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Introduction Symptomatic Adjacent segment disease presents in myriad ways with varying clinic-radiological presentation but the optimal management and the factors that predict need for revision surgery are unclear. Methodology Consecutive patients ( n  = 132) who experienced significant back or leg pain after an asymptomatic period (minimum 1 year) following a lumbar fusion were evaluated with dynamic radiographs and MRI. ASD was classified anatomically as proximal (86.3%), distal (12.1%, or combined (1.5%) and, sub-classified pathologically into six sub-types: Type 1: Disc prolapse (17.4%), Type 2: Disc degeneration with intra-discal instability (15.1%), Type 3: Anterolisthesis and facet instability (6.8%), Type 4: Retrolisthesis (25%), Type 5: Stenosis (21.9%) and Type 6: Combined types (13.6%). Results The mean duration between the index surgery and ASD was 5.9 ± 4.1 years. Surgery was required in 40.9% (54/132). Six factors were highly predictive of surgical treatment for ASD, viz., Diabetes mellitus (OR-4.3, p  = 0.007), ASD– disc prolapse (OR 6.3, p  = 0.018), ASD intra-discal instability (OR-16.8206, p  = 0.003), ASD - anterolisthesis (OR − 8.2998, p  = 0.043), Facet angle > 75° (OR 37.6, p  = 0.02) and radiculopathy (OR 48.0, p  = 0.002). Retrolisthesis was the most benign type as 84.8% patients were managed conservatively ( p  = 0.016). Among proximal ASD, retrolisthesis was the most common subtype (28.9%) while disc prolapse was the most common subtype in distal ASD 37.5% ( p  = 0.032). Conclusion The study classifies the versatile clinic-radiological presentation of ASD, and identifies factors that predicted the development of the different sub-types of ASD. Knowledge about the six clinic-radiological factors that predict the need for surgical treatment in ASD is beneficial.

Study Design: Review article. Objectives: A review of literature on the epidemiology, diagnosis, and management of spinal tuberculosis (TB). Methods: A systematic computerized literature search was performed using Cochrane Database of Systematic Reviews, EMBASE, and PubMed. Studies published over the past 10 years were analyzed. The searches were performed using Medical Subject Headings terms, and the subheadings used were “spinal tuberculosis,” “diagnosis,” “epidemiology,” “etiology,” “management,” “surgery,” and “therapy.” Results: Tissue diagnosis remains the only foolproof investigation to confirm diagnosis. Magnetic resonance imaging and Gene Xpert help in early detection and treatment of spinal TB. Uncomplicated spinal TB has good response to appropriately dosed multimodal ambulant chemotherapy. Surgery is warranted only in cases of neurological complications, incapacitating deformity, and instability. Conclusions: The incidence of atypical clinicoradiological presentations of spinal TB is on the rise. Improper dosing, inadequate duration of treatment, and inappropriate selection of candidates for chemotherapy has not only resulted in the resurgence of TB but also led to the most dreadful consequence of multidrug resistant strains. In addition, global migration phenomenon has resulted in worldwide spread of spinal TB. The current consensus is to diagnose and treat spinal TB early, prevent complications, promote early mobilization, and restore the patient to his or her earlier functional status.

PurposeIntradiscal vacuum phenomenon (IDVP), despite being ubiquitous, is poorly understood. The dynamic passage of peri-discal gases into the degenerated disc is a commonly accepted theory. But the reasons behind its selective appearance in some discs are unevaluated.Methods721 patients with chronic low back pain ± radiculopathy, were evaluated with AP and flexion–extension lateral radiographs and MRI. IDVP was classified based on its morphology and location. Radiographic parameters including sagittal translation, sagittal angulation, lateral listhesis, eccentric disc collapse, Pfirrmann’s grade, disc height, Modic changes, anterior longitudinal ligament status, and primary spinal disease at the level of IDVP was analyzed.ResultsIDVP was present in 342 patients, and they had a higher mean age (57.2 ± 12.5 years) than controls (p < 0.001). Eccentric disc space narrowing (26.5% vs 1.3%, p < 0.01), coronal listhesis (7.83% vs 1.1%, p < 0.001), sagittal angular motion difference (11.3 ± 4.6°, p < 0.001), higher mean disc degeneration (4.36 ± 0.69, p < 0.001), ALL disruption (30.3% vs 2.2%, p < 0.001) and Modic changes (88.6% vs 17.5%, p < 0.001) were significantly higher in IDVP discs (vs. non-IDVP). Binary logistic regression analysis indicated sagittal angular motion difference was the most predictive factor. IDVP was classified into three types—dense type (47.5%), linear (29.5%), dot type (23%). Dense type matched radiological correlations of IDVP while dot types behaved like non-IDVP discs.ConclusionModic disc-endplate contacts, ALL disruption and coronal translation could be pathways for the passage of peri-discal gases into the degenerated disc. In the pathogenesis of IDVP, advanced disc degeneration, the presence of pathways of gas transfer and angular/coronal instability seem to play complementary roles.

Introduction Unplanned readmissions after spine surgery are undesired, and cause significant functional, and financial distress to the patients and healthcare system. Though critical, knowledge about readmissions after surgery for traumatic spinal injuries (TSI) is scarce and under-evaluated. Methods Consecutive patients surgically treated for TSI and who had unplanned readmission within 90 days post-discharge were studied. Peri-operative demographic and surgical variables, surgical treatment, level of injury, delay in surgery, ASIA score, other organ injuries, peri-operative complications, smoking, ICU stay, co-morbidity, and the length of hospital stay were studied and correlated with the causes for readmission. Results Among 884 patients, 4.98% ( n  = 44) had unplanned readmissions within 90 days of discharge. Notably, 50% ( n  = 22) patients were readmitted within the first 30 days. The common causes of readmissions were urinary tract related problems (27%, n  = 12), pressure ulcers (20.4%, n  = 9), respiratory problems (13.6%, n  = 6), surgical wound related problems (14%, n  = 7,) limb injuries (11.4%, n  = 5), and others (11%, n  = 5). The total beds lost secondary to readmissions was 314 days, and the mean bed-days lost per patient was 7.2 ± 5.1. Thirteen peri-operative risk factors were associated with unplanned readmissions, among which, smoking (OR 2.2), diabetes (OR 2.4), and pressure sore during index admission (OR 16.7) were strong independent predictors. Conclusion The incidence of unplanned readmissions after TSI was 5%, which was similar to elective spine surgeries but the causes and risk factors are different. Non-surgical complications related to urinary tract, respiratory care and pressure sores were the most common causes. Pre-operative smoking status, diabetes mellitus and pressure sores noted in the index admission were important independent risk factors.

BackgroundTo document the role of sub-clinical infections in disc disorders and investigate the existence of microbiome in intervertebral discs (IVD).MethodsGenomic DNA from 24 lumbar IVDs [8—MRI normal discs (ND) from brain dead yet alive organ donors, 8—disc herniation (DH), 8—disc degeneration (DD)] was subjected to 16SrRNA sequencing for profiling the diversity of human disc microbiome in health and disease. The disc microbiome was further compared to established human gut and skin microbiomes.ResultsAll healthy MRI normal discs from brain dead yet alive organ donors also had a rich bacterial presence. A total of 424 different species (355-ND, 346-DD, and 322-DH) were detected, with 42.75% OTUs being classified at kingdom level, 44% at the phylum level, 22.62% at genus level, and 5.5% at species level. Varying biodiversity and abundance between healthy and diseased discs were documented with protective bacteria being abundant in normal discs, and putative pathogens abundant in DD and DH. Propionibacterium acnes had a similar but lower abundance to other pathogens in all three groups ND (3.07%), DD (3.88%), DH (1.56%). Fifty-eight bacteria were common between gut and IVD microbiomes, 29 between skin and IVD microbiomes, and six common to gut/skin/IVD.ConclusionOur study challenges the hitherto concept of sterility in healthy IVD and documented a microbiome even in MRI normal healthy discs. The varying abundance of bacteria between ND, DD, and DH documents ‘dysbiosis’ as a possible etiology of DD. Many known pathogens were identified in greater abundance than Propionibacterium acnes, and there was evidence for the presence of the gut/skin/spine microbiome axis.

IntroductionConventional diagnosis of spinal tuberculosis (TB) is based on a combination of clinical features, laboratory tests and imaging studies, since none of these individual diagnostic features are confirmatory. Despite the high sensitivity of MRI findings in evaluating spinal infections, its efficacy in diagnosing spinal TB is less emphasized and remains unvalidated through tissue studies.MethodologyWe reviewed consecutive patients evaluated for spondylodiscitis with documented clinical findings, MRI spine, and tissue analysis for histopathology, TB culture and genetic TB PCR. MRI features documented include location, contiguous/non-contiguous skip lesions, para/intraosseous abscess, subligamentous spread, vertebral collapse, abscess size/wall, disc involvement, end plate erosion and epidural abscess. Based on the results, patients were divided into two groups—CONFIRMED TB with positive culture/histopathology and NON-TB. The efficacy of MRI findings in accurately diagnosing spinal TB was compared between the two groups.ResultsAmong 150 patients, 79 patients were TB positive, and 71 were TB negative. Three MRI parameters showed significant differences (p < 0.001), namely subligamentous spread (67/79, 84.8%), vertebral collapse > 50% (55/79, 69.6%) and large abscess collection with thin abscess wall (72/79, 91.1%) being strongly predictive of TB. Combination of MRI findings had a higher predictive value. 97.5% of TB positive patients had at least one of these three MRI features, 89.8% patients had any two and 58.2% had all three.ConclusionOur study validated different MRI findings with tissue studies and showed spinal infections with large abscess with thin wall, subligamentous spread of abscess and vertebral collapse were highly suggestive of spinal tuberculosis.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

Thoracolumbar spine fractures are common injuries that can result in significant disability, deformity and neurological deficit. Controversies exist regarding the appropriate radiological investigations, the indications for surgical management and the timing, approach and type of surgery. This review provides an overview of the epidemiology, biomechanical principles, radiological and clinical evaluation, classification and management principles. Literature review of all relevant articles published in PubMed covering thoracolumbar spine fractures with or without neurologic deficit was performed. The search terms used were thoracolumbar, thoracic, lumbar, fracture, trauma and management. All relevant articles and abstracts covering thoracolumbar spine fractures with and without neurologic deficit were reviewed. Biomechanically the thoracolumbar spine is predisposed to a higher incidence of spinal injuries. Computed tomography provides adequate bony detail for assessing spinal stability while magnetic resonance imaging shows injuries to soft tissues (posterior ligamentous complex [PLC]) and neurological structures. Different classification systems exist and the most recent is the AO spine knowledge forum classification of thoracolumbar trauma. Treatment includes both nonoperative and operative methods and selected based on the degree of bony injury, neurological involvement, presence of associated injuries and the integrity of the PLC. Significant advances in imaging have helped in the better understanding of thoracolumbar fractures, including information on canal morphology and injury to soft tissue structures. The ideal classification that is simple, comprehensive and guides management is still elusive. Involvement of three columns, progressive neurological deficit, significant kyphosis and canal compromise with neurological deficit are accepted indications for surgical stabilization through anterior, posterior or combined approaches.

Purpose Acute Paraspinal compartment syndrome (PCS) is a very rare clinical condition resulting from high pressures within the erector spinae muscle compartment due to intense edema of the erector spinae muscles and can be associated with rhabdomyolysis and renal injury. Though several causes have been identified, PCS caused by power yoga has not been reported. Power yoga is a form of fast and vigorous yoga, and involves intense flexion–extension of the spine and other parts of the body in a repetitive manner. Methods We report the case of a 36-year-old male who presented with acute onset of intense low back pain following power yoga practice. His lower limb neurology was normal and MRI showed diffuse intramuscular oedema of the bilateral para-spinal erector spinae muscles around the lumbar region indicative of PCS. Laboratory values of elevated urine myoglobin and serum creatinine phosphate kinase (CPK) confirmed the presence of rhabdomyolysis. He was monitored closely for renal injury and treated by rest, analgesics, fluid management and supportive care. Results Serial CPK values indicated a decreasing trend and at sixth week, the value was normal. Follow-up MRI at 6 weeks showed complete resolution of muscle oedema. Patient had full recovery and returned to normal activities in 6 months. This report highlights the importance of vigilance and performing early MRI for diagnosing yoga-induced PCS, so that appropriate treatment can be initiated avoiding serious sequelae of rhabdomyolysis and paraspinal muscle loss. Conclusion This report highlights the need for suspicion and early MRI for diagnosing yoga-induced PCS and appropriate care.