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   Table of Contents - Current issue
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July-December 2021
Volume 9 | Issue 2
Page Nos. 51-100

Online since Thursday, June 23, 2022

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ORIGINAL ARTICLES  

Opioid use after adult spinal deformity surgery: A propensity-matched comparison of Japanese vs. American cohorts p. 51
Yoji Ogura, Jeffrey L Gum, Leah Y Carreon, Mitsuru Yagi, Naobumi Hosogane, Morio Matsumoto, Kota Watanabe, Justin S Smith, Christopher I Shaffrey, Virginie F Lafage, Douglas C Burton, Richard A Hostin, Michael P Kelly, Khaled Kebaish, Frank J Schwab, R Shay Bess, Christopher P Ames
DOI:10.4103/JOASP.JOASP_46_21  
BACKGROUND: Amidst a current US opioid epidemic, it is important to understand factors that contribute to long-term opioid use after elective surgery. In Asian countries, opioids are rarely prescribed for post-operative pain. MATERIALS AND METHODS: We propensity-matched 127 JPN to 619 US adult spinal deformity (ASD) patients based on age, sex, 3-column osteotomy, pelvic fixation, number of levels fused, and pre-operative sagittal vertical axis (SVA). Pre-operative and 2-year post-operative opioid use was determined using responses to SRS-22r Q11 and grouped into three categories (none, weekly, or daily). RESULTS: From each cohort, 34 cases were successfully matched, with no difference in baseline parameters, including baseline opioid use (P = 0.095), between the cohorts. At 2 years following surgery, 22 US (65%) vs. 31 JPN (91%) reported no opioid use; 11 US (32%) vs. 3 JPN (9%) reported daily use (P = 0.009). There was no difference in 2-year SRS-22r Self-image and Mental Health between the two groups, whereas US patients had better satisfaction (4.29 vs. 3.84, P = 0.032) but lower function scores (3.52 vs. 3.90, P = 0.029). CONCLUSION: In propensity-matched ASD cohorts, 35% of US patients were still using opioids 2 years after surgery compared with 9% of JPN patients, with the most taking opioids daily. Further studies are needed to identify sources of this variability.
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Surgical treatment of symptomatic non-union after transforaminal lumbar interbody fusion p. 56
Naveed Nabizadeh, Steven D Glassman, Morgan E Brown, Leah Y Carreon
DOI:10.4103/JOASP.JOASP_63_21  
INTRODUCTION: Transforaminal lumbar interbody fusion (TLIF) is frequently performed to treat lumbar degenerative diseases. As with any fusion procedure, there are patients who fail to achieve a solid fusion and require revision surgery. The purpose of this study is to evaluate the clinical and functional outcomes of revision procedures performed by different approaches for non-union following TLIF. MATERIALS AND METHODS: Electronic medical records and radiographs of 52 adult patients with symptomatic non-union confirmed at surgery after single or multilevel TLIF who underwent revision surgery from 2012 to 2019 and had at least 1-year follow-up were reviewed. Data collected included demographics, surgical approach, numeric back and leg pain scores (0–10), Oswestry Disability Index scores before and after revision and complications. RESULTS: Revision for non-union was performed for an average of 31.7 months, following the index procedure. Fifteen patients underwent an anterior-only approach, and 28 cases underwent a combined anteroposterior approach with exchange of posterior instrumentation and decompression. Nine cases underwent a posterior-only approach with or without decompression and bone graft on the lateral gutters. There were no significant differences between various surgical approaches in terms of demographics, surgical parameter, pain relief, functional improvement, or complications. CONCLUSIONS: The current study showed that improvement of clinical symptoms and functional outcome was less than 50%, regardless of the surgical approach type. A low percentage of individuals experienced aggravation of leg pain, back pain, or dysfunction. There was also no distinctive advantage for any individual approach in TLIF revision.
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Outcomes of medial opening wedge high tibial osteotomy following concomitant arthroscopic procedures in medial compartmental osteoarthritis of knee p. 60
Suresh Kumar Choudhary, Sunil Kumar Thakur, Chander Mohan Singh, Ravishekar Ningayya Hiremath, Sandhya Ghodke, Rishi Raj
DOI:10.4103/JOASP.JOASP_32_21  
BACKGROUND: The purpose of this study was to analyze the outcome of concomitant arthroscopic procedures followed by medial opening wedge high tibial osteotomy (HTO) in medial compartment osteoarthritis (OA) of the knee. MATERIALS AND METHODS: Based on inclusion and exclusion criteria, a prospective observational study was carried out on 26 patients with medial compartment OA of the knee who underwent concomitant arthroscopic procedures followed by medial opening wedge HTO at one of the multispecialty hospitals in Northern India and were followed-up for one year. The mean age of the study population was 46.9 years. Preoperative values of pain score, functional score, range of motion (ROM), and tibiofemoral angle were compared with postoperative values at 6 weeks, 12 weeks, 24 weeks, and 1 year. A telephonic consultation at five-year post-op was carried out enquiring about activities of daily living and any need for knee replacement in near future. RESULTS: There was a significant improvement in terms of pain relief and functional outcome as per the Knee Society Score. The mean ROM was improved from 120.42° preoperatively to 127.96° postoperatively. The targeted tibiofemoral angle was achieved and maintained at a one-year follow-up. The osteotomy site healed well in all patients. None of the patients developed, postoperative compartment syndrome, patella baja, instability, or peroneal palsy which are otherwise known complications. On telephonic consultation at the latest follow-up (five-year postoperative) all are comfortable with activities of daily living and none of them seek knee replacement in immediate future. In our study, one patient (3.8%) developed surgical site infection, which was treated with intravenous antibiotics and removal of the implant after the union and one patient (3.8%) had painful terminal movement at final follow-up. CONCLUSION: Concomitant arthroscopic procedures followed by medial opening wedge HTO is a joint preserving surgery with good to excellent outcomes for the treatment of the refractory pain and disability caused by OA of knee involving the medial compartment in a mal-aligned limb in young and middle-aged active patients. The deformity correction achieved by medial opening wedge HTO is translated in terms of comfort achieved in daily living activities, relief of symptoms of OA, and improvement in function with an unimpeded lifestyle. We also conclude that overtreatment of isolated medial compartment OA of the knee can be aborted by doing HTO, which can definitely buy time before the more radical procedure is unavoidable, it cannot the risk of future total knee replacement be prevented.
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The influence of referencing system on PCO and PCOR in primary total knee arthroplasty and its effect on postoperative range of motion and functional scores p. 68
Ratnakar Vecham, Aditya P Apte, Adarsh Annapareddy, Santhosh Kumar Govinde Gowda, T Chiranjeevi, Gurava Reddy
DOI:10.4103/JOASP.JOASP_39_21  
OBJECTIVE: The restoration of native posterior condylar offset (PCO) is considered to be an integral component of a successful total knee arthroplasty (TKA). Its effect on postoperative flexion is still not clear. The two referencing systems viz. anterior and posterior differ in their basic philosophy for selecting the appropriately sized femoral component. In this study, we aimed to evaluate their effect on the PCO, posterior condylar offset ratio (PCOR), notching, and anterior flange bone contact ratio. We also evaluated the influence of referencing system on postoperative flexion and functional scores at 2-year follow-up. MATERIALS AND METHODS: This was a retrospective single-center, single-surgeon study. Total 200 primary TKA (100––anterior referencing [AR]; 100––posterior referencing [PR]) were evaluated. The PCO and PCOR were measured pre- and postoperatively. In addition, if the femoral component was not seated properly, anterior flange–bone contact ratio and the incidence of notching were documented as well. RESULTS: Postoperatively, the mean PCO increased to 3.24 and 3.04 from 2.90 and 2.85 in the PR and AR groups, respectively. The comparative increase in PR group was significant (P < 0.001). Likewise, the PCOR increased postoperatively in both the groups and the comparative increase in PR was significant (P < 0.00). However, the comparative increase in flexion was not significant (P = 0.72)CONCLUSION: PR system provides better contact between anterior flange and anterior cortex of the femur. It also led to a significant increase in PCO and PCOR postoperatively. However, this does not significantly influence the ROM and Oxford knee scores at 2-year follow-up.
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Accuracy of pedicle screw fixation in lumbar spine by freehand technique studied postoperatively by computed tomography p. 73
Vaibhav Ukarda Mesare, Rajiv V Kulkarni, Amey Gursale, Anjali Tiwari, Rohit Kaware
DOI:10.4103/JOASP.JOASP_3_22  
Background: Spinal stabilization using pedicle screw has been widely used in spinal surgery for the management of various pathologies. Aims: We aimed to assess the accuracy of pedicle screw fixation in the lumbar spine by freehand technique studied by postoperative computed tomography (CT) scan. Setting and Design: This prospective observational study was carried out in a tertiary healthcare facility specializing in managing spine deformities. Materials and Methods: The study involved 55 patients with 253 pedicle screws. The accuracy of pedicle screws is determined by calculating breaches in the cortex based on a postoperative CT scan done on three weeks’ postoperative follow-up (on suture removal) and confirming by the index surgeon. Postoperative CT was done in all the patients to evaluate implant position within the first month after surgery. Statistical Analysis: Chi-squared test was used to find the statistical significance. Results: In this study, the accuracy of the pedicle screw in the fixation of the lumbar spine was 95.25%, and the incidence of pedicle breaches was 4.75%. The left breach was comparatively higher than the right breach (5.51% vs. 3.96%). Among 12 breaches of the pedicle trajectory, 7 (58.33%) breaches as compared to the 5 (41.66%) on the left side (P = 0.99). Conclusion: In conclusion, CT scan is a reliable and effective method for postoperative assessment of spinal pedicle screw placement.
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A prospective study analyzing the clinical outcome of degenerative lumbar canal stenosis treated by laminectomy p. 79
Ravi M Daddimani, Srinath M Murthy, Shatanand P Rao, Viswanath M Patil
DOI:10.4103/JOASP.JOASP_56_21  
BACKGROUND: Degenerative lumbar canal stenosis is a common disease occurring and one of the common indications for spine surgery in elderly. There are many objective measures such as neurological deficits, Japanese Orthopaedic Association score, and radiological evaluation to analyze the clinical outcome. Spinal surgeries are performed to improve the quality of life and to prevent long-term disabilities; hence self-assessing subjective measures are required to accurately assess the clinical outcome. Self-assessed subjective methods for assessing the quality of life are Oswestry disability index (ODI), self-paced walk test (SPWT), and visual analogue score (VAS). AIM OF THE STUDY: The aim of the study was to assess the clinical outcome using self-assessed subjective methods, namely, self-ODI score, SPWT score, and VAS for the back and leg. SETTING AND STUDY DESIGN: We performed a prospective study of a surgical outcome of lumbar canal stenosis using subjective methods. MATERIALS AND METHODS: Fifty patients diagnosed clinically with degenerative lumbar canal stenosis having ODI score of more than 40 and failed conservative surgery were evaluated with the magnetic resonance imaging of spine before undergoing surgical decompression. Preoperative self-assessed subjective measures ODI score, SPWT score, and VAS were compared with 12 months’ postoperative scores. STATISTICAL ANALYSIS USED: Statistical methods used for the analysis were dependent t test, Wilcoxon matched paired test, and Spearman’s rank correlation method. RESULTS: The mean preoperative ODI score was 57.3 and postoperative was 7.4. The mean SPWT distance was 124.9 meters preoperatively and 1482.0 meters postoperatively. CONCLUSION: We conclude that surgical decompression for degenerative lumbar stenosis gives good clinical results in terms of patient’s quality of life as suggested by improved postoperative ODI score, SPWT distance, and VAS compared with preoperative scores.
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CASE REPORTS Top

The spine duo: A rare case of Brucella spondylodiscitis with spondylolisthesis p. 85
Sushma Krishna, Sumanth Kaiwar, Amrithlal A Mascarenhas, G Poorani, Surya Dhilipan, GN Lakshmikantha
DOI:10.4103/JOASP.JOASP_38_21  
We describe a case of a 45-year-old dairy farmer who came with complaints of fever, back pain, and inability to walk following a fall. The diagnosis was based on consistent clinical features, radiological findings, positive antibody titers, and a favorable response to therapy. Brucella spondylitis, although rare, is a known entity in the literature. However to the best of our knowledge, this is the first case of concurrent Brucella spondylodiscitis with spondylolisthesis at the same vertebral level being reported from the country. A high index of suspicion is required to make the diagnosis of spine brucellosis presenting with features of spondylodiscitis with spondylolisthesis. Early initiation of definitive treatment helps in complete recovery. Emphasis has to be on educating the dairy farmers about the measures to prevent animal–human transmission, more so significant in cases presenting with complications.
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Correction of kyphosis by overcoming the challenge of pedicle screw fixation in previously augmented vertebrae by vertebroplasty p. 90
Shailesh Hadgaonkar, Himanshu Gurunath Kulkarni, Askhar Haphiz, Parag Sancheti, Ashok Shyam
DOI:10.4103/JOASP.JOASP_25_21  
Osteoporotic vertebral compression fractures (OVCF) is one of the most common degenerative spine pathologies that a spine surgeon comes across. Percutaneous cement augmented vertebroplasty or Balloon kyphoplasty are one of the most commonly used treatment modalities for OVCF. Spine surgeons may sometimes encounter situations in which they might need to operate for another spinal pathology, such as degenerative spinal instabilities, spinal infections, and neoplasms, which warrant posterior instrumented stabilization in patients who have already undergone vertebroplasty. Passing pedicle screws in these vertebrae can be very difficult and if these levels are skipped, the span of the fixation may increase and involve more normal levels for the sake of the stability of the construct. We present a case of a 49-year-old male with severe back pain, Cushing’s syndrome, and thoracicolumbar kyphosis occurring due to multiple osteoporotic fractures, which had been previously treated with vertebroplasties at five levels. With meticulous preoperative planning with CT scans and whole spine X-rays, pedicle screws were passed in vertebrae that had been previously augmented with vertebroplasty. Kyphosis and sagittal balance were completely corrected, and the patient exhibited significant symptomatic improvement. So, we suggest that even though many surgeons feel that the presence of vertebroplasty contraindicates the placement of pedicle screws in the vertebrae previously treated with vertebroplasty, it is feasible with proper preoperative planning.
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Management of C1-C2 instability with distorted cranio-vertebral anatomy by using 3D CT angiography model: A rare case report p. 94
Neetin P Mahajan, Ajay S Chandanwale, Dhiraj V Sonawane, Tushar Chandrakant Patil
DOI:10.4103/JOASP.JOASP_54_21  
Atlantoaxial instability is between C1/atlas and C2/axis, and it can be caused by different conditions such as congenital anomalies (Down syndrome, Morquio syndrome, and other skeletal dysplasias), inflammatory diseases, traumatic fractures, tumors, and infections. This necessitates the need for surgical occipito-cervical fusion (OCF) to prevent further injury to the spinal cord and subsequent myelopathy. Atlantoaxial instability is a rare condition and is commonly seen in 30% of patients with Down syndrome and in 30–80% of patients with rheumatoid arthritis; however, very few are symptomatic. Here, we present a rare case of a 17-year-old male with atlantoaxial instability due to occipitalized atlas and congenital fusion of C2-C3. The patient was operated by occipitoaxial fixation using C2 pedicle screws and an occipital plate with a rod construct with onlay bone allograft for bony fusion. Occipitoaxial fixation with a significant decrease in atlantodental interval (ADI) can be obtained by the use of C2 pedicle screws, and an occipital plate with a rod construct provides a rigid fixation and stability in the management of atlantoaxial joint instability with C1-C2 fusion due to an onlay bone allograft. Unnecessary C1 instrumentation and donor site morbidity for bone autografts can be avoided. Use of the 3D CT model helps to delineate the altered occipitocervical and vertebral artery anatomy intraoperatively, which aids in appropriate reduction and fixation.
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