STUDY DESIGN: Retrospective diagnostic study. PURPOSE: To define a new radiological sign, “Baltalimani sign,” in severe angular kyphosis (SAK) and to report its relationship with the risk of neurological deficits and deformity severity. OVERVIEW OF LITERATURE: Baltalimani sign was previously undefined in the literature. METHODS: We propose Baltalimani sign as the axial orientation of the vertebrae that are located above or below the apex of angular kyphosis on anteroposterior radiographs. Patients with SAK of various etiologies with kyphotic angles ≥90° were selected and evaluated for the presence of Baltalimani sign. Demographic data of the patients including age, gender, etiology, neurological status, local kyphosis angles, and the location of the kyphosis apex were recorded. Sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPV) of Baltalimani sign for the risk of the neurological deficits were evaluated by the IBM SPSS ver. 20.0. A p-values of <0.05 were considered statistically significant. Cohen's kappa was used for analysis of interrater agreement. RESULTS: The mean local kyphosis angle in all patients was 124.2° (range, 90°–169°), and 15 of 40 (37.5%) patients had neurological deficits. Baltalimani sign was seen in 13 of 15 patients with neurological deficits (p=0.001). Baltalimani sign showed a sensitivity and specificity PPV and NPV of 61.9%, 86.7%, 89.5%, and 68.8% for the risk of the neurological deficits in SAK patients, respectively. Cohen's kappa value was moderate (κ=0.506). CONCLUSIONS: The detection of Baltalimani sign in SAK may indicate severity of deformity and the risk of neurological deficits.
Congenital Abnormalities ; Humans ; Kyphosis* ; Retrospective Studies ; Sensitivity and Specificity ; Spine

STUDY DESIGN: A prospective clinical series with prospectively collected data. PURPOSE: The efficacy of using closed suction drains (CSD) after single-level lumbar disc surgery was evaluated. Postoperative CSD are regularly fitted to prevent postoperative epidural hematomas (EH) after multilevel lumbar decompression, although it remains unclear whether CSD also reduces postoperative EH following single-level lumbar disc surgery. OVERVIEW OF LITERATURE: Few articles have addressed the clinical outcome in patients with single-level lumbar disc disease who were treated by two different operative methods (with and without drainage). METHODS: Between 2012 and 2014, 115 patients with a single level discectomy underwent two surgical procedures: with CSD (group A, 60 cases) and without CSD (group B, 55 cases). There were no significant differences in age, sex, segment level, herniation type, or disease duration between the groups. Wound infection, EH, and epidural fibrosis (EF) were evaluated by magnetic resonance imaging. Pain intensity was evaluated using the visual analog scale (VAS) and Oswestry disability index (ODI). Reduction in analgesic treatment and patient satisfaction were also recorded. RESULTS: The overall rate of postoperative EH was 5% and 16.3% in group A and B, respectively, whereas the rate of postoperative EF was 11.6% in group A and 21.8% in group B. The postoperative VAS score was 0.32 (standard deviation [SD], 0.45) for group A and 2.62 (SD, 06.9) for group B, whereas ODI was 9.11 (SD, 0.68) and 8.23 (SD, 0.78) for group A and and group B, respectively, with no significant differences observed. CONCLUSIONS: In patients operated on by unilateral, single-level lumbar disc surgery, the use of suction CSD into the operation site results in lower levels of EH and EF radiologically, thereby providing a better clinical outcome.
Back Pain ; Decompression ; Diskectomy ; Drainage* ; Fibrosis* ; Hematoma* ; Humans ; Magnetic Resonance Imaging ; Patient Satisfaction ; Prospective Studies ; Spine ; Suction ; Visual Analog Scale ; Wound Infection

STUDY DESIGN: Retrospective clinical analysis. PURPOSE: To delineate the clinical presentation of melioidosis in the spine and to create awareness among healthcare professionals, particularly spine surgeons, regarding the diagnosis and treatment of melioidotic spondylitis. OVERVIEW OF LITERATURE: Melioidosis is an emerging disease, particularly in developing countries, associated with a high mortality rate. Its causative pathogen, Burkholderia pseudomallei, has been labeled as a bio-terrorism agent. METHODS: We performed a retrospective analysis of patients who were culture positive for B. pseudomallei. Assessment of patients was performed using clinical, radiological, and blood parameters. Clinical measures included pain, neurological deficit, and return to work. Radiological measures included plain radiography of the spine and magnetic resonance imaging. Blood tests included erythrocyte sedimentation rate and C-reactive protein levels. RESULTS: Four patients having melioidosis with spondylitis were evaluated. All of them had diabetes mellitus; three had multiple abscesses which required incision and drainage. Their clinical spectrum was similar to that of tuberculous spondylitis; all had back pain and radiology revealed infective spondylodiscitis with prevertebral and paravertebral collections with psoas abscess. Three patients underwent ultrasound-guided drainage of the psoas abscess and one had aspiration of the subcutaneous abscess. Bacteriological cultures showed presence of B. pseudomallei, and histopathology showed non-caseating granulomatous inflammation. All patients were treated with intravenous Ceftazidime for 2 weeks, followed by oral bactrim double strength and Doxycycline for 20 weeks. All patients improved with treatment and were healed at follow up. CONCLUSIONS: Melioidosis presents with a clinical spectrum similar to that of tuberculosis. A diagnosis of melioidotic spondylitis should be considered, particularly in patients with diabetes with neutrophilic leukocytosis and clinical-radiological features suggestive of infective spondylodiscitis. Bacteriological culture and histopathology helps in differentiating the two conditions. Health education for healthcare professionals is important for correctly diagnosing this disease.
Abscess ; Anti-Bacterial Agents ; Back Pain ; Blood Sedimentation ; Burkholderia pseudomallei ; C-Reactive Protein ; Ceftazidime ; Delivery of Health Care ; Developing Countries ; Diabetes Mellitus ; Diagnosis ; Discitis ; Doxycycline ; Drainage ; Follow-Up Studies ; Health Education ; Hematologic Tests ; Humans ; Inflammation ; Leukocytosis ; Magnetic Resonance Imaging ; Melioidosis ; Mortality ; Neutrophils ; Psoas Abscess ; Radiography ; Retrospective Studies ; Return to Work ; Spine ; Spondylitis* ; Surgeons ; Trimethoprim, Sulfamethoxazole Drug Combination ; Tuberculosis

STUDY DESIGN: This is a retrospective study on patients with traumatic subaxial cervical spondyloptosis and includes a review of the available literature regarding the management of this injury. PURPOSE: This study aimed to assess the biomechanics and varied clinical presentations of this rare but devastating injury. OVERVIEW OF LITERATURE: This is a case series of three patients and a review of the available literature on subaxial cervical spondyloptosis. Traumatic cervical spondyloptosis of the subaxial spine is rare, with varied clinical presentations. METHODS: The management of cervical subaxial spondyloptosis represents a challenge to all spine care specialists, and there is a paucity of literature on the best methods for managing this condition. Our experience includes three such patients who visited our tertiary trauma center. This article explains the diverse clinical features of the injury as well as the management of these patients and includes a review of the available literature. RESULTS: Subaxial cervical spondyloptosis is a devastating injury with diverse clinical features. We present a classification of these fractures based on clinical presentation and magnetic resonance imaging results, which can help in decision-making regarding the management of such patients. CONCLUSIONS: This article may help physicians assess this injury in an evidence-based manner and also elucidates the management strategies available for such patients.
Classification* ; Decompression ; Humans ; Magnetic Resonance Imaging ; Neurology ; Retrospective Studies ; Specialization ; Spine* ; Trauma Centers

STUDY DESIGN: Monocentric prospective study. PURPOSE: To assess the safety and effectiveness of the posterior approach for resection of advanced Pancoast tumors. OVERVIEW OF LITERATURE: In patients with advanced Pancoast tumors invading the spine, most surgical teams consider the combined approach to be necessary for “en-bloc” resection to control visceral, vascular, and neurological structures. We report our preliminary experience with a single-stage posterior approach. METHODS: We included all patients who underwent posterior en-bloc resection of advanced Pancoast tumors invading the spine in our institution between January 2014 and May 2015. All patients had locally advanced tumors without N2 nodes or distant metastases. All patients, except 1, benefited from induction treatment consisting of a combination of concomitant chemotherapy (cisplatin-VP16) and radiation. RESULTS: Five patients were included in this study. There were 2 men and 3 women with a mean age of 55 years (range, 46–61 years). The tumor involved 2 adjacent levels in 1 patient, 3 levels in 1 patient, and 4 levels in 3 patients. There were no intraoperative complications. The mean operative time was 9 hours (range, 8–12 hours), and the mean estimated blood loss was 3.2 L (range, 1.5–7 L). No patient had a worsened neurological condition at discharge. Four complications occurred in 4 patients. Three complications required reoperation and none was lethal. The mean follow-up was 15.5 months (range, 9–24 months). Four patients harbored microscopically negative margins (R0 resection) and remained disease free. One patient harbored a microscopically positive margin (R1 resection) and exhibited local recurrence at 8 months following radiation treatment. CONCLUSIONS: The posterior approach was a valuable option that avoided the need for a second-stage operation. Induction chemoradiation is highly suitable for limiting the risk of local recurrence.
Drug Therapy ; Female ; Follow-Up Studies ; Humans ; Intraoperative Complications ; Male ; Neoplasm Metastasis ; Operative Time ; Pancoast Syndrome* ; Prospective Studies ; Recurrence ; Reoperation ; Spine*

STUDY DESIGN: Case control study. PURPOSE: To identify the most significant laboratory marker for early detection of surgical site infection (SSI) using multiple logistic regression analysis. OVERVIEW OF LITERATURE: SSI is a serious complication of spinal instrumentation surgery. Early diagnosis and treatment are crucial. METHODS: We retrospectively reviewed the laboratory data of patients who underwent posterior lumbar instrumentation surgery for degenerative spinal disease from January 2003 to December 2014. Six laboratory markers for early SSI detection were considered: renewed elevation of the white blood cell count, higher at 7 than 4 days postoperatively; renewed elevation of the C-reactive protein (CRP) level, higher at 7 than 4 days postoperatively; CRP level of >10 mg/dL at 4 days postoperatively; neutrophil percentage of >75% at 4 days postoperatively; lymphocyte percentage of <10% at 4 days postoperatively; and lymphocyte count of <1,000/µL at 4 days postoperatively. RESULTS: Ninety patients were enrolled; five developed deep SSI. Multivariate regression analysis showed that a lymphocyte count of <1,000/µL at 4 days postoperatively was the sole significant independent laboratory marker for early detection of SSI (p=0.037; odds ratio, 11.9; 95% confidence interval, 1.2–122.7). CONCLUSIONS: A lymphocyte count of <1,000/µL at 4 days postoperatively is the most significant laboratory marker for early detection of SSI.
Biomarkers* ; C-Reactive Protein ; Case-Control Studies ; Early Diagnosis ; Humans ; Leukocyte Count ; Leukocytes ; Logistic Models ; Lymphocyte Count ; Lymphocytes ; Lymphopenia* ; Neutrophils ; Odds Ratio ; Retrospective Studies ; Spinal Diseases ; Surgical Wound Infection*

STUDY DESIGN: Prospective clinical study. PURPOSE: To observe the usefulness of anterior cervical osteophytes as intrinsic markers for spinal level localization (SLL) during sub-axial cervical spinal surgery via the anterior approach. OVERVIEW OF LITERATURE: Various landmarks, such as the mandibular angle, hyoid bone, thyroid cartilage, first cricoid ring, and C6 carotid tubercle, are used for gross cervical SLL; however, none are used during cervical spinal surgery via the anterior approach. We present our preliminary assessment of SLL over anterior vertebral surfaces (i.e., intrinsic markers) in 48 consecutive cases of anterior cervical spinal surgeries for the disc-osteophyte complex (DOC) in degenerative diseases and granulation or tumor tissue associated with infectious or neoplastic diseases, respectively, at an ill-equipped center. METHODS: This prospective study on patients undergoing anterior cervical surgery for various sub-axial cervical spinal pathologies aimed to evaluate the feasibility and accuracy of SLL via intraoperative palpation of disease-related morphological changes on anterior vertebral surfaces visible on preoperative midline sagittal T1/2-weighted magnetic resonance images. RESULTS: During a 3-year period, 48 patients (38 males,10 females; average age, 43.58 years) who underwent surgery via the anterior approach for various sub-axial cervical spinal pathologies, including degenerative disease (n= 42), tubercular infection (Pott's disease; n=3), traumatic prolapsed disc (n=2), and a metastatic lesion from thyroid carcinoma (n=1), comprised the study group. Intrinsic marker palpation yielded accurate SLL in 79% of patients (n=38). Among those with degenerative diseases (n=42), intrinsic marker palpation yielded accurate SLL in 76% of patients (n=32). CONCLUSIONS: Intrinsic marker palpation is an attractive potential adjunct for SLL during cervical spinal surgeries via the anterior approach in well-selected patients at ill-equipped centers (e.g., those found in developing countries). This technique may prove helpful when radiographic visualization is occasionally inadequate.
Clinical Study ; Female ; Humans ; Hyoid Bone ; Intervertebral Disc Displacement ; Osteophyte ; Palpation ; Pathology ; Prospective Studies ; Spine* ; Spondylosis ; Thyroid Cartilage ; Thyroid Neoplasms

STUDY DESIGN: Prospective observational study. PURPOSE: To introduce the techniques and present the surgical outcomes of mini-open anterior lumbar interbody fusion (ALIF) at the most caudal segments of the spine combined with lateral lumbar interbody fusion (LLIF) for the correction of adult spinal deformity OVERVIEW OF LITERATURE: Although LLIF is increasingly used to correct adult spinal deformity, the correction of sagittal plane deformity with LLIF alone is reportedly suboptimal. METHODS: Thirty-two consecutive patients with adult spinal deformity underwent LLIF combined with mini-open ALIF at the L5–S1 or L4–S1 levels followed by 2-stage posterior fixation. ALIF was performed for a mean 1.3 levels and LLIF for a mean 2.7 levels. Then, percutaneous fixation was performed in 11 patients (percutaneous group), open correction with facetectomy with or without laminectomy in 16 (open group), and additional pedicle subtraction osteotomy (PSO) in 5 (PSO group). Spinopelvic parameters were compared preoperatively and postoperatively. Hospitalization data and clinical outcomes were recorded. RESULTS: No major medical complications developed, and clinical outcomes improved postoperatively in all groups. The mean postoperative segmental lordosis was greater after ALIF (17.5°±5.5°) than after LLIF (8.1°±5.3°, p <0.001). Four patients (12.5%) had lumbar lordosis with a pelvic incidence of ±9° preoperatively, whereas this outcome was achieved postoperatively in 30 patients (93.8%). The total increase in lumbar lordosis was 14.7° in the percutaneous group, 35.3° in the open group, and 57.0° in the PSO group. The ranges of potential lumbar lordosis increase were estimated as 4°–25°, 23°–42°, and 45°–65°, respectively. CONCLUSIONS: Mini-open ALIF combined with LLIF followed by posterior fixation may be a feasible technique for achieving optimal sagittal balance and reducing the necessity of more extensive surgery.
Adult* ; Animals ; Congenital Abnormalities* ; Hospitalization ; Humans ; Incidence ; Laminectomy ; Lordosis ; Observational Study ; Osteotomy ; Prospective Studies ; Spine

STUDY DESIGN: Prospective study. PURPOSE: To compare the efficacy of 24-hour and 72-hour antibiotic prophylaxis in preventing surgical site infections (SSIs). OVERVIEW OF LITERATURE: Antimicrobial prophylaxis in surgical practice has become a universally accepted protocol for minimizing postoperative complications related to infections. Although prophylaxis is an accepted practice, a debate exists with regard to the antibiotic type and its administration duration for various surgical procedures. METHODS: Our institute is a tertiary care hospital with more than 100 spinal surgeries per year for various spine disorders in the department of orthopedics. We conducted this prospective study in our department from June 2012 to January 2015. A total of 326 patients were enrolled in this study, with 156 patients in the 72-hour antibiotic prophylaxis group (group A) and 170 patients in the 24-hour group (group B). Cefazolin was the antibiotic used in both groups. Two surgeons were involved in conducting all the spinal procedures. Our study compared SSIs among patients undergoing instrumented spinal fusion. RESULTS: The overall rate of SSIs was 1.8% with no statistical difference between the two groups. CONCLUSIONS: The 24-hour antimicrobial prophylaxis is as effective as the 72-hour dosage in instrumented spinal fusion surgery.
Antibiotic Prophylaxis ; Cefazolin ; Humans ; Orthopedics ; Postoperative Complications ; Prospective Studies ; Spinal Fusion* ; Spine ; Surgeons ; Surgical Wound Infection ; Tertiary Healthcare

STUDY DESIGN: Technique description and retrospective data analysis. PURPOSE: To describe the technique of cervical kyphosis correction with partial facetectomies and evaluate the outcome of single-stage posterior decompression and kyphosis correction in multilevel cervical myelopathy. OVERVIEW OF LITERATURE: Kyphosis correction in multilevel cervical myelopathy involves anterior and posterior surgery. With the advent of cervical pedicle screw-rod instrumentation, single-stage posterior kyphosis correction is feasible and can address stretch myelopathy by posterior shortening. METHODS: Nine patients underwent single-stage posterior decompression and kyphosis correction for multilevel cervical myelopathy using cervical pedicle screw instrumentation from March 2011 to February 2014 and were evaluated preoperatively and postoperatively with modified Japanese Orthopaedic Association (mJOA) scoring and computed tomography scans for radiological measurements. Kyphosis assessment was made with Ishihara curvature index and C2–C7 Cobb's angle. The linear length of the spinal canal and the actual spinal canal length were also evaluated. The average follow-up was 40.56 months (range, 20 to 53 months). RESULTS: The average preoperative C2–7 Cobb's angle of 6.3° (1° to 12°) improved to 2° (10° to −9°). Ishihara index improved from −15.8% (−30.5% to −4.7%) to −3.66% (−14.5% to +12.6%). The actual spinal canal length decreased from 83.64 mm (range, 76.8 to 91.82 mm) to 82.68 mm (range, 75.85 to 90.78 mm). The preoperative mJOA score of 7.8 (range, 3 to 11) improved to 15.0 (range, 13 to 17). CONCLUSIONS: Single-stage posterior decompression and kyphosis correction using cervical pedicle screws for multilevel cervical myelopathy may address stretch myelopathy, in addition to decompression in the transverse plane. However, cervical lordosis was not achieved with this method as predictably as by the anterior approach. The present study shows evidence of mild shortening of cervical spinal canal and a positive correlation between canal shortening and clinical improvement.
Animals ; Asian Continental Ancestry Group ; Decompression ; Follow-Up Studies ; Humans ; Kyphosis* ; Lordosis ; Methods ; Pedicle Screws* ; Retrospective Studies ; Spinal Canal ; Spinal Cord Diseases* ; Statistics as Topic