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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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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Sacral Fracture with Neurodeficit – Is Laid-Back Approach a Passe?

Volume 7 | Issue 1 | January-June 2022 | Page: 24-28 | Shreevijay A Phadke, Himanshu G Kulkarni, Sidheshwar S Thosar, Rajendra Sakhrekar

DOI: 10.13107/ijs.2020.v07i01.035

Authors: Shreevijay A Phadke [1], Himanshu G Kulkarni [2], Sidheshwar S Thosar [2], Rajendra Sakhrekar [3]

[1] Department of Spine Surgery, Chirayu Hospital, Ratnagiri, Maharashtra, India.
[2] Department of Spine Surgery, Shraddha Surgical and Accident Hospital, Sangli, Maharashtra, India.
[3] Department of Spine Surgery, Schoen Klinik Neustadt Holestine, Germany.

Address of Correspondence
Dr.Sidheshwar S Thosar,
Fellow Spine Surgery, Shraddha Surgical and accident Hospital, Sangli, Maharashtra, India.
E-mail: dr.sidheshwarthosar@gmail.com


Management of sacral fractures with neurological deficits has been a topic of debate. Literature is divided between conservative and operative management. We report a case of a 32-year-old male with post-traumatic unstable complex transverse sacrum fracture and associated stable pelvic ring fractures with loss of bowel and bladder control. He had a fall from the second floor over the buttocks. Plain lateral radiography showed a transverse sacral fracture located between S2 and S3 with kyphosis at the fracture site. MRI showed a compromised canal due to a large retro pulsed fragment pressing over the anterior aspect of sacral roots. Thorough decompression of cauda equina and sacral roots was performed, and sacral ala fracture was fixed with two percutaneous 6.5 mm cannulated cancellous Ilio-sacral screws and two 3.5 mm recon locking plates were applied for the sacrum. The patient regained his bladder control 3 months after the surgery and bowel control 4 months after the surgery. At the end of 1 year, the patient has persistent saddle anaesthesia but good bowel and bladder control. Early decompression and stabilization of unstable complex sacrum fractures with neurological compromise can facilitate optimum neurological improvement and favourable clinical outcomes in terms of early mobilization and pain relief.

Keywords: Fracture, Sacrum, Decompression surgery


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How to Cite this Article: Phadke SA, Kulkarni HG, Thosar SS, Sakhrekar R | Sacral Fracture with Neurodeficit – Is Laid-Back Approach a Passe? | International Journal of Spine | January-June 2020; 7(1): 24-28.

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Langerhans Cell Histiocytosis of Dorsal Spine in a Child Presenting with Deformity of the Back: A Rare Case Report and Review of Literature

Volume 7 | Issue 1 | January-June 2022 | Page: 19-23 | Bharath HD, Krishnakumar R, Jeffy John

DOI: 10.13107/ijs.2020.v07i01.034

Authors: Bharath HD [1], Krishnakumar R [1], Jeffy John [2]

[1] Department of Spine Surgery, Medical Trust Hospital, Cochin, Kerala, India.
[2] Department of Pathology, Medical Trust Hospital, Cochin, Kerala, India.

Address of Correspondence
Dr. Krishnakumar R,
Department of Spine Surgery, Medical Trust Hospital, Cochin, Kerala, India.
E-mail: krishnakumar.ram@gmaiall.com


Background: Back pain in the pediatric population is a common complaint with wide differentials including mechanical cause, musculoskeletal involvement, infectious or inflammatory pathologies, and tumors. Transient back pain is common among children, and in majority of cases resolves without any treatment or with rest and mere hot/cold fomentations. However, pain disproportionate to physical findings and not reduced by pain medications, strongly suggest the presence of a serious underlying pathology. Case presentation: A 13 year old boy presented with a history of mild mid back pain lasting for a week associated with gradually developing deformity of the back, noticed by his parents. There is no history of any injury or fall prior to presentation. He had no history of any other constitutional symptoms. Upon radiological investigations he was found to have an isolated lytic lesion in D9 vertebra with differentials of tubercular/neoplastic/metastatic etiologies. Histopathological examination after biopsy was suggestive of Langerhans cell histiocytosis and was proven by immunohistochemistry. He was managed with conservative line of treatment with analgesics and other supportive care. Discussion: LCH is considered a pediatric disease, and involvement of the pediatric spine in not uncommon. A child presenting with persistent and progressive back pain should be evaluated in detail even if the child is not presenting with any other constitutional symptoms to rule out rare causes of vertebral lytic lesions. There are no cases reported in the literature suggesting LCH of the spine in pediatric population presenting as the deformity of the back. Conservative treatment is a good choice for a patient with LCH without neurological deficits or spinal instability.
Keywords: Spine deformity, Children, LCH, Back pain


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12. Bertram C, Madert J, Eggers C (2002) Eosinophilic granuloma of the cervical spine. Spine 27(13):1408–1413

How to Cite this Article: HD Bharath, R Krishnakumar, John J Langerhans | Cell Histiocytosis of
Dorsal Spine in a Child Presenting with Deformity of the Back: A Rare Case Report and Review of Literature| International Journal of Spine | January-June 2020; 7(1): 19-23.

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Fat is Bad? Lumbar Discectomy in Patients with High Body Mass Index

Volume 7 | Issue 1 | January-June 2022 | Page: 12-18 | Akshay B Phuse, Sumit Sinha, Nishant Yagnik, Ankush Gupta

DOI: 10.13107/ijs.2020.v07i01.033

Authors: Akshay B Phuse [1], Sumit Sinha [2], Nishant Yagnik [2], Ankush Gupta [2]

[1] Department of Spine Surgery, Atlas Spine and Orthopaedic Hospital, Nagpur, Maharashtra, India.
[2] Department of Spine Surgery, Paras Hospitals, Gurgaon, Haryana, India.

Address of Correspondence
Dr. Akshay B Phuse,
Spine Surgeon, Department of Spine Surgery, Atlas Spine and Orthopaedic
Hospital, Nagpur, Maharashtra, India.
E-mail: phuse.akshay@gmail.com


Objective: Spine surgeons are experiencing increased morbidly obese patients with lumbar spine pathology in regular practice. There is a close association between back pain and morbid obesity, particularly due to chronic stresses on the spine. Our objective of this review of literature is to identify the difficulties encountered by the spine surgeons in lumbar spine microdiscectomy and to provide possible solutions for the same. All pre-operative, intra-operative including surgical techniques and post-operative complications with clinical outcomes are taken into consideration.

Methods: obesity was defined as body mass index (BMI) more than 30kg/m2 whereas  Morbidly obese are the people who have BMI more than 40kg/m2 or BMI 35kg/m2 associated with at least 2 co morbid conditions. Keywords were taken as Micro discectomy, lumbar spine disease, morbidly obese, obese, obesity related spine pathology, spinal surgery in obese, Body mass index. This review article examined articles published concerning “lumbar microdiscectomy in obese patients” on Pub Med and Google scholar. We also included some articles related to lumbar fusion surgery in obese patient. Articles in which lumbar spine surgeries operated on non-obese patients and surgeries performed at cervical and dorsal level were excluded. We included 71 articles published on the related topic

Results:  Review illustrated that obese patients were at higher risk of complications at all stages of management. Pre-operatively obese patients showed inferior outcome to conservative management. Health care professionals  are challenged in transportation, imaging, and resuscitation procedures of obese patients  because of large body fat. Intra operatively obese patients have showed increased blood loss, operative time and infection rates. Even surgeries in obese patients were technically demanding. Obese patients demonstrated inferior clinical outcomes, increased complications rates compared to non-obese patients. Minimally invasive spine surgery has shown better and promising results in lumbar discectomy.

Conclusion: lumbar surgeries on obese patients is fraught with multiple challenges starting from preoperative period might through the surgical procedure and rehabilitation With the increasing availability of technology and surgical expertise, MIS has proven to be equally effective, if not better, than traditional lumbar surgeries in this group of patients. Smaller surgical incisions, early mobilization and shorter duration of hospital stay are some of the advantages of this technique

Keywords: Micro discectomy, Lumbar spine disease, Morbidly obese, Obese, Obesity related spine pathology, Spinal surgery in obese, Body mass index.


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How to Cite this Article: Phuse AB, Sinha S, Yagnik N, Gupta A | Fat is Bad? Lumbar Discectomy in
Patients with High Body Mass Index | International Journal of Spine | January-June 2020; 7(1): 12-18.

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Recent Review Article on Os Odontoideum

Volume 7 | Issue 1 | January-June 2022 | Page: 07-11 | Rajendra Sakhrekar, Mohan Gavande, Sriram Srinivasan

DOI: 10.13107/ijs.2020.v07i01.032

Authors: Rajendra Sakhrekar [1], Mohan Gawande [2], Sriram Srinivasan [3], Himanshu G Kulkarni [4]

[1]  Department of Spine Surgery, Hospital for Sick Children, Toronto, Canada.
[2]  Department of Spine Surgery, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India.
[3] Department of Spine Surgery, Royal Stoke University Hospital, UK.
[4] Department of Spine Surgery, Shraddha Surgical and Accident Hospital, Sangli, Maharashtra, India.

Address of Correspondence
Dr Rajendra Sakhrekar,
Paediatric Spine Fellow, Department of Spine Surgery, Hospital for Sick Children,
Toronto, Canada.
E-mail: raj.sakhrekar1@gmail.com



Os-odontoideum is a rare condition, described radiographically and clinically as a congenital anomaly of the second cervical vertebra (axis), it a smooth, independent ossicle of variable size and shape separated from the base of a shortened odontoid process by an obvious gap, with no osseous connection to the body of C2.

Material and methods

This study reviewed the literature on OO to evaluate its etiology, the clinical presentations, differential diagnosis, imaging modalities and outcomes in the management of asymptomatic and symptomatic cases of os odontoideum. PubMed, EMBASE, Google Scholar and Cochrane key articles were searched.


Considering etiology traumatic hypothesis is favoured over congenital hypothesis as per recent literature on OO. Clinical presentation varies from asymptomatic to mild neck pain to severe myelopathy and neurodeficit. Various C1-C2 instrumentation and fusion techniques like wiring, trans articular screw and laminar screws have been described with good success rates.


Os odontoideum is a rare condition with limited existing literature. Considering significant risks involved if conservative management is opted like severe neurodeficit to sudden death on trivial trauma and the recent improvement of imaging tools helping to understand the pathology of the disease, surgery can be indicated even in an incidentally detected os odontoideum. Although for asymptomatic stable patients’ individual case-by-case approach can be considered depending on factors such as age, activity level, comorbidities, syndromic association and radiographic findings.

Keywords: ‘Os-odontoideum’, ‘surgical management’, ‘etiology’, ‘Atlanto-axial instability’ ‘complications’


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8) Klimo Jr P, Kan P, Rao G, Apfelbaum R, Brockmeyer D. Os odontoideum: Presentation, diagnosis, and treatment in a series of 78 patients. J Neurosurg Spine. 2008; 9(4): 332342.Website.http://thejns.org/doi/abs/10.3171/SPI.2008.9.10.332.

9) Klimo P, Jr., Coon V, Brockmeyer D: Incidental os odontoideum: current management strategies. Neurosurg Focus. 2011, 31:10. 10.3171/2011.9.focus11227

10) Goel A, Patil A, Shah A, Dandpat S, Rai S, Ranjan S. Os Odontoideum: Analysis of 190 Surgically Treated Cases. World Neurosurg. 2020 Feb;134:e512-e523. doi: 10.1016/j.wneu.2019.10.107. Epub 2019 Oct 26. PMID: 31669688.

11) Hughes TB Jr, Richman JD, Rothfus WE: Diagnosis of Os odontoideum using kinematic magnetic resonance imaging. A case report. Spine. 1999, 24:715–718.

12) Goel A. Indicators of atlantoaxial instability. J Craniovertebr Junction Spine. 2021 Apr-Jun;12(2):103-106.

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18) Dempster AG, Heap SW. Fatal high cervical spinal cord injury in an automobile accident complicating os odontoideum.Am J Foren Med Pathol. 1990; 11(3): 252-256.

19) Zhang Z, Zhou Y, Wang J, et al. Acute traumatic cervical cord injury in patients with os odontoideum. J Clin Neurosci. 2010; 17(10): 1289-1293. doi: 10.1016/j.jocn.2010.01.051

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21) Goyal N, Bali S, Ahuja K, Chaudhary S, Barik S, Kandwal P. Posterior Arthrodesis of Atlantoaxial Joint in Congenital Atlantoaxial Instability Under 5 Years of Age: A Systematic Review. J Pediatr Neurosci. 2021 Apr-Jun;16(2):97-105. [PMC free article] [PubMed]

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How to Cite this Article:  Sakhrekar R, Gawande M, Srinivasan S | Recent Review Article on Os Odontoideum | International Journal of Spine | January-June 2020; 7(1): 07-11.

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Detection of Spinal TB Infection: A Retrospective Study Evaluating Comparative Diagnostic Efficacy of AFB Smear, Gene Expert, Histopathology, Culture Sensitivity and LPA Tests From a Biopsy Sample

Volume 7 | Issue 1 | January-June 2022 | Page: 01-06 | Abhijith Shetty, Saijyot Raut, Manikant Anand, Vishal Kundnani, Praveen Goparaju, Mukul Jain

DOI: 10.13107/ijs.2020.v07i01.031

Authors: Abhijith Shetty [1], Saijyot Raut [1], Manikant Anand [1], Vishal Kundnani [1], Praveen Goparaju [1], Mukul Jain [1]

[1] Department of Orthopaedics, Bombay Hospital and Research Centre, Mumbai, Maharashtra, India.

Address of Correspondence
Dr. Abhijith Shetty,
Spine Surgeon, Department of Orthopaedics, Bombay Hospital and Research
Centre, Mumbai, Maharashtra, India.
E-mail: abhijithshettyabhi03@gmail.com


Background: Spinal Tuberculosis (TB) is one of the significant health dangers that affect the general wellbeing of an individual. It is one of the most common form of extra pulmonary tuberculosis that affects the general population. Diagnosis of tuberculosis is done using an array of techniques. The present study has compared the efficacy of these tests used for detecting the spinal TB in biopsy samples.
Material and Methods: The study was conducted on patients who suffered from spondylodiscitis and with biopsy proven spinal TB by one of the following tests and were treated in the study center. The study included a total of 150 patients with spinal TB who visited the department for further treatment. The biopsy samples of these patients were then processed for Line probe assay (LPA), Gene Xpert, liquid culture (bactec MGIT) followed by gram staining and fungal staining, and histopathological examination.
Result: In this study total of 150 patients were included who had ages ranging from 16-77 years with 93male and 57 female patients. When the study results were compared Gene Experts showed a 100% sensitivity and 80% of specificity. When we compared the histopathology results with gene expert, we get a sensitivity of 16.7% and specificity of 50%.
Gram stain with the sensitive gene expert, the sensitivity is 45.5% and specificity is 25%. Similar analysis was done with sensitive gene and now with the resistant gene to identify their sensitivity was 0% and the specificity was at 42.9%. Gram stain when correlated with gene, the sensitivity came out to be 9.1% and specificity at 25%. Fungal stain with resistant gene, when correlated, sensitivity comes to 9.1% and specificity is at 0%.
Conclusion: This study showed that for detection of tuberculosis rather than relying on only single technique it should be done with a combination of techniques.
Keywords: Gene Xpert, LPA, Histopathological examination, Tuberculosis, Gram staining


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How to Cite this Article: Shetty A, Raut S, Anand M, Kundnani V, Goparaju P, Jain M | Detection of Spinal
TB Infection: A Retrospective Study Evaluating Comparative Diagnostic Efficacy of AFB Smear, Gene Expert, Histopathology, Culture Sensitivity and LPA Tests From a Biopsy Sample | International Journal of Spine | January-June 2020; 7(1): 01-06.

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Unusual Association of KBG Syndrome with Scheuermann’s Disease

Volume 7 | Issue 1 | January-June 2022 | Page: 01-06 | Sanjay N. Murthy, Jaganaathan Srinivasan, Cheryl Honeyman, Rajendra Sakhrekar, Amit Bishnoi, Sriram H. Srinivasan

DOI: 10.13107/ijs.2020.v07i01.036

Authors: Sanjay N. Murthy [1], Jaganaathan Srinivasan [2], Cheryl Honeyman [3], Rajendra Sakhrekar [4], Amit Bishnoi [5], Sriram H. Srinivasan [6]

[1] Department of Orthopaedics, Royal Stoke University Hospital, UK.
[2] Department of Orthopaedics, James Cook University Hospital, Middlesbrough, BW.
[3] Department of Orthopaedic Nursing, James Cook University Hospital, Middlesbrough, BW.
[4] Department of Spinal Surgery, Schoen klinik Neustadt Holestine, Germany.
[5] Department of Spinal Surgery, Leicester University Hospital, UK.
[6] Department of Spinal Surgery, Ipswich University Hospital NHS Trust, UK.

Address of Correspondence
Dr. Sanjay N. Murthy,
Core Trainee, Department of Orthopaedics, Royal Stoke University Hospital, UK.
E-mail: sanjayn293@gmail.com


In this paper we discuss a novel case in which a patient had a comorbid diagnosis of KBG syndrome and Scheuermann’s disease. The patient was a 14-year-old boy, referred to orthopaedics for assessment of his spinal deformity. Initial assessment revealed that he had a rib prominence on his right side, which was corrected upon bending forward. SLR examination indicated significantly tight hamstrings. Plantars were upturning, but other reflexes were normal. He had kyphosis measuring up to 59.4 degrees. MRI of the spine depicted features of classic Scheuermann’s disease, from D6-D10. The patient was given conservative treatment consisting of physical therapy and postural training. He remained asymptomatic during the course of a 5-year follow-up period. This case is unique due to the comorbidity of Scheuermann’s disease and KBG syndrome, which has never been reported in the literature. This case report suggests that routine spinal screening in cases of KBG syndrome would contribute to a better understanding of treatment and diagnosis.

Keywords: KBG syndrome, Scheuermann’s disease


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How to Cite this Article: Murthy SN, Srinivasan J, Honeyman C, Sakhrekar R, Swamy G, Srinivasan SH Unusual Association of | KBG Syndrome with Scheuermann’s Disease | International Journal of Spine | January-June 2020; 7(1): 29-32.

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