vijay Kumar Loya,
Consultant Spine Surgeon, Germanten Hospital, Hyderabad, Telangana, India.
E-mail: dr.vijaykumarloya@gmail.com.


Spontaneous spinal epidural hematoma is an uncommon entity. We present a 42-year gentleman who was a known case of chronic deep vein thrombosis of leg on Tab. Acitrom (6 mg OD) for one & half year presented with sudden-onset weakness of bilateral upper & lower limbs with bowel & bladder involvement. MRI showed ventral epidural haematoma extending from the lower margin of C2 to C6 with severe canal compromise. Patient underwent emergency decompression with hematoma evacuation on the same day within 06 hours of presentation to our centre. At a 2-year follow-up, the patient has recovered good bowel and bladder control and has a residual left leg foot drop. Spontaneous spinal epidural hematoma is a rare condition where early management is the key. If associated with neuro deficits, early decompression (<48 hours) is indicated for a better prognosis. This case report highlights the fact, if dealt proactively patient can have a good neurologic recovery.
Keywords: Epidural hematoma, Quadriparesis, Cervical spine, Anti-coagulants


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How to Cite this Article: Loya VK, Dhillon CS, Narayana TVK, Pophale CS, Sameen VK | Spontaneous Cervical Epidural Hematoma Following Anti-Coagulant Medications with Quadriparesis: A Case Report and Narrative Review | International Journal of Spine | July-December 2022; 7(2): 23-27 | https://doi.org/10.13107/ijs.2022.v07i02.41

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Efficiency of Spinal Anaesthesia Versus General Anaesthesia for Single Level Lumbar Micro-Discectomy Prospective Analysis of 50 Patients: An Observational Study

Volume 7 | Issue 2 | July-December 2022 | Page: 19-22 | Ashutosh.C. Tripathi, Chaitanya Chikhale, Ganesh N. Pundkar, Rajendra.W. Baitule, Yogesh Rathod, Sanjeev Jaiswal

DOI: https://doi.org/10.13107/ijs.2022.v07i02.40

Authors: Ashutosh.C. Tripathi [1], Chaitanya Chikhale [1], Ganesh N. Pundkar [1], Rajendra.W. Baitule [1], Yogesh Rathod [1], Sanjeev Jaiswal [1]

[1] Department of Orthopaedics, PDMMC, Amravati, Maharashtra, India.

Address of Correspondence
Dr. Ashutosh C. Tripathi,
Department of Orthopaedics, PDMMC, Amravati, Maharashtra, India.
E-mail: ashutoshckv.95@gmail.com


Background: In most of the institutes Lumbar Microdiscectomy surgery is done under General Anaesthesia. However, it is not uncommon to do these surgeries under Spinal Anaesthesia
Aims and objectives: To compare the analgesic effectiveness in postoperative pain, cost-effectiveness and complications of spinal anaesthesia and general anaesthesia who underwent single Level Lumbar Microdiscectomy under General Anaesthesia vs who were administered Spinal anaesthesia for the same
Materials and methods: A prospective observational study was conducted on patients undergoing lumbar micro-discectomy in the department of orthopaedics of a tertiary care hospital in Maharashtra, India. The study duration was two years [January 2020 to December 2020]. The patients older than 18 years who were not responding to 6 weeks of conservative therapy, epidural steroid injection, physiotherapy, and having low back pain with radiculopathy with claudication with or without neurological deficit were included in the study. We included 25 cases each in the spinal anaesthesia (SA) and general anaesthesia (GA) group. Outcome variables like peri-operative complications (blood loss, urinary retention, PONV), surgery length, length of stay (LOS), time from entering OT to incision, time from bandaging to exit time, and time of stay in the recovery room were studied among both the groups. Chi-square or fishers exact test to test the difference between proportions and student t-test to test between the means were statistical tests used.
Results: The VAS score reduction immediately post-operative among GA group was 79% and SA group was 75% and this difference was not significant. (p>0.05)The time from post anaesthesia care unit from operation theatre [GA Vs. SA; 60.44 minutes Vs. 20.45 minutes] , time of surgery (time to enter in OT to incision) [GA Vs. SA; 30.22 minutes Vs. 15.55 minutes], time from bandaging to exit from OT[GA Vs. SA; 16.34 minutes Vs. 6.12 minutes] and average hospital stay[GA Vs. SA; 3.05 days Vs. 1.61 days] were significantly higher among GA group when compared to SA group. (p<0.05) The average cost of procedure among GA group was 26500 INR and among SA group was 18500 INR. (p<0.05)
Conclusions: In terms of VAS pain score reduction, SA was comparable with GA. Our study showed that SA was superior to GA in terms of time consumption, cost, and hospital stay while maintaining better perioperative hemodynamic stability without increasing adverse side effects.
Keywords: Lumbar micro-discectomy, Spinal Anaesthesia, General Anaesthesia, Cost-effectiveness


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3. De Cassai A, Geraldini F, Boscolo A, Pasin L, Pettenuzzo T, Persona P, et al. General anesthesia compared to spinal anesthesia for patients undergoing lumbar vertebral surgery: A meta-analysis of randomized controlled trials. J Clin Med. 2021;10(1):1–13.
4. Ahmed Jonayed S, Alam MS, Al Mamun Choudhury A, Akter S, Chakraborty S. Efficacy, safety, and reliability of surgery on the lumbar spine under general versus spinal anesthesia- an analysis of 64 cases. J Clin Orthop Trauma. 2021;16(June 2016):176–81.
5. S R, Halagunaki B P, B N R. Comparative Retrospective Study on Anaesthesia Approaches for Lumbar Spine Surgery. J Evol Med Dent Sci. 2016;5(60):4217–20.
6. Talukder MH, Ahmed M, Hossain KS, Uddin MB, Shikder S, Ahmed F. Comparison of Patient Satisfaction between Spinal versus General Anaesthesia for Lumbar Disc Surgery. Sch J Appl Med Sci. 2022;10(3):357–61.
7. Morris MT, Morris J, Wallace C, Cho W, Sharan A, Abouelrigal M, et al. An Analysis of the Cost-Effectiveness of Spinal Versus General Anesthesia for Lumbar Spine Surgery in Various Hospital Settings. Glob Spine J. 2019;9(4):368–74.
8. Pierce JT, Kositratna G, Attiah MA, Kallan MJ, Koenigsberg R, Syre P, et al. Efficiency of spinal anesthesia versus general anesthesia for lumbar spinal surgery: A retrospective analysis of 544 patients. Local Reg Anesth. 2017;10:91–8.
9. de Biase G, Gruenbaum SE, West JL, Chen S, Bojaxhi E, Kryzanski J, et al. Spinal versus general anesthesia for minimally invasive transforaminal lumbar interbody fusion: implications on operating room time, pain, and ambulation. Neurosurg Focus.2021;51(6):1–7.

How to Cite this Article: Tripathi Ac, Chikhale C, Pundkar GN, Baitule RW, Rathod Y, Jaiswal S | Efficiency of Spinal Anaesthesiaversus General Anaesthesia for Single level Lumbar Micro-discectomy Prospective Analysis of 50 Patients: An Observational Study | International Journal of Spine | July-December 2022; 7(2): 19-22 | https://doi.org/10.13107/ijs.2022.v07i02.40

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