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1.  The Extended Posterior Circumferential Decompression Technique in the Management of Tubercular Spondylitis with and without Paraplegia 
Asian Spine Journal  2014;8(6):711-719.
Study Design
Retrospective clinical series.
To study the clinical, functional and radiological results of patients with tuberculous spondylitis with and without paraplegia, treated surgically using the "Extended Posterior Circumferential Decompression (EPCD)" technique.
Overview of Literature
With the increasing possibility of addressing all three columns by a single approach, posterior and posterolateral approaches are gaining acceptance. A single exposure for cases with neurological deficit and kyphotic deformity requiring circumferential decompression, anterior column reconstruction and posterior instrumentation is helpful.
Forty-one patients with dorsal/dorsolumbar/lumbar tubercular spondylitis who were operated using the EPCD approach between 2006 to 2009 were included. Postoperatively, patients were started on nine-month anti-tuberculous treatment. They were serially followed up to thirty-six months and both clinical measures (including pain, neurological status and ambulatory status) and radiological measures (including kyphotic angle correction, loss of correction and healing status) were used for assessment.
Disease-healing with bony fusion (interbody fusion) was seen in 97.5% of cases. Average deformity (kyphosis) correction was 54.6% in dorsal spine and 207.3% in lumbar spine. Corresponding loss of correction was 3.6 degrees in dorsal spine and 1.9 degrees in the lumbar spine. Neurological recovery in Frankel B and C paraplegia was 85.7% and 62.5%, respectively.
The EPCD approach permits all the advantages of a single or dual session anterior and posterior surgery, with significant benefits in terms of decreased operative time, reduced hospital stay and better kyphotic angle correction.
PMCID: PMC4278975  PMID: 25558312
Extended posterior approach; Circumferential spinal canal decompression; Kyphosis correction; Interbody fusion; Neurological recovery
2.  Lumbar plexopathy following instrumented posterior lumbar interbody fusion: a complication with use of Hohmann’s retractor 
European Spine Journal  2013;22(9):2039-2046.
A series of 12 patients in our centre following single level instrumented posterior lumbar interbody fusion at L4–L5 developed unexplainable motor weakness in the proximal lumbar nerve roots (L2, L3) and numbness of the whole limb, a clinical picture resembling lumbar plexopathy. Even though lumbar plexopathy has been reported following gynaecological procedures and in transpsoas interbody fusion surgeries, there is no literature reporting this complication following conventional instrumented posterior lumbar interbody fusions.
Study design
Retrospective observational study.
To find the possible mechanism of development of lumbar plexopathy in patients who underwent posterior lumbar interbody fusion surgeries in our centre.
Material and methods
We analyzed retrospectively the medical records, electrophysiological reports of the patients, literatures on the anatomy of lumbar plexus and other literature reporting similar complications. We also dissected lumbar plexus of three cadavers and simulated surgical technique on them to find the mechanism of development of this unusual complication.
We found injury to lumbar plexus that probably occurred intraoperatively with Hohmann’s retractor that was used for retraction of the paraspinal muscles. This theory was favoured by many clinical factors and further confirmed by cadaveric dissections.
We conclude that surgical technique with improper use of Hohmann’s retractor causes traction and compression injury to the lumbar plexus resulting in this complication. We propose proper technique of insertion of Hohmann’s retractor and also recommend use of modified Hohmann’s retractor with shorter tips for spinal procedures to prevent such complication.
PMCID: PMC3777048  PMID: 23543368
Lumbar plexopathy; Instrumented posterior lumbar interbody fusion; Hohmann’s retractor
3.  Symptomatic Solitary Osteochondroma of the Subaxial Cervical Spine in a 52-Year-Old Patient 
Asian Spine Journal  2014;8(1):84-88.
Osteochondromas are the most common benign tumors of the bone. They mostly arise from the appendicular skeleton and present clinically in the second or third decade of life. Ostechondromas arising from the subaxial cervical spine and presenting after the 5th decade of life are extremely rare. We report a 52-year-old male patient who presented with numbness and subjective weakness of left upper and lower limbs and neck pain, and had lobulated bony hard fixed swelling in the right lower cervical paraspinal region. Radiological images revealed a bony swelling arising from C4 and C5 lamina with a cartilaginous cap and intraspinal extension. Excision biopsy with stabilisation of the spine was performed. Histopathalogical examination of the specimen confirmed the diagnosis of osteochondroma. We conclude surgical excision of such rare tumors, including the cartilaginous cap as well as the intraspinal component can reliably produce a good clinical outcome.
PMCID: PMC3939376  PMID: 24596611
Osteochondroma; Cervical spine; Elderly
4.  Lumbosacral Transition Vertebra: Prevalence and Its Significance 
Asian Spine Journal  2014;8(1):51-58.
Study Design
Retrospective analysis of radiological images.
To determine the prevalence of lumbosacral transition vertebra (LSTV) and to study its significance with respect to clinically significant spinal symptoms, disc degeneration and herniation.
Overview of Literature
LSTV is the most common congenital anomaly of the lumbosacral spine. The prevalence has been debated to vary between 7% and 30%, and its relationship to back pain, disc degeneration and herniation has also not been established.
The study involved examining the radiological images of 3 groups of patients. Group A consisted of kidney urinary bladder (KUB) X-rays of patients attending urology outpatient clinic. Group B consisted of X-rays with or without magnetic resonance images (MRIs) of patients at-tending a spine outpatient clinic, and group C consisted of X-rays and MRI of patients who had undergone surgery for lumbar disc herniation. One thousand patients meeting the inclusion criteria were selected to be in each group. LSTV was classified by Castellvi's classification and disc degeneration was assessed by Pfirrmann's grading on MRI scans.
The prevalence of LSTV among urology outpatients, spine outpatients and discectomy patients was 8.1%, 14%, and 16.9% respectively. LSTV patients showed a higher Pfirrmann's grade of degeneration of the last mobile disc. Results were found to be significant statistically.
The prevalence of LSTV in spinal outpatients and discectomy patients was significantly higher as compared to those attending the urology outpatient clinic. There was a definite causal relationship between the transitional vertebra and the degeneration of the disc immediately cephalad to it.
PMCID: PMC3939369  PMID: 24596605
Lumbosacral transitional vertebra; Castellvi's classification; Pfirrmann's grading; Spine outpatients; Urology outpatients; Discectomy patients
5.  Gorham's Disease of Spine 
Asian Spine Journal  2013;7(3):242-247.
Gorham's disease is a rare disorder characterized by clinical and radiological disappearance of bone by proliferation of non-neoplastic vascular tissue. The disease was first reported by Jackson in 1838 in a boneless arm. The disease was then described in detail in 1955 by Gorham and Stout. Since then, about 200 cases have been reported in the literature, with only about 28 cases involving the spine. We report 2 cases of Gorham's disease involving the spine and review related literature to gain more understanding about this rare disease.
PMCID: PMC3779779  PMID: 24066223
Gorham's disease; Spine
6.  Recurrent Echinococcal Infection of the Lumbar Spine: An 11 Year Follow-up 
Asian Spine Journal  2013;7(1):39-43.
Spinal hydatid cyst is a rare occurrence in non endemic countries. We present a case of recurrent lumbar hydatid disease in a 21-year-old male who following initial treatment had a good functional outcome and healing for 8 years, following which he came back with complaints of low back ache and neurological deficit. Patient underwent a second surgery with global debridement of L3-L5 vertebrae followed by medical management for two years. He had a good surgical outcome with recovery from the neurological deficit. Patient has returned to his routine activities and is being reviewed every year; there is no evidence of recurrence in the past 3 years. To the best of our knowledge recurrence after 8 years of initial treatment, followed by good clinical and radiological outcome for 3 years after surgery and treatment of the recurrence has not been reported in literature.
PMCID: PMC3596583  PMID: 23508512
Echinococcosis; Lumbar vertebrae; Albendazole
7.  Chondrosarcoma of the Spinous Process: A Rare Presentation 
Asian Spine Journal  2012;6(4):279-283.
Chondrosarcomas are malignant cartilage forming tumours. They form the second most common primary malignant tumour involving the vertebral axis. We present a rare presentation of a secondary chondrosarcoma from the spinous process of lumbar vertebra and discussed its management. The main emphasis is on the rare presentation and the need for awareness and suspicion of the pathology.
PMCID: PMC3530703  PMID: 23275812
Chondrosarcoma; Spinous process; Diagnosis; Treatment
8.  Left Second Rib Exostosis, Spinal Cord Compression and Left Upper Thoracic Scoliosis: A Rare Triad 
Asian Spine Journal  2012;6(3):207-210.
Exostosis of the rib with neural foraminal extension as a cause of spinal cord compression and scoliosis has to the best of our knowledge not been reported. We describe a young male with hereditary multiple exostosis who presented with a spastic gait, lower limb weakness and a deformity of the upper back. Radiographic imaging revealed a lesion arising from the left second rib which was encroaching the spinal canal and a scoliotic deformity of the upper thoracic spine. Through a single T shaped posterior approach he underwent a decompressive laminectomy of T1 and T2 vertebra and excision of the lesion. The diagnosis of osteochondroma was confirmed by histopathological studies. He was followed up at one year when his neurological condition had returned to normal however the scoliosis had increased.
PMCID: PMC3429613  PMID: 22977702
Rib; Osteochondroma; Cord compression; Scoliosis; Excision
9.  The Use of Titanium Mesh Cages in the Reconstruction of Anterior Column Defects in Active Spinal Infections: Can We Rest the Crest? 
Asian Spine Journal  2011;5(3):155-161.
Study Design
Retrospective clinical series.
To assess whether titanium cages are an effective alternative to tricortical iliac crest bone graft for anterior column reconstruction in patients with active pyogenic and tuberculous spondylodiscitis.
Overview of Literature
The use of metal cages for anterior column reconstruction in patients with active spinal infections, though described, is not without controversy.
Seventy patients with either tuberculous or pyogenic vertebral osteomyelitis underwent a single staged anterior debridement, reconstruction of the anterior column with titanium mesh cage and adjuvant posterior instrumentation. The lumbar spine was the predominant level of involvement. Medical co-morbidities were seen in 18 (25.7%) patients. A significant neurological deficit was seen in 32 (45.7%) patients. At follow up patients were assessed for healing of disease, bony fuson, and clinical outcome was assessed using Macnab's criteria.
Final follow up was done on 64 (91.4%) patients at a mean average of 25 months (range, 12 to 110 months). Pathologic organisms could be identified in 42 (60%) patients. Forty two (60%) patients had histopathological findings consistent with tuberculosis. Thirty of 32 (93.7%) patients showed neurological recovery. The surgical wound healed uneventfully in 67 (95.7%) patients. Bony fusion was seen in 60 (93.7%) patients. At final follow up healing of infection was seen in all patients. As per Macnab's criteria 61 (95.3%) patients reported a good to excellent outcome.
Inspite of the theoretical risks, titanium cages are a suitable alternative to autologous tricortical iliac crest bone graft in patients with active spinal infections.
PMCID: PMC3159063  PMID: 21892387
Thoracolumbar spine; Discitis; Anterior column reconstruction; Titanium cage
10.  Pathological dislocation of the dorsal spine following granulocytic sarcoma in a non-leukaemic patient 
European Spine Journal  2009;19(Suppl 2):114-117.
We describe a previously healthy, non-leukaemic young male presenting with neurological deficit and a pathological dislocation of D8 over D9 vertebra. The magnetic resonance imaging showed an enhancing soft tissue tumour. His basic laboratory workup as well as a bone marrow biopsy was normal. Through a single midline posterior approach, he underwent a decompressive laminectomy of D8 and D9 vertebra, anterior column reconstruction with a meshed titanium cage and posterior pedicle screw instrumentation. The histological diagnosis of granulocytic sarcoma was confirmed by appropriate immuno-histochemical studies. He received postoperative radiotherapy following which his wound dehiscesed and the tumour fungated and spread to his left thigh. He declined chemotherapy and unfortunately expired 9 months later. This case is presented to draw attention to the unusual presentation and to stress that granulocytic sarcoma should be kept in mind when making the differential diagnosis in patients with signs of spinal cord compression even in non-leukaemic individuals.
PMCID: PMC2899635  PMID: 19688354
Granulocytic sarcoma; Non-leukaemia; Pathological dislocation; Surgery

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