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PurposeInappropriate use of MRI leads to increasing interventions and surgeries for low back pain (LBP). We probed the potential effects of a routine MRI report on the patient’s perception of his spine and functional outcome of treatment. An alternate ‘clinical reporting’ was developed and tested for benefits on LBP perception.MethodsIn Phase-I, 44 LBP patients were randomized to Group A who had a factual explanation of their MRI report or Group B, who were reassured that the MRI findings showed normal changes. The outcome was compared at 6 weeks by VAS, PSEQ-2, and SF-12. In Phase-II, clinical reporting was developed, avoiding potential catastrophizing terminologies. In Phase-III, 20 MRIs were reported by both routine and clinical methods. The effects of the two methods were tested on four categories of health care professionals (HCP) who read them blinded on their assessment of severity of disease, possible treatment required, and the probability of surgery.ResultsBoth groups were comparable initial by demographics and pain. After 6 weeks of treatment, Group A had a more negative perception of their spinal condition, increased catastrophization, decreased pain improvement, and poorer functional status(p = significant for all). The alternate method of clinical reporting had significant benefits in assessment of lesser severity of the disease, shift to lesser severity of intervention and surgery in three groups of HCPs.ConclusionRoutine MRI reports produce a negative perception and poor functional outcomes in LBP. Focussed clinical reporting had significant benefits, which calls for the need for ‘clinical reporting’ rather than ‘Image reporting’.

Study Design: Prospective observational study.Purpose: In this study, we determined the effects of lumbar disk herniation (LDH) on male sexual activity and whether surgical intervention improved any related sexual dysfunction.Overview of Literature: The impact of surgery on sexual activity has been extensively studied in arthroplasty, uro-gynecological surgery, and stroke, but there are relatively few studies on spine surgery, and none involve an Asian population to the best of our knowledge.Methods: We evaluated sexually active male patients (n=22, 40.8±6.8 years) admitted for microdiscectomy with a questionnaire for assessing sexual function before and 8 weeks after surgery. The questionnaire included the Oswestry Disability Index, Hospital Anxiety Depression Score, and Brief Sexual Function Inventory (BSFI), as well as questions about perceived sexual dysfunction (frequency, performance, satisfaction).Results: The average preoperative Visual Analog Scale (VAS) score was 4.36±2.59 (n=18) for low back pain (LBP) and 6.81±2.1 (n=22) for leg pain. The mean preoperative BSFI score was 27.8±11.2. Among the five BSFI components, sexual drive was reduced in 63.0% of patients, while erection and ejaculation were affected in 40.9% and 31.8%, respectively. The VAS score for LBP had a negative correlation with the preoperative BSFI score (p <0.03). After LDH onset, 54.5% of patients noted a decrease in frequency, and 77.2% described a decrease in desire and satisfaction. At 8 weeks after surgery, the mean BSFI score significantly improved to 33.23 (p =0.002). Sexual drive was normal in 77.7% of patients, and erection and ejaculation were normal in 77.7% and 91.0%, respectively. Overall, 59.1% had resumed sexual intercourse within 6 weeks of surgery.Conclusions: LDH resulted in sexual dysfunction in up to 77% of patients, which significantly improved after surgery. By 6 weeks, the majority had resumed sexual activity without undue discomfort. Therefore, this study supports counseling for patients with LDH about sexual function.

Study Design Retrospective cohort study. Objective Lumbosacral transitional vertebra (LSTV) results in numerical alterations of the lumbar and sacral segments. Literature concerning true prevalence, associated disc degeneration, and variation in numerous anatomical landmarks concerning LSTV is lacking. Methods This is a retrospective cohort study. The prevalence of LSTV was determined in whole spine MRIs of 2011 poly-trauma patients. LSTV was identified as sacralization (LSTV-S) or lumbarization (LSTV-L) and further sub-classified into Castellvi’s and O’Driscoll’s type respectively. Disc degeneration was evaluated using Pfirmann grading. Variation in important anatomical landmarks was also analysed. Results Prevalence of LSTV was 11.6% with 82% having LSTV-S. Castellvi’s type 2A and O’Driscoll type 4 were the commonest sub-types. LSTV patients demonstrated considerably advanced disc degeneration. The median termination level of conus medullaris (TLCM) in non- LSTV and LSTV-L groups was at middle L1 (48.1% and 40.2%) while in the LSTV-S group, it was at upper L1 (47.2%). The median level of right renal artery (RRA) in non- LSTV patients was at middle L1 in 40.0% of individuals while in the LSTV-L and LSTV-S groups, it was at upper L1 level in 35.2% and 56.2% respectively. The median level of abdominal aortic bifurcation (AA) in non-LSTV and LSTV-S patients was at middle L4 in 83.3% and 52.04% respectively. However, in the LSTV-L group, the most common level was middle L5 (53.6%). Conclusion The overall prevalence of LSTV was 11.6%, with sacralization accounting for more than 80%. LSTV is associated with disc degeneration and a variation in the levels of important anatomical landmarks.

Study design: Prospective comparative cohort study. Objectives: The study aims to elucidate the relationship between Modic endplate changes and clinical outcomes after a lumbar microdiscectomy. Methods: Consecutive patients undergoing microdiscectomy for lumbar disc herniation (LDH) were prospectively studied. Pre-operative clinical and radiological parameters were recorded. The pain was assessed by Numeric pain rating scale (NPRS), and functional assessment by Oswestry Disability Index (ODI). Minimal clinically important difference (MCID) in outcome was calculated for both the groups. Complications related to surgery were studied. Follow-up was done at 6 weeks, 3 months, 6 months and 1 year. Mac Nab criteria were used to assess patient satisfaction at 1 year. Results: Out of 309 patients, 86 had Modic changes, and 223 had no Modic changes. Both groups had similar back pain (p-value: 0.07) and functional scores (p-value: 0.85) pre-operatively. Postoperatively patients with Modic changes had poorer back pain and ODI scores in the third month, sixth month and 1 year (p-value: 0.001). However, MCID between the groups were not significant (p-value: 0.18 for back pain and 0.58 for ODI scores). Mac Nab criteria at 1 year were worse in Modic patients (p-value: 0.001). No difference was noted among Modic types in the pre-operative and postoperative pain and functional outcomes. Four patients in Modic group (4.7%) and one patient in the non-Modic group (0.5%) developed postoperative discitis (p-value: 0.009). Conclusions: Preoperative Modic changes in lumbar disc herniation is associated with less favorable back pain, functional scores and patient satisfaction in patients undergoing microdiscectomy.

Study Design: This is a retrospective study.Purpose: Recent advances in intraoperative imaging and closed reduction techniques have led to a shifting trend toward surgical management in every unstable sacral fracture. This study aimed to evaluate the clinicoradiological outcome of the sacroiliac (SI) screw and lumbopelvic fixation (LPF) techniques and thereby delineate the indications for each.Overview of Literature: Optimal management guidelines for unstable sacral fractures are still lacking probably due to the rarity of these injuries and varying fixation trends.Methods: Out of the 67 patients, 40 and 27 were in the SI and LPF groups, respectively. The electronic medical record for each patient was reviewed, including patient demographic data, mode of trauma, coexisting injuries, neurological status (Gibbon’s four-grade system), Injury Severity Score, time from admission to operative stabilization, type of surgical stabilization, complications, return to the operating room, and treatment outcome measures using Majeed’s functional grading system and Matta’s radiological criteria. The minimum follow-up period was 2 years.Results: Noncomminuted longitudinal injuries with normal neurology and acceptable closed reduction have undergone SI screw fixation (n=40). Irreducible, comminuted, or high transverse fractures associated with dysmorphic anatomy or neurodeficit were managed by LPF (n=27). Excellent and good Majeed and Matta scores at 86.57% and 92.54% of the patients, respectively, were postoperatively achieved.Conclusions: Unstable sacral fractures can be effectively managed with percutaneous SI screw including vertically unstable injuries by paying strict attention to preoperative patient selection whereas LPF can be reserved for comminuted fractures, unacceptable closed reduction, associated neurodeficit, lumbosacral dysmorphism, and high transverse fractures.

Study Design: Prospective observational study.Purpose: To assess the safety, efficacy, and benefits of computed tomography (CT)-guided C1 fracture fixation.Overview of Literature: The surgical management of unstable C1 injuries by occipitocervical and atlantoaxial (AA) fusion compromises motion and function. Monosegmental C1 osteosynthesis negates these drawbacks and provides excellent functional outcomes.Methods: The patients were positioned in a prone position, and cranial traction was applied using Mayfield tongs to restore the C0–C2 height and obtain a reduction in the displaced fracture fragments. An intraoperative, CT-based navigation system was used to enable the optimal placement of C1 screws. A transverse rod was then placed connecting the two screws, and controlled compression was applied across the fixation. The patients were prospectively evaluated in terms of their clinical, functional, and radiological outcomes, with a minimal follow-up of 2 years.Results: A total of 10 screws were placed in five patients, with a mean follow-up of 40.8 months. The mean duration of surgery was 77±13.96 minutes, and the average blood loss was 84.4±8.04 mL. The mean combined lateral mass dislocation at presentation was 14.6±1.34 mm and following surgery, it was 5.2±1.64 mm, with a correction of 9.4±2.3 mm (p <0.001). The follow-up CT showed excellent placement of screws and sound healing. There were no complications and instances of AA instability. The clinical range of movement at 2 years in degrees was as follows: rotation to the right (73.6°±9.09°), rotation to the left (71.6°±5.59°), flexion (35.4°±4.5°), extension (43.8°±8.19°), and lateral bending on the right (28.4°±10.45°) and left (24.8°±11.77°). Significant improvement was observed in the functional Neck Disability Index from 78±4.4 to 1.6±1.6. All patients returned to their occupation within 3 months.Conclusions: Successful C1 reduction and fixation allows a motion-preserving option in unstable atlas fractures. CT navigation permits accurate and adequate monosegmental fixation with excellent clinical and radiological outcomes, and all patients in this study returned to their preoperative functional status.

Study Design Observational comparative study. Objective To study the role of magnetic resonance spectroscopy (MRS) and T2 relaxometry (T2r) as imaging biomarkers for identifying early lumbar disc degeneration. Methods We evaluated 236 discs in normal volunteers and 215 discs in low back pain (LBP) patients by MRS and T2r to document the molecular spectra of various metabolites as well as disc hydration and collagen content, respectively. All volunteer discs were Pfirrmann grade 1 (PF1), whereas patients with LBP had PF 1 (n = 156) and PF 2 (n = 59). The study population was compared in three age groups: A (20-30 years), B (30-40 years), and C (40-50 years). Results T2r, an indicator of collagen and hydration, was higher in volunteers (121.8 ± 31.1), compared to PF 1 patients (110.68 ± 23.96) and PF 2 patients (90.15 ± 25.81) (P = 0.001). Proteoglycan assessed by MRS was more stable for volunteers (3.39 ± 1.69) and PF 1 patients (3.6 ± 1.69) but reduced in PF 2 patients (2.86 ± 1.47), showing that structural molecules did not alter within the PF 1. However, lactate and other metabolites showed a difference even within PF1 between volunteers and LBP patients. We were able to identify a unique subset of PF 1 that had a normal value of proteoglycan and T2r but altered metabolite distribution, which may represent early disc degeneration (DD). Conclusion MRS and T2r can be used as imaging biomarkers for early DD by identifying altered metabolic activity with an intact matrix.

Study Design: Randomized controlled trial.Purpose: To compare the functional and radiological outcomes of anterior cervical discectomy and fusion (ACDF) using local graft and allograftOverview of Literature: The choice of bone grafts for ACDF varies among different types: iliac crest, allograft, and substitutes. Availability, cost, and donor site morbidity are potential disadvantages. Local osteophyte grafts are then advantageous and shows to have good fusion.Methods: We randomly sampled participants requiring a single level ACDF for degenerative conditions (n=27) between allograft (n=13) and local graft (n=14) groups. Follow-up of patients occurred at 6 weeks, 3 months, 6 months, and 1 year using Numerical Pain Rating Scale (NPRS) scores for arm and neck pain, Neck Disability Index (NDI), 2-item Short Form Health Survey (SF-12), and lateral disk height. We then assessed radiological fusion using computed tomography (CT) scan at 12 months, and graded as F- (no fusion), F (fusion seen through the cage), F+ (fusion seen through the cage, with bridging bone at one lateral edge), and F++ (fusion seen through cage with bridging bone bilaterally).Results: There were no significant differences in the age, sex, duration of intervention, blood loss, and hospital stay between the two groups (p>0.05). Both groups showed significant improvements in all functional outcome scores including NPRS for arm and neck pain, NDI, and SF-12 at each visit (p<0.01). We observed a marked improvement in disk height in both groups (p<0.05), but at 1 year of follow-up, there was a significant though slight subsidence (p=0.47). CT at 1 year showed no non-unions. We recorded F, F+, and F++ grades of fusion in 23.2%, 38.4%, and 38.4% in allograft group and 28.6%, 42.8%, and 28.6% in local graft group, respectively, though no significant differences observed (p=0.73).Conclusions: Marginal osteophytes are effective as graft inside cages for ACDF, since they provide similar radiological outcomes, and equivalent improvements in functional outcomes, as compared to allografts.

Study Design: Retrospective study.Purpose: Postoperative wound complications occurring after transforaminal lumbar interbody fusion (TLIF) are unique, as they can involve different tissue zones (subcutaneous, subfascial, osseous, peri-implant, and disc). Overview of Literature: Management of postoperative infections occurring after TLIF remains controversial in the context of retention or removal of implants.Methods: A total of 1,279 consecutive patients (1,520 segments) who underwent TLIF with a minimum follow-up of 1 year were analyzed. Patients with wound complications were classified anatomically into the following five types: type 1, suprafascial necrosis; type 2, wound dehiscence; type 3, pus around screws and rods; type 4, bone marrow edema; and type 5, pus in the disc space. Details pertaining to clinicoradiological and laboratory findings and management were also recorded.Results: Of the 62 patients (4.8%) with wound complications, there were seven patients in type 1, 35 in type 2, 10 in type 3, four in type 4, and six in type 5. Patients in types 1 and 2 manifested delayed wound healing and were systemically well. In type 1, five patients were managed with resuturing and two were managed conservatively. In type 2, all patients had wound gaping and were managed by debridement, whereas three patients required vacuum-assisted closure. Patients in type 3 had severe back pain and fever, with demonstrable pus around the screw site. Tissue culture identified organisms in 90% of the patients. Patients in type 4 presented with increasing back pain, and magnetic resonance imaging revealed vertebral bone marrow edema. Those in type 5 had severe back pain and fever, with demonstrable pus in the disc space. Patients in types 3–5 required debridement, implant revision/retention, and long-term antibiotics.Conclusions: The new anatomical classification of surgical site infections could help grade the severity of infection and provide tangible treatment guidelines, resulting in better infection clearance and patient outcomes.