Volume 1 | Issue 2 | Sep – Dec 2016 | Page 27-32 | Ketan Khurjekar, Himanshu Kulkarni, Mayur Kardile

Authors : Ketan Khurjekar [1], Himanshu Kulkarni [1], Mayur Kardile1 [1]

[1] Department of Spine Surgery, Sancheti Institute for Orthopaedics and Rehabilitation, Pune India

Address of Correspondence
Dr. Ketan Khurjekar
Department of Spine Surgery, Sancheti Institute for Orthopaedics and Rehabilitation, Pune India
Email : kkhurjekar@gmail.com

Introduction

Burst fractures comprise of approximately 17% of all thoracolumbar fractures. These type of fractures result from compression failure of both the anterior and middle columns under substantial axial loads [1]. Between the immobile, kyphotic thoracic spine above, and the relatively mobile, lordotic lumbar spine below, throracolumbar region makes a transition zone where all the stress forces are concentrated. This makes the thoraco lumbar zone more prone to injuries than any other part of the spinal column. According to Denis, a spinal fracture is described as burst if there is compression of the anterior column, fracture of the middle column, and retropulsion of bone fragments into the spinal canal [2]. As a result neurologic injury has been reported to occur in 30% of the patients with thoracolumbar fractures [3]. The management of thoracolumbar burst fractures remains challenging. An ideal treatment modality should induce neurological recovery, should correct the deformity efficiently and allow early mobilization, should enable minimization of loss of work hours and should have minimal treatment related complications. For years together, a lot has been written in literature about how these aims can be achieved, with strong proponents for both non-operative and operative treatments existing. This difference of opinion and polarising philosophies can be confusing for an inexperienced clinician. So we have tried to put forth step by step approach to decode the dilemma that is the unstable thoracolumbar burst fracture with the help of a case.

Case-
A 21 year old engineering student came to casualty with history of fall from height 4 hours back. Patient was unable to move both his lower limbs. Power in both Hips wad grade 2 for flexion, Grade 1 for Knee extension and Grade 0 for ankle and great toe movements. There was partial loss of sensations with diminished sensations present in L1-2-3 dermatomes and complete loss of sensations below that. There was loss of sensation for micturition, but it was associated with weak anal contraction. Patient was shifted to department of radiology and plane radiogram was done. Plain lateral radiogram showed fracture of L2 vertebral body with a retropulsed fragment crossing posterior vertebral line (Fig. 1).

After this, MRI scan of the thoracolumbar spine was done. The scan showed the retropulsed fragments causing severe compression of the cord (Fig. 2).
Once the imaging studies were done, following steps were followed.

Assesment of Neurology –
Assessment of neurology has to be the first thing to be considered in a methodical treatment approach. In most circumstances, the treatment protocol and prognosis depends upon early neurological state. Frankel categorised the spinal cord injuries in a comprehensive classification. The injury was divided into 5 types, from severe to less severe. Modification of Frankel grading was included in now widely accepted American Spine Injury Association grading (ASIA Grading) in 1997 which was revised in 2011 [4]. ASIA grading grades the injury into complete or incomplete, with extensive dermatomal and myotomal charting.
Power charting for upper and lower limb myotomes was done. According to Frankel grading, the injury was labelled as Frankel 3, since some voluntary motor function was preserved below level of lesion but too was weak to serve any useful purpose. Some sensations were preserved too.

Assessment of stability-
In 1949, Nicoll [7] first introduced the concept of posttraumatic spinal instability. He defined unstable spinal injuries based on the presence of subluxation or dislocation, disruption of interspinal ligaments, or laminar fractures at L4 or L5. This concept has been used as a base for all the treatment approaches for unstable injures. It was stated by White and Panjabi that a stable spine is able, under physiological load, to maintain its normal movement so that there is no initial or additional neurological deficit, no major deformity, and no incapacitating pain.8 They also made a check list for thoracic instability.
According to Denis [2], there are 3 types of instability in the thoracolumbar spine; the mechanical instability that refers to the potential of spinal collapse with subsequent deformity, the neurological instability that refers to the potential of further neurological injury, and the combined mechanical and neurologic instability. The 3-column model is useful for the assessment of spinal instability; any thoracolumbar burst fracture can be unstable, while middle 2, or 2-column failures are absolute criteria for instability.
Mcafee et al in 1984 described factors indicative of instability in compression burst fractures of thoracic lumbar junction. According this criteria, fracture in our case was considered unstable. The fracture had progressive neurological deficit, had >50% loss of vertebral height, local kyphosis > 20 degrees and retropulsion of a bony fragment in the canal was present (Fig. 3).

Classifying the fracture pattern –
Since Bohler first tried to classify thoracolumbar spine fractures combining both anatomic appearance and mechanisms of injury as early as in 1930, classification of spinal fractures to facilitate communication and encourage optimal treatment protocols has long been a focus of the spine community [9]. Numerous classification systems have been put forth till now. Discussion of all is beyond the scope of this topic but none has been proven to be a gold standard yet due to the complexity of spinal anatomy and mechanisms of injury, as well as widely differing philosophies in treatment[10].
Some classification systems have gained more acceptance than others though. In 1994, McCormack et al [11]. stated that in long bone fixation, load sharing between the bone and the implant is of paramount importance. It helps in uneventful healing of the fracture and prevents implant failure. They applied same concept in spinal fractures, and put forth a CT based Load sharing classification taking into account the amount of comminution, apposition and Kyphosis.
The fracture in this case was classified as a Grade 2, with moderate comminution (Fig. 4) apposition and Kyphosis. Fracture was also classified according to Thoracolumbar injury classification and severity score (TICS) which is useful guide to treatment options. The classification holds a scoring system categorising the injury into operative or non-operative category based on the score.
The score for our fracture was found to be 8, which indicated the management should be operative. Like other long bone fractures, AO classification was also introduced in as AO- Magerl classification [12]. The classification system failed to gain wide universal international adoption due to its complexity. SO, the system was revised in 2013 into 3 main injury patterns: type A (compression), type B (tension band disruption), and type C (displacement/translation) injuries[13].
Our facture was classified as L2-B2;N3;M1.

Management Options –
Ideally, the treatment Goal in burst fracture should be to
1. Effective correction the deformity
2. Induction neurological recovery
3. Should allow early mobilization
4. Should have minimal risk of complication
Because of different philosophical ideologies, and there has been considerable controversy on the efficacy of conservative treatment and the need for surgical intervention in burst fractures with intact neuro status.
Argument for proponents of Surgery has always been on points of additional stability, prevention of neurological deterioration, attainment of canal clearance, prevention of kyphosis and early relief of pain. Denis et al [2]. reported late neurological deterioration in 17% of conservatively treated patients. They stated that prophylactic stabilization and fusion of acute burst fractures without neurologic deficit have significant advantages over conservative treatment. Likewise, Bohlman et al too were biased towards operative intervention. They expressed that operative intervention enhances clinical outcome and facilitates early rehabilitation [14]. However, Many subsequent trials showed that deterioration of the neurological status in patents who had intact neurology initially was unlikely [15,16]. To comment about the concerns about the persistent canal compromise in neurologically intact patients, Shen et al [17]. noted a resorption of approximately 50% of the retroplused fragment within 12 months. Also, no statistical difference was found in the degree of spinal canal remodelling between patients treated conservatively and operatively [18]. Also, Some surgeons have chosen direct decompression and canal clearance when CT scan has showed more than 40 % canal compromise [19]. However paralysis occurs at the moment of injury and it is not related to position of bony fragment [26]. Also, High-speed video tests have shown that at higher levels of occlusion, the final position of the bone fragments was inadequately correlated with the maximum level of impingement [27].
So, even though the preferred treatment for these fractures with intact neurology is still an ongoing debate amongst clinician, data has shown no significant superiority of operative treatment over non operative treatment. TLICS is a useful tool to make the decision of preferred treatment modality easy.

In patients with progressive neurological deterioration, or ones with unstable fractures & complete neurological loss, there’s no debate about the choice of surgical intervention as a preferred treatment modality. It ensures decompression of the spinal canal and nerve roots, and gives the fractured spine sufficient stability and realignment with correction of kyphosis to start early mobilization and rehabilitation [14]. Timing of the surgery is also a debatable factor. It’s a common opinion that surgery at the earliest can be beneficial for ultimate outcome. Carlo Bellabarba et al in 2010 stated that stabilization within 72 hours was safe and decreased respiratory morbidity. But other than decreased ICU and overall hospital stay, no other significant benefit of early surgery was found. It was also stated that currently there is very low supporting evidence in literature for benefits early surgery [19]. Surgery for these fractures can be via Anterior, posterior or a combined approach. Fracture morphology, neurologic status, and surgeon preference play major roles in making the decision about preferred approach. Usually, the anterior approach surgery should be limitedly used for severe Denis type B fracture with direct reduction. The posterior approach is used in most Denis type A and B fractures with indirect reduction and has less complication [20]. Some authors also stated that anterior only showed statistically significant improvement in sagittal alignment in long term follow up than posterior only fixation [21]. Anterior and middle column injuries with partial neurology have been effectively treated by anterior approach; decompression under direct vision and sagittal alignment are the key factor.
In our experience, anterior decompression and reconstruction for burst fractures with anterior and median column injury is effective. Decompression and reconstruction can be performed under direct vision at one stage, and the sagittal alignment can be corrected at the same time. Since anterior approach has a more surgical morbidity than posterior approach, it should be reserved for patients with canal compromise >67%. Focal kyphosis > 30 degree [22].
But at the same time, The benefits of posterior approach cant be undermined. It is more than once described that creating a posterior tension band and stabilisation is biomechanicvally more stronger It helps in Indirect decompression by ligamentotaxis ( though, ligamentotaxis has been shown to be inefficient in greater than 50% canal compromise 22), direct access to spinal canal for decompression, relieve hematoma, repair dural tears and extricate trapped nerve roots. Direct canal decompression through a posterior approach can be obtained by laminectomy, pediculectomy, fragment reposition or fragment removal [23]. Also, adequate neural canal decompression can also be achieved by a new modified transpedicular approach less invasively to avoid anterior surgery [24]. Kaya et al extended the transpedicular decompression for spinal cord and nerves by posterior alone approach along with stabilisation and showed adequately good results for burst fracture (spine J 2004) In posterior approach, the extent of fixation should be decided according to the classification of the fracture. Short segment fixation could usually suffice in AO type A and B fractures. Long segment fixations should be carried out in AO type 3 fractures, severely comminuted fractures and osteoporotic bones [25]. We feel that incomplete neurological deficit with demonstrable radiological compression on MRI, should be subjected to canal clearance either by transpedicular approach or direct decompression, anteriorly or posteriorly. So patient underwent Posterior surgery on 3rd day after injury with laminectomy, transpedicular neural decompression with partial corpectomy, reduction, fixation of two levels above and below with pedicle screws and reconstruction of anterior column by transforaminal approach with partial bone graft and Titaneum cage.

Take Home message –
To conclude, unstable thoracolumbar junctional fracture are known to cause neurological deficit though that is not the rule. Neurological deficit and structural instability dictates Surgical Intervention Classifying the grade of Instability and establishing level of neurological deficit is paramount. Pendulum is shifting towards all posterior spine surgery. Every fracture is unique and management is tailor made. Depending on Fracture pattern, stability, neurology and disruption of ligament complex will dictate the treatment protocol. Anterior versus posterior, short versus long fixation, open decompression versus indirect decompression have been issues. In today’s era, every treatment protocol is evidence based and result oriented. Issues of anterior surgery are well described, morbidity of approach, risk to major vascular structures and organs, need definite consideration. We have given algorithm depending on the literature and their clinical experience over years of managing thoracolumbar fractures.

References

1. Rajasekaran S, Thoracolumbar burst fractures without neurological deficit: the role for conservative treatment, Eur Spine J. 2010 Mar;19 Suppl 1:S40-7.
2. Dennis F. The three column spine and its signifi cance in the classifi cation of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976). 1983; 8(8):817-831.
3. Tator CH, Koyanagi I (1997) Vascular mechanisms in the pathophysiology
of human spinal cord injury. J Neurosurg 86:483– 492
4. Steven C. Kirshblum et al, International standards for neurological classification of spinal cord injury (Revised 2011) J Spinal Cord Med. 2011 Nov; 34(6): 535–546.
5. Frankel HL, Hancock DO, Hyslop G, et al. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. Paraplegia 1969;7(3):179–192
6. American Spinal Injury Association: International Standards for Neurological Classification of Spinal Cord Injury, revised 2000; Atlanta, GA, Reprinted 2008.
7. Nicoll EA. Fractures of the dorso-lumbar spine. J Bone Joint Surg Br. 1949; 31(3):376-395.
8. Panjabi MM, Thibodieau LL, Crisco JJ, White AA. What constitutes spinal instability? Clin Neurosurg. 1988; (34):313-319
9. Bohler L. Die techniek de knochenbruchbehandlung imgrieden und im kriege. Verlag von Wilhelm Maudrich 1930 (in German).
10. Joon Y. Lee et al, Thoracolumbar injury classification and severity score: a new paradigm for the treatment of thoracolumbar spine trauma, J Orthop Sci (2005)
11. McCormack, Thomas MD; Karaikovic, Eldin MD; Gaines, Robert W. MD
Spine:The Load Sharing Classification of Spine Fractures, SPINE vol9, pp1741-1744, J.B Lippincott
12. Magerl F, Aebi M, Gertzbein SD, et al. A comprehensive classification of thoracic and lumbar injuries. Eur Spine 1994;3: 184-201.
13. Alexander R. Vaccaro et al, AOSpineThoracolumbar Spine Injury Classification System, SPINE Volume 38, Number 23, pp 2028-2037 Spine 2013, Lippincott Williams & Wilkins
14. Fan KF, Tu YK, Hsu RW et al (1997) The high fixation failure rate of short segment pedicle instrumentation for unstable thoracolumbar burst fractures. Orthop Trans 21:267
15.Celibi L, Muratli HH, Dogan O et al (2004) The efficacy of nonoperative treatment of burst fractures of the thoracolumbar vertebrae. Acta Orthop Traumatol Turc 38(1):16–22
16. Shen WJ, Liu TJ, Shen YS (2001) Nonoperative treatment versus posterior fixation for thoracolumbar junction burst fractures without neurologic deficit. Spine 26:1338–1345
17. Lu J, Ashwell KW, Waite P (2000) Advances in secondary spinal cord injury: role of apoptosis. Spine 25:1859–1866
18. Bohlman HH, Freehafer A, Dejak J. The results of treatment of acute injuries of the upper thoracic spine with paralysis. J Bone Joint Surg Am 1985;67A:360–369
19. Bellabarba C, Fisher C, Chapman JR, Dettori JR, Norvell DC. Does early fracture fixation of thoracolumbar spine fractures decrease morbidity or mortality? Spine (Phila Pa 1976). 2010 Apr 20;35(9 Suppl):S138-45.
20. Wu H, Fu C, Yu W, Wang J. The options of the three different surgical approaches for the treatment of Denis type A and B thoracolumbar burst fracture. Eur J Orthop Surg Traumatol. 2014 Jan;24(1):29-35.
21. Zahra B, Jodoin A, Maurais G, Parent S, Mac-Thiong JM. Treatment of thoracolumbar burst fractures by means of anterior fusion and cage. J Spinal Disord Tech. 2012 Feb;25(1):30-7.
22. Schnee CL, Ansell LV. Selection criteria and outcome of operative approaches for thoracolumbar burst fractures with and without neurological deficit. J Neurosurg. 1997 Jan;86(1):48-55
23. M. Payer. Unstable burst fractures of the thoraco-lumbar junction: treatment by posterior bisegmental correction/fixation and staged anterior corpectomy and titanium cage implantation Acta Neurochir (Wien) (2006) 148: 299
24. Kaya RA, Aydin Y. Modified transpedicular approach for the surgical treatment of severe thoracolumbar or lumbar burst fractures. Spine J. 2004 Mar-Apr;4(2):208-17
25. Altay M, Ozkurt B, Aktekin CN, Ozturk AM, Dogan O, Tabak AY. Treatment of unstable thoracolumbar junction burst fractures with short- or long-segment posterior fixation in magerl type a fractures. Eur Spine J. 2007;16:1145–1155
26. Limb D, Shaw DL, Dickson RA. Neurological injury in thoracolumbar burst fractures. J Bone Joint Surg Br. 1995; 77(5):774–777
27. Wilcox R, Boerger T, Allen D, et al. A dynamic study of thoracolumbar burst fractures. J Bone Joint Surg Am. 2003; 85(11):2184–2189
28. Boerger TO, Limb D, Dickson RA. Does ‘canal clearance’ affect neurological outcome after thoracolumbar burst fractures?J Bone Joint Surg Br. 2000; 82(5):629–635.

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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.

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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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

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Volume 1 | Issue 2 | Sep – Dec 2016 | Page 44-48 | Dhiraj Vithal Sonawane, Ganesh Yeotiwad, Ajay Chandanwale, Swapnil Keny, Abhijeet Salunke, Ambarish Mathesul, Eknath Pawar

Authors : Dhiraj Vithal Sonawane [1], Ganesh Yeotiwad [1], Ajay Chandanwale [3], Swapnil Keny [1], Abhijeet Salunke [4], Ambarish Mathesul [3], Eknath Pawar [2]

[1] Department of Orthopaedics, Grant Medical college, & Gokuldas Tejpal Hospital, Mumbai
[2] Department Of Orthopaedics, Grant medical college, Mumbai.
[3] Sasoon Hospital & BJMC, Pune
[4] Gujarat Cancer Research Institute

Address of Correspondence
Dr. Dhiraj V. Sonawane
Grant Medical college, & Gokuldas
Tejpal Hospital, Mumbai
Email: dvsortho@gmail.com

Abstract

Objective: The aim of the current study was to document the demographic pattern, mode of injury, level of cervical spine injury in patients so that it can be extrapolated for formulating guidelines in developing nations for proper management of this life threatening injury.
Methods: This study comprised of 275 patients of cervical spine injury admitted in a tertiary care centre from January 2006 to October 2015.
Results: The mean age was (3 to 95) and male to female ratio was 11.5: 1. Majority (30 %) of cases were of third and fourth decade. 60 % of patient fall from height as mechanism of injury. The urban to rural ratio of patients was 3:1 and 184 patients (67%) belonged to the rural areas. The most common mode of injury in the present study was fall from height, 166 cases (60%) of which most of them occurred while working and fall from tree. Dislocation at C 5-6 vertebral level was commonest and a C 5 vertebra was most commonly fractured. Incomplete cord injury of ASIA grade C scale was the commonest pattern seen in 156 cases. Head injury was commonest associated injury with cervical spine injury.
Conclusion: Identification of demographic data and mechanism of injury pattern helps to identify the preventable risk factors for controlling them. Proper education and training of paramedical staff in rural areas of initial aid and transportation of patients having spinal cord injuries can reduce the frequency and morbidity of spine injuries
Keywords: Cervical spine, Injury, Epidemiology, demographic study, Spinal cord, Mechanism of injury

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