Discrepancies Between Radiologist and Spine Surgeon Interpretations of Cervical and Lumbar Stenosis

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Volume 4 | Issue 1 | April 2023 – September 2023 | page: 32-34 | Ankitkumar A. Desai

DOI: https://doi.org/10.13107/bbj.20232.v04i01.058

Authors: Ankitkumar A. Desai [1]

[1] Department of Orthopaedics, Haria L.G. Rotary Hospital, Vapi, Gujarat, India.

Address of Correspondence

Dr. Ankitkumar A. Desai,
Consultant Spine Surgeon, Department of Orthopaedics, Haria L.G. Rotary Hospital, Vapi, Gujarat, India.
E-mail: dr.ankitdesai85@gmail.com

Letter to Editor

Henceforth, nowadays demonstrated poor interpreter reliability of imaging interpretation between surgeons of various specialties and radiologists for a variety of pathologic conditions. Particularly in spine surgeons’ practice Discrepancies in radiologic interpretations can lead to diagnostic frustration and difficulty in formulating treatment plans. Moreover, the third-party payee (insurance party) only relies on documented radiology reports rather than surgeons’ independent interpretation of imaging studies (and never reviews the actual images without clinical findings), which can impact insurance authorization for surgery or reimbursement. Ultimately, conflicting Radiological interpretations may negatively impact patient care. The purpose of my letter to the editor and running research design was to evaluate the rate and degree to which radiologists and spine surgeons differ in interpreting magnetic resonance imaging (MRI) studies in the setting of cervical and lumbar spinal stenosis.
Assessment of The MRI:
Magnetic resonance imaging (MRI) is the standard mode of investigation in spine pathology. Stenosis is a disability triggered by a cord or sac compression because of degenerative spine structure changes with its adjacent structure changes. Compression correlates poorly with Quantifiable language and words used for describing compressive pathology in reports aren’t standardized. MRI [1] is the tool for assessing the extent of cord or sac compromise or injury [2] and typical features include cord or sac compression, altered cord or signals or MRI myelogram in the lumbar spine, canal stenosis, and altered spinal balancing. Despite an investigation, no standard MRI characteristics consistently representing disease severity in canal stenosis have been found [4], cord or sac compression is considered a stamp of authority, and its extent correlates poorly with severity. This may be due to the dynamic component of injury mechanics being untraceable by MRI protocol. [5] or Mechanical stress is the cause of biological differences. Asymptomatic individuals can have a significant cord or sac compression [4, 5]. At present, quantitative measurements such as ‘Spinal Cord Occupation Ratio’, “Maximum spinal cord compression “, ‘Transverse Area’, ‘Compression Ratio’, and ‘Maximum Canal Compromise’ have been used regularly with description. Although their opinions and use of such words, to quantify or qualify the compression are just to provide an objective to the measurements of the cord or sac compression. Standardized terminology exists to describe disc pathology which is a good verse by us, for radiologists aren’t! The nomenclature used by radiologists to report cord or sac compromise impact on clinical management gives the surgeon a drive to extend the surgical plan. I think I will plan to do research with aims to 1) identify terminology used for cord or sac compression 2) compare it 3) From asymptomatic cord compression to symptomatic stenotic features are they able to distinguish between them and 4) Rule out either a language or qualifiers influences spine surgeons opinions.
Do Qualitative or Quantitative Features Identify Spinal Compression Levels?
Maximum Canal Compromise (MCC), Maximum Spinal Cord Compression’ (MSCC) [7]; ‘Spinal Cord Occupation Ratio ‘(SCOR) (3), and ‘Compression Ratio’ (CR) this four are measurements used to calculate compression based on MRI records I found. These represent the visible compromise and good clinical significance [3]. Greater cord compromise is indicated by a larger MCC, MSCC or SCOR, or smaller CR. Quantitative vocabulary used to understand spinal cord or sac compression are: ‘Compress’, and ‘Indent’. ‘Abut’, ‘Flatten’, ‘Touch’, ‘Mould’, ‘Compromise’, ‘Contact’, ‘Displace’ ‘Distort’ ‘Encroach’ ……. Qualifier Term Greater, Just, Lesser Degree, Mild, Mild-Moderate, Minimal, Minor ….maximum numbers of MRI shows the canal diameter as a sign of canal stenosis. Which are non-compared to Slandered deviation and which vary from patient to patient according to their age, sex, height, weight from which demographic region they belong, etc…Many variable terms are used in MRI reporting of spinal cord involvement, with the overlap in their quantitative features. For example, the term ‘Compressed’ = greater quantifiable compromise meaning is inconsistent. Neither qualitative nor quantitative measures of cord or sac involvement correlated with clinical symptoms, despite it generating referral to spinal surgeons. Some relationships are present between radiological reporting of spinal MRI; findings of the clinician by examination clinicians which generate the requirement for MRI to diagnose canal stenosis although the stage of disease and severity can not be specified. Qualitative versus quantitative descriptors are debatable for a longer period for various conditions [8-9]. However, terms chosen by radiologist has no clear guideline or individual meaning. Clinical decision-making depends on radiological reports & their finds. Research shows Radiologist and their reports are better judges that the majority of clinicians [10]. All to gather, research shows suggests that radiologists’ choice of language may have unintended effects on patient care. This is consistent with our findings suggesting that language choice may influence non-expert clinicians’ decisions about whether to refer patients with canal stenosis. The degree of radiological compromise correlates poorly with disease severity. Patients with cord or sac compression may not suffer from UMN or LMN disease respectively. [11] and some patients suffer UMN or LMN diseases without visualized compression due to dynamic injury [5]. Henceforth As the ratio of GP (general physician) to spine specialist is very high in India .They are reliable enough to treat basic family diseases but due to this large gap patients has been already undergone an expensive investigation in the form of an MRI and also informed about the report which was made by radiologist .Hence for the very first consultation the spine surgeon force to see the MRI and not to be evaluated as per the standard protocol and go forward accordingly for the patient profile, this also creates misunderstanding between the GP and Spine Specialist in Indian Scenario. Treating any canal stenosis patient is the work of “BHIM” from “MAHABHARATA” rather than “ARJUNA” who sees a tunnel vision rather than a broad spectrum view.
As Matter of fact, MR imaging cannot currently replace the clinical assessment and vice versa but, notably, interpretation of MRI reports by non-expert clinicians may contribute to false reassurances and variable care. To prevent confusion for non-expert clinicians, descriptive terminology could be removed from reporting and replaced by statements of consistency (or non-consistency) with canal stenosis but further investigation is needed to confirm the value of such an approach. There are, of course, limitations to the conclusions with a lack of data from various centers, and patterns of language likely differ across individual centers, different cities, and countries. Nowadays endoscopy spine is the new sunrise in the world of spine surgery which gives different stories and different tale in a different part of the world, some research article shows that patient underwent endoscopy spine surgery goes for a follow-up MRI after a year shows no signs of surgery, I don’t know how things are going to turn in the future.

Conclusion
That disagreements in MRI interpretation between orthopedic spine surgeons and radiologists occur often. The discrepancies were often with some fold, with spine surgeons rating pathology as more severe. why do I hypothesize that? This is due to the spine surgeons also having clinical data, physical examination, and its interpretation and differentials in their mind while interpreting imaging studies. Insurance companies should not only rely on MR imaging and radiologist interpretation but should also be given equal importance to clinicians and clinical findings. I do agree and pushing a thought that doing better research for this problem by doing collaboration of spine surgeon and radiologist, so we can have better reporting of MRI and radiologist can also took in some clinical inputs from surgeons respectively with their expertise.

References

1. Suleiman LI, Bhatt SA, Parrish TB, Patel AA. Imaging modalities and tests for cervical myelopathy. Semin Spine Surg. 2014. June;26(2):68–72.
2. Batzdorf U, Flannigan BD. Surgical decompressive procedures for cervical spondylotic myelopathy. A study using magnetic resonance imaging. Spine (Phila Pa 1976). 1991. February;16(2):123–7.
3. Nouri A, Martin AR, Mikulis D, Fehlings MG. Magnetic resonance imaging assessment of degenerative cervical myelopathy: a review of structural changes and measurement techniques. Neurosurg Focus. 2016. June 1;40(6):E5 10.3171/2016.3.
4. Wilson JR, Tetreault LA, Kim J, Shamji MF, Harrop JS, Mroz T, et al. State of the Art in Degenerative Cervical Myelopathy: An Update on Current Clinical Evidence. Neurosurgery. 2017. March 1;80(3S):S33–45.
5. Xu N, Wang S, Yuan H, Liu X, Liu Z. Does Dynamic Supine Magnetic Resonance Imaging Improve the Diagnostic Accuracy of Cervical Spondylotic Myelopathy? A Review of the Current Evidence. World Neurosurg. 2017. April;100:474–9.
6. Kovalova I, Kerkovsky M, Kadanka Z, Kadanka Z, Nemec M, Jurova B, et al. Prevalence and Imaging Characteristics of Nonmyelopathic and Myelopathic Spondylotic Cervical Cord Compression. Spine (Phila Pa 1976). 2016. December 15;41(24):1908–16.
7. Nakashima H, Yukawa Y, Suda K, Yamagata M, Ueta T, Kato F. Abnormal Findings on Magnetic Resonance Images of the Cervical Spines in 1211 Asymptomatic Subjects. Spine (Phila Pa 1976). 2015. March 15;40(6):392–8.
8. Kang Y, Lee JW, Koh YH, Hur S, Kim SJ, Chai JW, et al. New MRI Grading System for the Cervical Canal Stenosis. Am J Roentgenol. 2011. July;197(1):W134–40.
9. Fehlings MG, Rao SC, Tator CH, Skaf G, Arnold P, Benzel E, et al. The optimal radiologic method for assessing spinal canal compromise and cord compression in patients with cervical spinal cord injury. Part II: Results of a multicenter study. Spine (Phila Pa 1976). 1999. March 15;24(6):605–13.
10. Bosmans JML, Weyler JJ, De Schepper AM, Parizel PM. The Radiology Report as Seen by Radiologists and Referring Clinicians: Results of the COVER and ROVER Surveys. Radiology. 2011. April 1;259(1):184–95.
11. Witiw CD, Mathieu F, Nouri A, Fehlings MG. Clinico-Radiographic Discordance: An Evidence-Based Commentary on the Management of Degenerative Cervical Spinal Cord Compression in the Absence of Symptoms or With Only Mild Symptoms of Myelopathy. Glob Spine J. 2017. December 18;219256821774551.

How to Cite this Article: Desai AA | Discrepancies Between Radiologist and Spine Surgeon Interpretations of Cervical and Lumbar Stenosis| Back Bone: The Spine Journal | April 2023-September 2023; 4(1): 32-34 |

https://doi.org/10.13107/bbj.2023.v04i01.058

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A Comparative Study About Diagnostic Yield of Fluoroscopy Guided Transpedicular Biopsy Done by Orthopaedicians V/S CT Guided Biopsy Done by Radiologists in Cases of Koch’s Spine

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Volume 4 | Issue 1 | April 2023 – September 2023 | page: 28-31 | Meet Shah, Ashok Rathod, Punith K, Rohan Killekar, Kunal Bharadwaj

DOI: https://doi.org/10.13107/bbj.20232.v04i01.057

Authors: Meet Shah, Ashok Rathod, Punith K, Rohan Killekar, Kunal Bharadwaj

[1] Department of Orthopaedics, Lokmanya Tilak Municipal General Hospital, Sion, Mumbai, Maharashtra, India.

Address of Correspondence

Dr. Meet Shah,
Department of Orthopaedics, Lokmanya Tilak Municipal General Hospital, Sion, Mumbai, Maharashtra, India.
E-mail: meetkshah29@gmail.com

Abstract

Introduction: Tuberculosis is one of the leading causes of mortality worldwide due to a single infectious agent. Koch’s spine or spinal tuberculosis is one of the most crippling manifestations of extra-pulmonary tuberculosis. Owing to the lack of image-guided biopsy centers and the high prevalence of the disease, most of the patients are diagnosed and treated on clinical grounds. This practice was thought to lead to a delay in the diagnosis of other pathologies and multi-drug-resistant tuberculosis. This study aims to compare the diagnostic yield of fluoroscopy (C-arm) guided transpedicular biopsy done by orthopaedicians v/s CT guided biopsy done by radiologists in cases of Koch’s spine.
Materials and Methods: The study involved 60 consented patients with a clinico-radiological diagnosis of Koch’s spine randomly divided into 2 groups for biopsy 1) CT-guided biopsy to be done by radiologists 2) C-arm guided biopsy to be done by orthopedicians and results were compared.
Results: The use of CT-guided biopsy and C-arm guided biopsy in the diagnosis of Koch’s spine is increasing taking into consideration of increasing MDR TB. We got a positive answer in 70% of cases via CT-guided biopsy and 53.33% via C-arm guided biopsy. Detection of MDR TB on GeneXpert was the commonest diagnostic feature with a comparatively low rate of positive AFB smear and histopathology.
Conclusion: Results of C-arm guided biopsy are similar to CT guided biopsy with the latter being better.
Keywords: Koch’s spine, biopsy, multi-drug resistant tuberculosis

References

1) https://www.who.int/news-room/fact sheets/detail/tuberculosis#:~:text=Worldwide%2C%20TB%20is%20the%2013th,all%20countries%20and%20age%20groups.
2) Moon MS. Tuberculosis of the spine: controversies and a new challenge. Spine (Phila Pa 1976) 1997;22: 1791-7.
3) Wang H, Li C, Wang J, Zhang Z, Zhou Y. Characteristics of patients with spinal tuberculosis: seven-year experience of a teaching hospital in Southwest China. Int Orthop 2012;36:1429-34.
4) McLain RF, Isada C. Spinal tuberculosis deserves a place on the radar screen. Cleve Clin J Med 2004;71: 537-9.
5) World Health Organization (WHO). Pakistan: stop tuberculosis [Internet]. Islamabad: WHO; 2014 [cited 2015 Apr 22]. Available from: http://www.emro.who. int/pak/programmes/stop-tuberculosis.html.
6) Francis IM, Das DK, Luthra UK, Sheikh Z, Sheikh M, Bashir M. Value of radiologically guided fine needle aspiration cytology (FNAC) in the diagnosis of spinal tuberculosis: a study of 29 cases. Cytopathology 1999; 10:390-401.
7) Colmenero JD, Ruiz-Mesa JD, Sanjuan-Jimenez R, Sobrino B, Morata P. Establishing the diagnosis of tuberculous vertebral osteomyelitis. Eur Spine J 2013;22 Suppl 4:579-86.
8) Laurent Pierot and Anne Boulin, Percutaneous Biopsy of the thoracic and lumbar spine; Transpedicular approach under fluoroscopic guidance, Jan 1998.

How to Cite this Article: Shah M, Rathod A, Punith K, Killekar R, Bharadwaj K | A Comparative Study About Diagnostic Yield of Fluoroscopy Guided Transpedicular Biopsy Done by Orthopaedicians v/s CT Guided Biopsy Done by Radiologists in Cases of Koch’s Spine| Back Bone: The Spine Journal | April 2023-September 2023; 4(1): 28-31 | https://doi.org/10.13107/bbj.2023.v04i01.057

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Cervical Spine Trauma in Cameroonian Judokas: Risk Factors and Prognosis in Two Cases in Yaounde

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Volume 4 | Issue 1 | April 2023 – September 2023 | page: 24-27 | Muluem O.K, Bissou M, Fonkoue L, Ndongmoui N.G, Chifen U, Haman N.O, Djientcheu V.P

DOI: https://doi.org/10.13107/bbj.20232.v04i01.056

Authors: Muluem O.K [1], Tsiagadigui J.G [2], Fonkoue L [1], Ndongmoui N.G [2], Chifen U [1], Haman N.O [1], Djientcheu V.P [1]

[1] Department of Orthopaedics, General Hospital, Yaounde, Cameroon.
[2] Department of Medicine and Biomedical Sciences, Yaounde, Cameroon.

Address of Correspondence

Dr. Muluem Olivier Kennedy,
Department of Orthopaedics, General Hospital, Yaounde, Cameroon.
E-mail: kennedymuluem@yahoo.fr

Abstract

Motor Cervical spine injuries during the practice of judo rarely occur. When they occur, they can be responsible for serious injuries such as fractures, dislocations and sprains. The objective of our work was to evaluate the factors favoring the occurrence of these lesions, the diagnostic approach, the emergency management and the medium-term prognosis in two Cameroonian judokas.
Keywords: Cervical spine, Injury, Judo, Risk factor, Prognosis

References

1. Akoto R, Lambert C, Balke M, Bouillon B, Frosch KH, Höher J. Epidemiology of injuries in judo: a cross-sectional survey of severe injuries based on time loss and reduction in sporting level. Br J Sports Med 2018 ;52(17) :1109—15.
2. Godt P, vogelsang P. Uncommon judo injuries. Cervical disc herniation and acute high cervical cord damage associated with congenital stenosis of the cervical spinal canal. Unfallheilkunde, 1979 ; 82 : 215-218.
3. Wirbel R, Pistorius G, Braun C, Eichler A., Mutschler W. Bilateral vertebral artery lesion after dislocating cervical spine trauma. A case report. Spine, 1996 ; 21 : 1375-1380
4. Elena Pocecco 1, Gerhard Ruedl, Nemanja Stankovic, Stanislaw Sterkowicz, Fabricio Boscolo Del Vecchio, Carlos Gutiérrez-García, Romain Rousseau. Injuries in judo: a systematic literature review including suggestions for prevention. Br J Sports Med. 2013 Dec ;47(18) :1139-43
5. A-P. Uzel, R. Massicot, O. Delattre, F. Lemonne. Fracture-luxation uni-articulaire C5-C6 lors d’une compétition de judo : L’uchi-mata en cause. J. Traumatol. Sport 2005, 22, 65-69
6. Campus de Neurochirurgie. Traumatology vertebra-médulaire.s.d
7. Takeshi Kamitani, Yuji Nimura, Shinji Nagahiro, Seiji Miyazaki and Taisuke Tomatsu Am J Sports Med 2013 41: 1915 originally published online June 13, 2013
8. Mr wadii BNOUHANNA, S.AIT BEN ALI : prise en charge ddes traumatismes du rachis cervical inférieur ; thèse /03/2007
9. Adil HABBAB, Y. Quamous, A. AKHADDAR : Prise en charge du rachis cervical traumatique en milieu de réanimation chirurgicale à l’hôpital militaire Avicenne à-propos de 20 cas ; thèse 140.
10. K.Kansoue et al(eds), sport injuries and prevention DOI 10.1007/978-4-431-55318-2_6
11. Brito CJ, Castro Martins Roas AF, Souza Brito IS, et al. Methods of body-mass reduction by combat sport athletes. Int J Sport Nutr Exerc Metab 2012; 22:89–97.
12. Langan-Evans C, Close GL, Morton JP. Making weight in combat sports. Strength Cond J 2011 ;33 :25–39.
13. LAHLAH Ismahane et MOUSSAOUI Kahina : traumatisme du rachis cervical de l’enfant 2017/2018 CHU BEJAIA
14. Doran SE, Papadopoulos SM, Ducker TB, Lillehel KO. Magnetic resonance imaging documentation of coexistent traumatic locked facets of the cervical spine and disc herniation. J. Neurosurg, 1993 ; 79 : 341-345.
15. RIZZOLO SJ, PIAZZA MR, COTLER JM et al. Intervertebral disc injury complicating cervical spine trauma. Spine, 1991; 16 S: 187-189.
16. DE CREE Carl Traumatic Atlanto-Axial Rotary Subluxation (AARS) in a 6-YearOld Child during Recreational Jūdō Practice: A Case Report and Mini-Review of Serious Neck Injuries in Jūdō. Arch Sports Med 3(1) 2019 :134-148

How to Cite this Article: Muluem OK, Bissou M, Fonkoue L, Ndongmoui NG, Chifen U, Haman NO, Djientcheu VP | Cervical Spine Trauma in Cameroonian Judokas: Risk Factors and Prognosis in Two Cases in Yaounde| Back Bone: The Spine Journal | April 2023-September 2023; 4(1): 24-27 | https://doi.org/10.13107/bbj.2023.v04i01.056

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Desflurane as an Effective Anaesthetic Agent for Intra-Operative Neuro-Monitoring in Spine Surgeries

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Volume 4 | Issue 1 | April 2023 – September 2023 | page: 20-23 | Meeta Agarwala, Hitesh N Modi, Deep J. Patel

DOI: https://doi.org/10.13107/bbj.20232.v04i01.055

Authors: Meeta Agarwala [1], Hitesh N Modi [1], Deep J. Patel [1]

[1] Department of Anaesthesia, Zydus Hospitals, Ahmedabad, Gujarat, India.
[2] Department of Spine Surgery, Zydus hospital, Ahmedabad, Gujarat, India.

Address of Correspondence

Dr. Meeta Agarwala,
Department of Anaesthesia, Zydus Hospitals, Ahmedabad, Gujarat, India.
E-mail: meetasomaiya@yahoo.com

Abstract

Background & Aims: Motor evoked potentials (MEP) have been widely used as intraoperative neuromonitoring in patients undergoing spine surgery to prevent neurological complications. The present study aims to show the significance of 6% desflurane as an effective agent in maintaining anaesthesia at a minimum alveolar concentration (MAC) of 0.8–1.0 in patients undergoing spine surgery with neuromonitoring.
Methods: This retrospective, cohort, single-centre study was conducted between 2016 and 2018. Patients who underwent spinal surgery along with intraoperative neuromonitoring were included. Anaesthesia was given with weight adjusted intravenous propofol (2-3 mg/kg) and maintained with Oxygen and air with inhalation desflurane (6%) with MAC of 0.8-1.0 and Bispectral index of 40-60. The data of MEP signals were collected at baseline, after instrumentation, decompression, and closure. The MEP data were correlated using Spearman correlation test and Wilcoxon rank test with minimum alveolar concentration, mean arterial pressure, temperature and bispectral index at different time intervals. P value <0.05 was considered statistically significant.
Results: A total of 37 patients (26 females and 11 males) were included in the study with the mean of 52.46±12.85 years. There was no statistically significant correlation between the variables at different time intervals. Although, a statistically significant negative correlation was observed between bispectral index and latency after decompression (p=0.006). A significant difference was observed in visual analogue scale and Oswestry disability index before and after procedure (p< 0.001).
Conclusion: Anaesthesia with 6% desflurane in 0.8-1.0 MAC does not alter MEP signals in patients undergoing spinal surgery without any complication and with adequate recovery rate from anaesthesia.
Keywords: Anaesthesia, Desflurane, Motor evoked potentials, Propofol

References

1. Park J-H, Hyun S-J. Intraoperative neurophysiological monitoring in spinal surgery. World Journal of Clinical Cases: WJCC. 2015;3(9):765.
2. Kunisawa T, Nagata O, Nomura M, et al. A comparison of the absolute amplitude of motor evoked potentials among groups of patients with various concentrations of nitrous oxide. Journal of anesthesia. 2004;18(3):181-4.
3. Nathan N, Tabaraud F, Lacroix F, et al. Influence of propofol concentrations on multipulse transcranial motor evoked potentials. British journal of anaesthesia. 2003;91(4):493-7.
4. Pechstein U, Ceclzich C, Nadstawek J, et al. Transcranial high-frequency repetitive electrical stimulation for recording myogenic motor evoked potentials with the patient under general anesthesia. Neurosurgery. 1996;39(2):335-44.
5. Lieberman JA, Lyon R, Feiner J, et al. The effect of age on motor evoked potentials in children under propofol/isoflurane anesthesia. Anesthesia & Analgesia. 2006;103(2):316-21.
6. Liu H-Y, Zeng H-Y, Cheng H, et al. Comparison of the effects of etomidate and propofol combined with remifentanil and guided by comparable BIS on transcranial electrical motor-evoked potentials during spinal surgery. Journal of neurosurgical anesthesiology. 2012;24(2):133-8.
7. Lo Y-L, Dan Y-F, Tan Y, et al. Intraoperative motor-evoked potential monitoring in scoliosis surgery: comparison of desflurane/nitrous oxide with propofol total intravenous anesthetic regimens. Journal of neurosurgical anesthesiology. 2006;18(3):211-4.
8. Heavner J, Kaye A, Lin BK, et al. Recovery of elderly patients from two or more hours of desflurane or sevoflurane anaesthesia. British journal of anaesthesia. 2003;91(4):502-6.
9. Tachibana S, Hayase T, Osuda M, et al. Recovery of postoperative cognitive function in elderly patients after a long duration of desflurane anesthesia: a pilot study. Journal of anesthesia. 2015;29(4):627-30.
10. Chong CT, Manninen P, Sivanaser V, et al. Direct comparison of the effect of desflurane and sevoflurane on intraoperative motor-evoked potentials monitoring. Journal of neurosurgical anesthesiology. 2014;26(4):306-12.
11. Martin DP, Bhalla T, Thung A, et al. A preliminary study of volatile agents or total intravenous anesthesia for neurophysiological monitoring during posterior spinal fusion in adolescents with idiopathic scoliosis. Spine. 2014;39(22):E1318-E24.
12. Malcharek M, Loeffler S, Schiefer D, et al. Transcranial motor evoked potentials during anesthesia with desflurane versus propofol–a prospective randomized trial. Clinical Neurophysiology. 2015;126(9):1825-32.

How to Cite this Article: Agarwala MS, Modi HN, Patel DJ Desflurane | as an Effective Anaesthetic Agent for Intra- Operative Neuro-Monitoring in Spine Surgeries| Back Bone: The Spine Journal | April 2023- September 2023; 4(1): 20-23 | https://doi.org/10.13107/bbj.2023.v04i01.055

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Prospective Cohort Study for Discectomy for Herniated Lumbar Disc in Resource Limited Hospital in Rural and Urban City : Loupe Vs Microscope

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Volume 4 | Issue 1 | April 2023 – September 2023 | page: 14-19 | Ankitkumar A. Desai, Siddharth Patel, Kamlesh Jain, Keyur Buddhdev, Shubhdeepsingh Chugh

DOI: https://doi.org/10.13107/bbj.20232.v04i01.054

Authors: Ankitkumar A. Desai [1], Siddharth Patel [1], Kamlesh Jain [1], Keyur Buddhdev [1], Shubhdeepsingh Chugh [1]

[1] Department of Orthopaedics, Haria L.G. Rotary Hospital, Vapi, Gujarat, India.

Address of Correspondence

Dr. Ankitkumar Arunbhai Desai,
Consultant Spine Surgeon, Department of Orthopaedics, Haria L.G. Rotary Hospital, Vapi, Gujarat, India.
E-mail: dr.ankitdesai85@gmail.com

Abstract

Introduction: In resource limited Hospital in rural and urban city where microscopes are not readily available, I hypothesize that if properly used, good magnifying loupes could offer comparable results to the microscope in relieving rediculpathy which is the primary goal of discectomy.
Material and Methods: Prospective cohort study was conducted on 49 single level lumbar disc prolapsed patients with ridiculer leg pain between January 2017 and March 2021. The microscope was used in 15 patients (29.9%) and loupe in 34 cases (70.1%). Pre-operative assessment clinical examination with spine assessment. Surgical indications included failure of at least 6 weeks medical , physio treatment, pain or progressive neurological deficits. Micro lumbar discectomy was done in all patients. Per-and post operative parameters recorded included: length of the incision, operative time, blood loss, the presence of a wound drain, length of hospital stay, leg and back pain before discharge and in follow up visits and complications. visual analogue scale (VAS) used as a tool.
Results: The demographic, clinical characteristic , radiological characteristics and surgical technique were similar and comparable (p>0.05). The mean length of the incision was 2.5 cm for the microscope group and 3 to 3.5 cm for the loupes group (P value =0.0007).There wasn’t any statistically significant difference in both groups as regard the blood loss (p=1), complication rate and length of hospital stay (p=0.21). There wasn’t any statistically significant difference in VAS score for leg pain (p=0.32) and low back pain (p=0.46). Radicular pain recurred in equal proportion in both groups (p=0.17). 13 (86.2%) in the microscope and 32 (92.6%) in the loupe group had a 3 months post-operative VAS of zero (p=0.32).
Conclusion: Operative microscope and loupes are both justifiable alternative device in lumbar micro discectomy since both have similar and comparable outcome. In rural n urban city hospitals with less resources & less access to microscopes and other minimally invasive equipment such as the endoscope, MLD system or tubular with proven safety and effectiveness over macro disectomy , loupes are safe and effective tools for in lumbar discectomy. Operating Microscopes is more surgeon friendly as it’s gives good viewing angle without or less Work-related Musculoskeletal Disorders (WMSD).
Keywords: Microdiscectomy, Loupe, Microscope, Work-related Musculoskeletal Disorders (WMSD) Rapid Upper Limb Assessment (RULA).

References

1. Abou-Zeid A, Palmer J, Gnanalingham K. Day case lumbar discectomy–viable option in the UK? Br J Neurosurg 28:320-3, 2014.
2. Pearson AM, Blood EA, Frymoyer JW, Herkowitz H, Abdu WA, Woodward R, et al. SPORT lumbar intervertebral disk herniation and back pain: does treatment, location, or morphology matter? Spine 15;33:428-35,2008.
3. Peul WC, van den Hout WB, Brand R, Thomeer RT, Koes BW. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ 14; 336:1355-8, 2008.
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6. Koebbe CJ, Maroon JC, Abla A, El-Kadi H, Bost J. Lumbar microdiscectomy: a historical perspective and current technical considerations. Neurosurg Focus 15; 13:E4,2002.
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8. Tureyen K. One-level one-sided lumbar disc surgery with and without microscopic assistance: 1- year outcome in 114 consecutive patients. J Neurosurg 99: S247-50, 2003.
9. Rasouli MR, Rahimi-Movaghar V, Shokraneh F, Moradi-Lakeh M, Chou R. Minimally invasive discectomy versus microdiscectomy/open discectomy for symptomatic lumbar disc herniation. Cochrane Database Syst Rev 9:CD010328. 2014.
10. Riesenburger RI, David CA. Lumbar microdiscectomy and microendoscopic discectomy. Minim Invasive Ther Allied Technol 15:267-70. 2006.
11. Schick U, Dohnert J, Richter A, Konig A, Vitzthum HE. Microendoscopic lumbar discectomy versus open surgery: an intraoperative EMG study. Eur Spine J 11:20-6,2002.
12. Cenic A, Kachur E. Lumbar discectomy: a national survey of neurosurgeons and literature review. Can J NeurolSci 36:196-200, 2009.
13. Kumar SS, Mourkus H, Farrar G, Yellu S, Bommireddy R. Magnifying loupes versus microscope for microdiscectomy and microdecompression. J Spinal Disord Tech 25: E235-39,2012.
14. Alberto Pispero , Marco Marcon , Carlo Ghezziet al. Posture Assessment in Dentistry for Different Visual Aids Using 2D Markers. Sensors2021, 21(22), 7717.

How to Cite this Article: Desai AA, Patel S, Jain K, Buddhdev K, Chugh S Prospective | Cohort Study for Discectomy for Herniated Lumbar Disc in Resource Limited Hopital in Rural and Urban City : Loupe Vs Microscope | Back Bone: The Spine Journal | April 2023-September 2023; 4(1): 14-19 | https://doi.org/10.13107/bbj.2023.v04i01.054

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Developing Sustained Competitive Advantages in Spine Practice

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Volume 4 | Issue 1 | April 2023 – September 2023 | page: 01-03 | Hitesh N. Modi

DOI: https://doi.org/10.13107/bbj.20232.v04i01.051

Authors: Hitesh N. Modi [1]

[1] Department of Spine Surgery, Zydus Hospitals and Healthcare Research Pvt. Ltd, Thaltej, Ahmedabad, Gujarat, India.

Address of Correspondence

Dr. Hitesh N. Modi,
Spine Surgeon, Department of Spine Surgery, Zydus Hospitals and Healthcare Research Pvt. Ltd, Thaltej, Ahmedabad, Gujarat, India.
E-mail: drmodihitesh@gmail.com

Abstract

Competition is rapidly increasing across all specialties in the field of medicine due to increase in the number of doctors as well as developing technological and marketing changes. It is mandatory to develop and sustain the advantage of surgical skill in particular specialty for the long-term to take advantage of the experience and skills. Fierce competition in turn decreases the overall practice if we do not sustain the competitive advantage which we have in the beginning. It is imperative that we develop sustained competitive advantage to sustain and grow our professional journey for the long-term. In this article we have focussed on how to develop a sustained competitive advantage in the field of spine surgery which can be also applied to other surgical or medical specialties like the other business industries.
Keywords: Medical Profession, Fierce competition, Sustained competitive advantage, Grow professional competence.

References

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11. Porter ME. Competitive Advantage: Creating and Sustaining Superior Performance. the free press, 2021. Chapter 2. Value chain and competitive advantage. Pg: 33-59.

How to Cite this Article: Modi HN | Developing Sustained Competitive Advantages in Spine Practice| Back Bone: The Spine Journal | April 2023-September 2023; 4(1): 01-03 | https://doi.org/10.13107/bbj.2023.v04i01.051

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Should 3D Navigation be the Standard of Care for MIS TLIF?

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Volume 4 | Issue 1 | April 2023 – September 2023 | page: 09-13 | Bharat R. Dave, Ajay Krishnan, Devanand Degulmadi, Shivanand Mayi, Ravi Ranjan Rai, Mirant B. Dave

DOI: https://doi.org/10.13107/bbj.20232.v04i01.053

Authors: Bharat R. Dave [1], Ajay Krishnan [1], Devanand Degulmadi [1], Shivanand Mayi [1], Ravi Ranjan Rai [1], Mirant B. Dave [1]

[1] Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, Gujarat, India.

Address of Correspondence

Dr. Ravi Ranjan Rai,
Spine Surgeon, Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Ahmedabad, Gujarat, India.
E-mail: drravirai84@gmail.com

Abstract

Introduction- Traditionally MIS TLIF is being performed under fluoroscopic guidance, which is technically difficult in few cases, often inaccurate and involves excessive radiation exposure to the surgeon and OR personnel. Navigation promises to be a better tool, however, literature regarding its accuracy is still evolving.
Aims & Objectives- To evaluate the pedicle screw perforation rate in Navigation guided MIS TLIF
Materials and Methods- All consecutive patients undergoing MIS TLIF under 3D Navigation at single institute between January 2019 to January 2021 were included in the study. O-arm and S8 Stealth Navigation was used in all cases. After prone positioning and part preparation, patient tracker was fixed to a bony point nearest to the operative site, and then first CT scan spin was taken. Under Navigation guidance, all four guide wires were placed. Decompression was planned from the side which was more symptomatic. Screws on the opposite side were placed and connected with rod. Decompression was performed, and interbody cage was inserted from the symptomatic side, followed by insertion of remaining two screws under Navigation. A final CT scan spin was taken to determine the accuracy of hardware.
Results- 92 MIS TLIF were performed during the study period under 3D Navigation. 368 screws in 92 patients were analysed for accuracy. The direction and degree of breach was recorded. Four screws were found to breach, two were lateral breach, one superior breach and one medial breach. All breaches were Gr 1 and none of the screws required revision. Overall accuracy was 98.91 percent.
Conclusion- 3D Navigation is a useful tool in guiding placement of pedicle screws with high accuracy. This tool would be particularly indispensable in MISS cases, when tactile feedback is minimal.
Keywords- Surgical Navigation Systems, Computer-Assisted surgery, Minimally Invasive Surgical Procedures, Pedicle Screws.

References

1) Tian NF, Xu HZ. Image-guided pedicle screw insertion accuracy: a meta-analysis. Int Orthop 2009; 33:895-903. 10.1007/s00264-009-0792
2) Nathaniel W. Jenkins, James M. Parrish, Evan D. Sheha, Kern Singh. Intraoperative risks of radiation exposure for the surgeon and patient. Ann Transl Med 2021;9(1):84.
3) Go Yoshida, Koji Sato, Tokumi Kanemura, Toshiki Iwase, Daisuke Togawa, Yukihiro Matsuyama. Accuracy of Percutaneous Lumbosacral Pedicle Screw Placement Using the Oblique Fluoroscopic View Based on Computed Tomography Evaluations. Asian Spine J. 2016 Aug; 10(4): 630–638. Published online 2016 Aug 16.
4) Kim MC, Chung HT, Cho JL, Kim DJ, Chung NS. Factors affecting the accurate placement of percutaneous pedicle screws during minimally invasive transforaminal lumbar interbody fusion. Eur Spine J 2011; 20:1635-43.
5) Zhang Q., Xu Y. F., Tian W., et al. Comparison of superior‐level facet joint violations between robot‐assisted percutaneous pedicle screw placement and conventional open fluoroscopic‐guided pedicle screw placement. Orthopaedic Surgery. 2019;11(5):850–856.
6) Babu R, Park JG, Mehta AI, et al. Comparison of superior-level facet joint violations during open and percutaneous pedicle screw placement. Neurosurgery, 2012, 71: 962–970.
7) Park Y, Ha JW, Lee YT, Sung NY. Cranial facet joint violations by percutaneously placed pedicle screws adjacent to a minimally invasive lumbar spinal fusion. Spine J, 2011, 11: 295–302.
8) Jones-Quaidoo, S. M., Djurasovic, M., Owens, R. K., II, & Carreon, L. Y. (2013). Superior articulating facet violation: percutaneous versus open techniques, Journal of Neurosurgery: Spine SPI, 18(6), 593-597.
9) Gertzbein SD, Robbins SE. Accuracy of pedicular screw placement in vivo. Spine (Phila Pa 1976) 1990; 15:11–4.
10) Tarun Dusad, Vishal Kundnani, Shumayou Dutta, Ankit Patel, Gaurav Mehta, Mahendra Singh. Comparative Prospective Study Reporting Intraoperative Parameters, Pedicle Screw Perforation, and Radiation Exposure in Navigation-Guided versus Non-navigated Fluoroscopy-Assisted Minimal Invasive Transforaminal Lumbar Interbody Fusion. Asian Spine J 2018;12(2):309-316.
11) Xiaofeng Lian, Rodrigo Navarro-Ramirez, Connor Berlin, Ajit Jada, Yu Moriguchi, Qiwei Zhang, and Roger Hartl. Total 3D Airo Navigation for Minimally Invasive Transforaminal Lumbar Interbody Fusion. BioMed Research International Volume 2016, Article ID 5027340, 8 pages.
12) Guan‐yu Cui, Xiao‐guang Han, Yi Wei, Ya‐jun Liu, Da He, Yu‐qing Sun, Bo Liu, Wei Tian.Robot‐Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Treatment of Lumbar Spondylolisthesis. Orthop Surg. 2021 Oct; 13(7): 1960–1968.
13) Shangju Gao, Jingchao Wei, Wenyi Li, Long Zhang, Can Cao, Jinshuai Zhai, Bo Gao. Accuracy of Robot-Assisted Percutaneous Pedicle Screw Placement under Regional Anesthesia: A Retrospective Cohort Study. Pain Res Manag. 2021; 2021: 6894001. Published online 2021 Dec 20.
14) Yang J.-S., He B., Tian F., et al. Accuracy of robot-assisted percutaneous pedicle screw placement for treatment of lumbar spondylolisthesis: a comparative cohort study. Medical Science Monitor. 2019; 25:2479–2487.
15) Kim H. J., Jung W. I., Chang B. S., Lee C. K., Kang K. T., Yeom J. S. A prospective, randomized, controlled trial of robot-assisted vs. freehand pedicle screw fixation in spine surgery. The international journal of medical robotics + computer assisted surgery: MRCAS. 2017;13(3).
16) Joseph A. Weiner, Michael H. McCarthy, Peter Swiatek, Philip K. Louie, Sheeraz A. Qureshi. Narrative review of intraoperative image guidance for transforaminal lumbar interbody fusion. Ann Transl Med. 2021 Jan; 9(1): 89.
17) Erik Wang, Jordan Manning, Christopher G. Varlotta, Dainn Woo, Ethan Ayres, Edem Abotsi, Dennis Vasquez-Montes, Themistocles S. Protopsaltis, Jeffrey A. Goldstein, Anthony K. Frempong-Boadu, Peter G. Passias, and Aaron J. Buckland. Radiation Exposure in Posterior Lumbar Fusion: A Comparison of CT Image-Guided Navigation, Robotic Assistance, and Intraoperative Fluoroscopy. Global Spine Journal 2021, Vol. 11(4) 450-457.
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19) Nicolas Dea, MD, MSca, *, Charles G. Fisher, MD, MHScb , Juliet Batke, BScb , Jason Strelzow, MDb , Daniel Mendelsohn, MDb , Scott J. Paquette, MDb , Brian K. Kwon, MD, PhDb , Michael D. Boyd, MDb , Marcel F.S. Dvorak, MDb , John T. Street. Economic evaluation comparing intraoperative cone beam CT-based navigation and conventional fluoroscopy for the placement of spinal pedicle screws: a patient-level data cost-effectiveness analysis. The Spine Journal 16 (2016) 23–31.

How to Cite this Article: Dave BR, Krishnan A, Degulmadi D, Mayi S, Rai RR, Dave MB | Should 3D Navigation be the Standard of Care for MIS TLIF?| Back Bone: The Spine Journal | April 2023-September 2023; 4(1): 09-13 | https://doi.org/10.13107/bbj.2023.v04i01.053

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Minimal Invasive Scoliosis Surgery (MISS): Current State of Art for Adolescent Idiopathic Scoliosis

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Volume 4 | Issue 1 | April 2023 – September 2023 | page: 04-08 | Udit D. Patel, Rohit A Kavishwar, Seung Woo Suh, Jae Hyuk Yang, Hitesh N. Modi

DOI: https://doi.org/10.13107/bbj.20232.v04i01.052

Authors: Udit D. Patel [1], Rohit A Kavishwar [1], Seung Woo Suh [1], Jae Hyuk Yang [2], Hitesh N. Modi [3]

[1] Department of Orthopaedic Surgery, Korea University Guro Hospital, College of Medicine, Korea University, Seoul, Republic of Korea 08308.
[2] Department of Orthopaedic Surgery, Korea University Anam Hospital, College of Medicine, Korea University, Seoul, Republic of Korea 02841.
[3] Department of Spine Surgery, Zydus Hospitals and Healthcare Research Private Limited, Zydus hospital road, Thaltej, Ahmedabad, Gujarat, India 380054.

Address of Correspondence

Dr. Seung Woo Suh,
Department of Orthopaedic Surgery, Korea University Guro Hospital, College of Medicine, Korea University, Seoul, Republic of Korea 08308
E-mail: spine@korea.ac.kr

Abstract

In recent years, minimally invasive spine surgery techniques have grown increasingly popular with both patients and surgeons. MIS have become increasingly feasible, efficient, and popular for the treatment of a variety of spinal pathologies. Minimally invasive scoliosis surgery (MISS) is not a familiar concept among many spine surgeons, but it is a novel technique with demonstration of advantages of MISS over traditional open technique in the final outcomes and will be the future of adolescent idiopathic scoliosis (AIS) surgery.

Keywords: Minimal invasive spine surgery, Minimally invasive scoliosis surgery (MISS), Adolescent idiopathic scoliosis (AIS).

References

1. de Bodman C, Miyanji F, Borner B, Zambelli PY, Racloz G, Dayer R. Minimally invasive surgery for adolescent idiopathic scoliosis: correction of deformity and peri-operative morbidity in 70 consecutive patients. The bone & joint journal. 2017 Dec;99(12):1651-7.
2. Maruyama T, Takeshita K. Surgical treatment of scoliosis: a review of techniques currently applied. Scoliosis. 2008 Dec;3(1):1-6.
3. Alhammoud A, Alborno Y, Baco AM, Othman YA, Ogura Y, Steinhaus M, Sheha ED, Qureshi SA. Minimally invasive scoliosis surgery is a feasible option for management of idiopathic scoliosis and has equivalent outcomes to open surgery: a meta-analysis. Global Spine Journal. 2022 Apr;12(3):483-92.
4. Sarwahi V, Amaral T, Wendolowski S, Gecelter R, Gambassi M, Plakas C, Liao B, Kalantre S, Katyal C. Minimally invasive scoliosis surgery: a novel technique in patients with neuromuscular scoliosis. BioMed Research International. 2015 Nov 16;2015.
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7. Sarwahi V, Wollowick AL, Sugarman EP, Horn JJ, Gambassi M, Amaral TD. Minimally invasive scoliosis surgery: an innovative technique in patients with adolescent idiopathic scoliosis. Scoliosis. 2011 Dec;6(1):1-0.
8. Samdani AF, Asghar J, Miyanji F, Haw J, Haddix K. Minimally invasive treatment of pediatric spinal deformity. InSeminars in Spine Surgery 2011 Mar 1 (Vol. 23, No. 1, pp. 72-75). WB Saunders.
9. Miyanji F, Samdani A, Ghag A, Marks M, Newton PO. Minimally invasive surgery for AIS: an early prospective comparison with standard open posterior surgery. J Spine. 2013;5:001.
10. de Bodman C, Miyanji F, Borner B, Zambelli PY, Racloz G, Dayer R. Minimally invasive surgery for adolescent idiopathic scoliosis: correction of deformity and peri-operative morbidity in 70 consecutive patients. The bone & joint journal. 2017 Dec;99(12):1651-7.
11. Yang JH, Chang DG, Suh SW, Damani N, Lee HN, Lim J, Mun F. Safety and effectiveness of minimally invasive scoliosis surgery for adolescent idiopathic scoliosis: a retrospective case series of 84 patients. European Spine Journal. 2020 Apr;29(4):761-9.
12. Yang JH, Kim HJ, Chang DG, Suh SW. Minimally invasive scoliosis surgery for adolescent idiopathic scoliosis using posterior mini-open technique. Journal of Clinical Neuroscience. 2021 Jul 1;89:199-205.
13. Park SC, Son SW, Yang JH, Chang DG, Suh SW, Nam Y, Kim HJ. Novel Surgical Technique for Adolescent Idiopathic Scoliosis: Minimally Invasive Scoliosis Surgery. Journal of Clinical Medicine. 2022 Oct 2;11(19):5847.
14. Yang JH, Kim HJ, Chang DG, Suh SW. Comparative Analysis of Radiologic and Clinical Outcomes between Conventional Open and Minimally Invasive Scoliosis Surgery for Adolescent Idiopathic Scoliosis. World Neurosurgery. 2021 Jul 1;151:e234-40.
15. Yang JH, Chang DG, Honnurappa AR, Kim SH, Ham CH, Suh SW. Minimally invasive surgery for correcting adolescent idiopathic scoliosis: a novel approach called coin hole technique. Journal of Advanced Spine Surgery. 2016;6(1):20-8.
16. Anand N, Baron EM. Minimally invasive approaches for the correction of adult spinal deformity. European Spine Journal. 2013 Mar;22(2):232-41.

How to Cite this Article: Patel UD, Kavishwar RA, Suh SW, Yang JH, Modi HN | Minimal Invasive Scoliosis Surgery (MISS): Current State of Art for Adolescent Idiopathic Scoliosis | Back Bone: The Spine Journal | April 2023-September 2023; 4(1): 04-08 | https://doi.org/10.13107/bbj.2023.v04i01.052

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