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   Table of Contents - Current issue
Coverpage
July-December 2022
Volume 5 | Issue 2
Page Nos. 143-250

Online since Wednesday, June 8, 2022

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EDITORIAL  

Evolution of management of spinal tumors p. 143
Gautam R Zaveri, Venkatesh Krishnan
DOI:10.4103/isj.isj_81_21  
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SYMPOSIUM - METASTATIC SPINAL TUMORS Top

Systemic therapies for the management of cancers with spinal metastases p. 145
Mohan Menon, Gautam R Zaveri
DOI:10.4103/isj.isj_78_21  
Management of spinal metastatic disease aims to improve the quality of remaining life in patients who have potentially limited survival. The treatment strategy necessitates multimodality, multidisciplinary involvement. Systemic therapies primarily aim to control systemic spread of the primary cancer. The armamentarium of systemic therapies includes traditional chemotherapy, bone-modifying agents, hormonal therapy, targeted molecular therapy, immunotherapy, and radioisotopes. The newer systemic therapies have resulted in a significant increase in overall survival of patients with metastatic disease. Consequently, treatment strategies must aim to achieve lasting local control of the spinal metastasis. The overall treatment strategy for an individual patient is planned based on a careful consideration of the anticipated survival, medical comorbidities, and the general condition of the patient.
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Epidemiology, pathogenesis, clinical presentation, and diagnostic approach p. 150
Pratik Patel, Kshitij Chaudhary, Samir Dalvie
DOI:10.4103/isj.isj_77_21  
Spinal metastatis is a diagnostic and treatment challenge for the spine surgeon and must be addressed through multidisciplinary, multimodal, and individualized management. The presence of tumor cells in bone metastases results in homeostatic disruption between bone formation and remodeling and leads to osteolytic, osteoblastic, or mixed bone lesions. Spinal metastases are a significant cause for morbidity characterized by severe pain, impaired mobility, pathological fractures, spinal instability, and neurological involvement. Radiographs, magnetic resonance imaging, computed tomography, and positron emission tomography are widely used for the detection and staging of the disease. Histopathological examination is crucial to establish an oncological diagnosis. Our review focuses on epidemiology, pathogenesis, clinical presentation, and diagnosis of spinal metastasis.
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Concepts, rationale, and techniques of the open approach in the surgical management of metastatic spine disease p. 158
Naresh Kumar, Sean Junn Kit Lee, Sridharan Alathur Ramakrishnan, Andrew Cherian Thomas, Sarah Shuyun Tang, Balamurugan A Vellayappan
DOI:10.4103/isj.isj_73_21  
Advancements in medical therapy have led to the increased incidence of metastatic spine tumor surgery (MSTS) owing to the increased survivability of cancer patients. Over the years, surgical techniques have evolved from simple laminectomy to advanced radical surgery with reconstruction. Surgery with radiotherapy (RT) and chemotherapy have been established as key paradigms for the management of metastatic spine disease (MSD). In general, surgical treatment is split into two categories, open and minimally invasive. Decompression and stabilization form the basis of the common surgical techniques for managing MSD. Pedicle screw-rod instrumentation forms the basis of fixation, whereas decompression can be achieved through techniques such as laminectomy, separation surgery, partial corpectomy, near piecemeal corpectomy, or en bloc corpectomy. However, complications such as infection, wound dehiscence, and instrument failure remain the challenges of MSTS. This gives the need for auxiliary techniques and advancements to improve the efficacy of MSTS and reduce complications. Recent advancements such as intraoperative cell salvage in MSTS have reduced the need for allogenic blood transfusion, thus reducing the risk of infection and other complications. Additionally, implant materials such as carbon-fiber-reinforced polyether–ether-ketone (PEEK) and titanium-coated PEEK with better biocompatibility, imaging, and RT compatibility have been explored for use in MSTS. Current trends in MSTS are shifting toward minimally invasive surgery (MIS); however, open surgery remains the “gold standard.” Open surgery is preferred in cases with compromised visibility, i.e., hypervascular tumor secondaries and in regions of spinal column with limited access where the MIS approach is likely to be dangerous. We recommend that all spine surgeons be familiar with the concepts and techniques of open surgery for MSD.
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Minimally invasive surgery for spinal metastases: Principles, techniques, and outcomes p. 168
Naresh Kumar, Andrew Cherian Thomas, Sean Junn Kit Lee, Keith Gerard Lopez, Sarah Shuyun Tang, James Thomas Patrick Decourcy Hallinan
DOI:10.4103/isj.isj_72_21  
The incidence of metastatic spine disease (MSD) is on the rise and is currently present in 70% of patients presenting with systemic cancer. The majority of patients with MSD present with clinical symptoms such as neurological deficit, pathological fracture causing pain and spinal instability. Management of MSD is a multidisciplinary endeavor that involves surgery, radiotherapy (RT), and chemotherapy. The conventional open spine surgery approach has evolved into a less invasive surgery model categorized as minimally invasive spine surgery (MISS) or minimal access spine surgery. This evolution was brought about to address the complications associated with open surgery such as longer hospital stays and wound-related problems. MISS has been now widely explored in MSD due to lower wound-related complications, decreasing operative time, less neurological complications, and shorter hospital stays. Decompression and stabilization still remain the core concepts in MISS. Kyphoplasty/vertebroplasty, percutaneous pedicle screw fixation, separation surgery, and radiofrequency ablation are some of the minimally invasive techniques and procedures for surgical management of MSD. MISS is used in conjunction with other modern techniques like intraoperative neuromonitoring to help identify any adverse neurological events. MIS techniques will evolve with time, extending their application for the management of hypervascular tumors with significant anterior cord compression and recurrent tumors in which the open surgery currently remains the choice of approach.
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Decision making in the management of metastatic spinal tumors p. 176
Gautam Zaveri
DOI:10.4103/isj.isj_101_21  
The advent of newer systemic therapies has resulted in improved survival of cancer patients. Increased life expectancy necessitates strategies not only for palliation to improve quality of life but also for lasting local control of the spinal metastasis. In patients with a short life expectancy, palliative surgery involves decompression of neural structures by debulking the tumor and spine stabilization followed by conventional external beam radiotherapy (cEBRT). Ablative surgery involves more aggressive tumor resection followed by cEBRT. The introduction of stereotactic body radiotherapy (SBRT) has challenged traditional paradigms for decision-making further. With SBRT, hitherto radioresistant tumors can also be successfully treated with radiotherapy alone, in selected cases without spinal instability or severe epidural spinal cord compression. Minimally invasive surgical techniques such as percutaneous cement augmentation, percutaneous stabilization, and minimally invasive decompression and tumor resection have further reduced the surgical morbidity, enabling extension of treatment to more sick patients. The eventual decision regarding the treatment strategy is made on a case-by-case basis by a multidisciplinary team along with the patient and his/her family.
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Radiotherapy for spinal metastasis: A narrative review p. 185
Rajesh Balakrishnan, Patricia Sebastian, Gautam R Zaveri
DOI:10.4103/isj.isj_79_21  
Despite the rapid evolution of systemic therapies and significant advances in surgical techniques, radiation therapy by itself or as an adjuvant to surgery remains the modality of choice for local control of spinal metastasis. Radiation can be used with an ablative intent for lasting local control of spinal metastasis or with a palliative intent to ameliorate pain, prevent pathological fractures, and relieve epidural spinal cord compression. This article aims to review the various modalities of radiotherapy. The lack of precision with conventional external beam radiotherapy (cEBRT) poses a significant radiation hazard to vital structures adjacent to the spine. This necessitates lowering of the radiation dosage, which may not be adequate to treat certain resistant tumors. Currently, the use of cEBRT is recommended for radiosensitive histologies only. Stereotactic body radiotherapy (SBRT) allows tumoricidal doses of radiation to be safely delivered to the tumor tissue. SBRT has been shown to provide durable local control, even for spine metastasis from tumors with radioresistant histologies. SBRT can also be offered as a reirradiation technique for tumor progression following a course of cEBRT. Currently, SBRT alone is recommended for radioresistant spinal metastasis limited to 1–2 spinal segments, with limited paraspinal spread and mild-to-moderate spinal cord compression in a stable spine. Charged particle therapy is useful for resistant histologies and further reduces the dose to normal structures within the vicinity of the tumor.
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Outcomes of surgical treatment in spinal metastasis p. 193
Nischal Ghimire, Venkatesh Krishnan
DOI:10.4103/isj.isj_16_22  
With increase in the elderly population and improved survival among patients with malignancies, the rates of patients presenting with metastatic involvement of the spine is on the rise. Surgical management of spinal metastasis requires a multidisciplinary approach and surgery is a key component of multimodality management of metastatic spinal lesions. A PubMed search of relevant articles was performed and a narrative review of available pertinent literature in English language is presented.
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SPINE CLINIC Top

Spinal metastases: Clinical scenarios p. 199
Gautam R Zaveri, Venkatesh Krishnan
DOI:10.4103/isj.isj_98_21  
The goal of treatment in patients with spinal metastasis is palliation, that is, to improve the quality of remaining life as judged by alleviation of pain, preservation or restoration of neurology, and improvement in function. Local control of the spinal metastasis not only influences the overall survival of a cancer patient but is vital to maintain treatment benefits for the duration of the patient`s survival. However, cancer therapy––both surgical and nonsurgical––carries a significant risk of complications, morbidity, and even mortality. Decision-making regarding the most appropriate treatment strategy is vital when treating terminally ill patients with spinal metastatic disease.
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ORIGINAL ARTICLES Top

The correlation between lumbosacral transitional anatomy and pars defect p. 209
Gabriel S Gonzales-Portillo, Mauricio J Avila, Omar Rizvi, Travis M Dumont
DOI:10.4103/isj.isj_59_21  
Background: Transitional anatomy and pars defects are two common incidental findings seen on imaging of the lumbosacral spine. The purpose of this study was to investigate whether there is a correlation between these two lumbar spine phenomena. Materials and Methods: A retrospective review of spinal imaging was conducted of patients presenting with thoracolumbar fractures at our Level I Trauma Center between 2017 and 2018. Computed tomography scans from 260 patients were obtained and assessed for the presence of lumbosacral transitional anatomy and pars defect. Results: From the 260 patients reviewed, 16 patients had transitional anatomy (6%) and 20 patients had lumbar non-traumatic pars defect (8%). Only one patient presented with both transitional anatomy and pars defect. Overall, there was no difference in incidence of pars defect whether transitional lumbosacral anatomy was present (5%) or not (6.25%), P = 1.00, Fisher’s exact test. Conclusion: The findings suggest that patients with transitional anatomy do not have an increased association with lumbar pars defects.
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An operative technique for management of neglected bi-facetal cervical dislocations p. 215
Pawar Jayesh, Bapat Mihir, Gujral Amandeep, Bharat Patel, Upadhyay Arpit
DOI:10.4103/isj.isj_60_21  
Background: Bi-facetal cervical dislocations can be missed due to misinterpretation of clinical signs and radiographs at initial assessment. In such cases, an ensuing fibrous union makes reduction and surgical stabilization both difficult and challenging. Multiple-stage approaches are required for its management. The guidelines for the surgical treatment of neglected bi-facetal dislocation are not yet clearly defined. The aim of this retrospective case series is to discuss the operative approach for the management of neglected bi-facetal cervical dislocation and the assessment of its clinical outcomes. Methods and Materials: From 2014 to 2019, five patients with neglected bi-facetal cervical dislocation were surgically treated in two stages by the posterior-anterior approach and were followed up for one year. The average age was 47.4 years, with a mean delay of 9.8 weeks. A posterior approach was preferred first, where a reduction was achieved with the help of lateral mass reduction screws after soft tissue release and facetectomy. This was followed by anterior discectomy and stabilization. Neck pain was assessed by the neck disability index (NDI) and the Visual analogue score (VAS). Neurology was assessed by using the modified Japanese Orthopaedic Association (mJOA) score. Sagittal alignment and fusion were also recorded. Results: Anatomical reduction was achieved in all patients without neurological worsening. NDI, VAS and mJOA score were significantly improved after the surgery. In all patients, complete fusion occurred at the final follow-up and no complications were encountered. Conclusion: It is difficult to reduce a neglected bi-facetal dislocation. Liberal facetectomy and the use of reduction lateral mass screws provides for a safe and controlled reduction. The reported two-stage technique successfully achieves an anatomical reduction and a stable circumferential fusion.
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Surgical management of aggressive vertebral hemangioma: Case series and review of literature p. 222
Selvin V Prabhakar, Christopher Gerber, Anindya Basu, Dipendra K Pradhan, Sukalyan Purkayastha
DOI:10.4103/isj.isj_48_21  
Background: This study includes management of aggressive vertebral hemangioma (VH). VH is the most common primary tumor affecting the vertebral column. In 0.9–1.2% of patients, VH can become symptomatic and is termed as “aggressive vertebral hemangiomas.” They usually require surgery along with adjuvant modalities. Due to its relatively low incidence, there is sparse reporting in the open literature and lack of universal consensus on treatment protocol. We would like to present our institutional experience in managing aggressive VH by surgery along with adjuvant modalities and a comprehensive review of the literature. Materials and Methods: A retrospective review of records of VH cases managed surgically in the past 3 years at our institute was done. All the relevant records and imaging of the patients were retrieved. Results: Five patients were included in the study. All were male with four dorsal and one lumbar lesion. All were treated with surgery along with an adjuvant therapy. Selective arterial embolization was used in one patient, alcohol ablation in three, and vertebroplasty in one. Only one patient had gross total resection, and others had only decompression. Fixation was done in all. All showed good clinical improvement without any complications, except in one. Conclusion: Aggressive VH often requires surgery. Currently, a decompression surgery is preferred due to less morbidity with good clinical outcomes. Various adjuvant therapies have been described in literature to be used perioperatively; yet there is no universal consensus on a standard protocol. Each of them has its own advantages and limitations and thus needs to be carefully selected on an individual basis. Alcohol ablation is an established adjuvant modality, but has to be used with caution.
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CASE REPORTS Top

Iatrogenic fracture in a patient of ankylosing spondylitis planned for surgical correction of chin-on-chest deformity: A case report and review of literature p. 231
Saumyajit Basu, Kushal Gohil, Ashish Gupta, Jallipalli Ranga Sai Gowtham, Dheeraj Manikanta, Gokul Bandagi, Amitava Biswas
DOI:10.4103/isj.isj_66_21  
Ankylosing spondylitis (AS) is a progressive systemic chronic inflammatory rheumatic disease that causes arthritis of spine and sacroiliac joints and finally results in contracture or bony fusion of these joints. The ankylosed spine has increased propensity to fracture due to rigidity, long lever arms, and osteoporosis. However, iatrogenic fracture occurring in AS patients with chin-on-chest deformity during positioning has not been reported. A 46-year-old male, known case of AS, presented with progressive deformity of neck for the last 6 months due to C5 fracture with C4/5 dislocation. He had chin-on-chest deformity with chin-brow vertical angle of 106o with spastic tetraparesis (mJOA score 6, Nurick grade-3). The patient was put on sustained halo-gravity traction by gradually increasing the weight up to 30 lbs for 4 weeks and then was planned for deformity correction. After intubation and application of same traction, we found anterior wedge opening and fracture through C6/7 disc space. His neurology was found to be same as in the preoperative state on neural monitoring and wake up test. Front and back instrumented fusion was done with anterior bone grafting. Postoperatively, he was maintained on halo-vest immobilization for three months. By the end of first year, the fracture had united well and he was mobilizing well with mJOA score 13 and Nurick grade-1. AS patients are at higher risk of fracture and need utmost care while positioning during surgery. Traction or any corrective maneuver must be done carefully.
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Epidural angiolipoma and Andersson lesion: A rare co-occurence—A case report and literature review p. 235
Selvin Prabhakar Vijayan, Christopher Gerber, Anindya Basu, Garga Basu, Radhika Mhatre
DOI:10.4103/isj.isj_47_21  
Spinal angiolipomas (SALs) are very rare benign extradural neoplasms, representing 0.14%–1.2% of all spinal tumors. Andersson lesion is a localized vertebral or disco-vertebral lesion in ankylosing spondylitis. Co-occurrence of these lesions is very rare and has never been reported. We are reporting one such case of a 61-year-old man presented with features of dorsal compressive myelopathy. On magnetic resonance imaging (MRI), he was diagnosed to have a SAL at D6–D9 and Andersson lesion at D7–D8 and L1–L2. He was managed surgically with a long-segment fixation and decompression and gross total excision of the tumor. Diagnosis of a SAL was confirmed in a biopsy, and postoperatively, he showed good clinical improvement. In conclusion, given the rarity of co-occurrence of these pathologies, a strong clinical suspicion is required. MRI and CT scan help in diagnosis. Both these pathologies warrant surgical management. When diagnosed early and managed appropriately, they have a good prognosis.
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Brucellosis sacroiliitis masquerading as inflammatory spondyloarthropathy p. 241
Alok Gupta, Ashok M Shyam, Parag K Sancheti, Siddharth N Aiyer
DOI:10.4103/isj.isj_38_21  
Brucellosis is the most common zoonosis globally, and it is endemic to the Indian subcontinent. It can mimic a number of febrile illnesses and inflammatory disease conditions. An 18-year-old boy presented with low back pain and a fever of three-month duration. Magnetic resonance imaging revealed a unilateral sacroiliitis, which was being treated as an inflammatory spondyloarthropathy. Because of non-resolving symptoms, a biopsy was performed, which showed a granulomatous inflammation that was consistent with tuberculosis or brucellosis infection. A history of exposure to livestock and consumption of unpasteurized milk led to a clinical suspicion of brucellosis, which was confirmed on a positive serology. He was treated with antibiotics with improvement in symptoms and complete resolution of the sacroiliitis. A high index of suspicion must be maintained for brucellosis, especially in patients with a rural residence, exposure to livestock, and febrile illness with a clinically suspected unilateral sacroiliitis.
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Primary spinal melanoma: A radiological diagnostic dilemma confirmed by histopathology p. 246
Paramita Paul
DOI:10.4103/isj.isj_53_21  
Primary malignant melanoma of central nervous system accounts for approximately 1% of all melanomas. Primary spinal melanomas are even more unusual. The clinico-radiological features of primary spinal melanoma are complex and non-specific, resulting in a high misdiagnosis rate. Here, primary cervico-thoracic spinal melanoma is presented in a 53-year-old woman which mimicked a hematoma on magnetic resonance imaging and an arteriovenous malformation intraoperatively. Histopathology and immunohistochemistry confirmed the diagnosis of malignant melanoma.
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