Background: Surgical management of high-grade spondylolisthesis in the young is not only challenging but also controversial, from in-situ fusion to complete reduction. It is fraught with dangers such as neurological injury, pseudoarthrosis, and progressive deformity with subsequent global sagittal imbalance. We describe our experience of progressive reduction technique and restoration of lumbosacral alignment.Methods: This study is a retrospective review of patients who underwent surgery between 1998 and 2012. The surgical technique involved positioning the hips in extension with traction, pedicle screw fixation, correction of lumbosacral kyphosis with a specific distraction maneuver, wide decompression, and gradual reduction of the deformity and maintenance of reduction with interbody fusion. All patients were serially assessed at 1, 3, and 6 months and yearly thereafter with clinical, radiological, and Oswestry Disability Index and Visual Analogue Scale outcome measures.Results: Twenty-seven patients with high-grade spondylolisthesis at L5-S1 (3 cases grade 3, 7 grade 4, 17 grade 5) with an average age of 13.9 years were reviewed. Mean follow-up was 120 months (range 24-192). All patients presented a solid fusion at the 6-month visit; mean slip percentage was reduced from 89% to 23%, with all cases reduced to grade 2 or less. The slip angle improved from 458 to 38 postoperatively, with improvement in sacral slope from 138 to 358. Four spondyloptosis patients had concomitant scoliosis which corrected spontaneously after the surgery and did not need further intervention. All but one patient (96.2%) had good functional outcomes and returned to their full normal activities One patient developed a deep infection necessitating implant removal, with eventual deformity progression leading to a poor outcome. Three patients (11.1%) suffered partial drop foot that resolved in full by 12 weeks.Conclusion: Our technique demonstrated a significant reduction of high grade spondylolisthesis, with restoration of global sagittal balance via correction of the lumbosacral kyphosis. Though surgically demanding, it is safe and reproducible.Level of Evidence: IV

Background: Transforaminal lumbar interbody fusion (TLIF) with bilateral pedicle screw instrumentation is a well-accepted technique in lumbar degenerative disc disorder. Unilateral instrumentation in TLIF has been reported in the literature. This study aims to compare the clinical and radiological outcomes of unilateral and bilateral instrumented TLIF in a selected series of patients.Methods: We retrospectively analyzed patients operated with unilateral pedicle screw fixation in TLIF (UPSF TLIF) or with bilateral pedicle screw fixation in TLIF (BPSF TLIF) with a minimum of 2 years of follow-up. Patients were evaluated at regular intervals for functional and radiological outcomes. Functional outcome was assessed using the Oswestry disability index (ODI) and visual analog score (VAS) preoperatively and at 6 months, 1 year, and 2 years after surgery. Fusion rates were assessed using Bridwell interbody fusion grading.Results: Our study shows that there was a significant improvement in VAS and ODI in both groups at 2 years follow-up, and there was no significant difference in improvements between the groups. The complication rates between the groups were similar. The fusion rate in UPSF TLIF was 97.3% and was 98.34% in BPSF TLIF; this was not statistically significant between groups. There is a significant difference in terms of blood loss, duration of surgery, and average duration of hospital stay between the groups (P , .001), favoring UPSF TLIF.Conclusions: Unilateral pedicle screw fixation in open TLIF is comparable with bilateral pedicle screw fixation in terms of patient-reported clinical outcomes, fusion rates, and complication rates with the additional benefits of less operative time, less blood loss, shorter hospitalization, and less cost in selective cases.

Background and Aims: Posterior lumbar spine fusion surgeries are associated with severe postoperative pain necessitating a multimodal analgesic regime. Wound infiltration with local anaesthetic is an accepted modality for postoperative analgesia in spine surgeries. Thoracolumbar interfascial plane (TLIP) block is a novel technique being evaluated for providing analgesia in lumbar spine surgeries. This study aimed to compare the analgesic efficacy of TLIP block compared to that of wound infiltration with local anaesthetic in terms of time to request the first dose of rescue analgesic. Methods: Seventy-one patients scheduled for posterior lumbar spine fusion under general anaesthesia were included in this double-blinded randomised controlled trial. Preoperatively, patients were randomly allocated to receive either a TLIP block (TLIP group) or wound infiltration (LI group). The primary endpoint was the time of the first request for rescue analgesia. Secondary endpoints were the total tramadol consumption and pain and comfort scores measured at various time points in the 48-h postoperative period. The trial was terminated after second interim analysis as the analgesic benefit of TLIP was evident both clinically and statistically. Results: The median (interquartile range) duration of the time of the first request for rescue analgesia was 1440 (1290, 2280) min in the TLIP group and 340 (180, 360) min in the infiltration group; P value <.001. The mean tramadol consumption was significantly higher in the infiltration group compared to the TLIP group, with a P value <.001. Conclusion: TLIP block provided better postoperative analgesia than that provided by wound infiltration with local anaesthetic.

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Introduction With the high prevalence of tuberculous spondylodiscitis in India and the tendency to label all spondylodiscitis astuberculous, it is prudent to have a high index of suspicion for non tuberculous infections and treat them accordingly. With the concern on the usage of metal implants in the infected spine, we study the safety and efficacy of debridement and stabilization with metal implants in infective spondylodiscitis. Material and Methods Patient records and radiographs of 34 patients of non tuberculous spondylodiscitis who were operated between 2003 and 2013, were reviewed. All the patients were managed with debridement of the infected segment, reconstruction and stabilization of the spine using titanium pedicle screws with interbody spacers. Clinico-radiological follow up was done at 1, 3, 6 and then yearly thereafter. Results 34 patients (M:23, F:11) with an average age of 48 years (20–68yrs)operated between 2003 and 2013. Low back pain with left radiculopathy for an average duration of 4 months (1–12months) was the most common presentation. Neurological involvement was seen in 12 patients (Foot drop- 8, Paraparesis-2 and Sensory deficits - 2). The pathology was monosegmental in 27 patients (L5-S1:10, L4–5:13, L3–4:2, L2–3:2). The infection was hematogenous in 18, post surgery (discectomy/laminectomy) in 15 and post UTI in 1 patient. The surgical isolates were mainly Staphylococcus aureus-17, E.coli and Gram negative bacilli-7, MRSA-5, Pseudomonas-1 and Fungal-4. 28 patients underwent posterior procedure, 1 anterior alone and 5 underwent combined anterior and posterior procedures. All the patients had appropriate antimicrobial therapy and mobilized as early as tolerated. All patients had excellent to good functional results and no evidence of infection at average follow-up of 72 months (27–130 months). ODI and Kirkaldy-Willis criteria showed significant improvement of function postoperatively. All the blood parameters were normalized in 3 months. 1 patient had dural tear which was repaired peroperatively without sequelae, 2 cases required wound exploration and lavage. No other major complications were encountered. All cases showed radiological fusion and no evidence of metal related complications at the latest followup. Conclusion Thorough debridement of necrotic material creates a good vascularised environment and restoring stability compromised by either infection or prior surgery helps in healing process and reduces morbidity of patients, with early return to normal activity. The use of metal implants is safe and efficacious even in the presence of infection.