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

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.

Introduction A morphometric analysis of convex and concave pedicles in scoliotic spines depends on the three-dimensional reconstructions of the spine. As the standard of care relies on two-dimensional X-rays, there have been few reports on this topic and an underestimation of the morphological irregularities. We present our data of AIS patients who underwent HRCT as part of the preoperative planning for robotic-guided corrective surgery. Material and Methods A retrospective study of adolescent idiopathic scoliosis patients indicated for corrective surgery at our center. All patients underwent a CT scan with 1-mm slice thickness as part of their preoperative planning. The morphometric parameters documented were: transverse pedicle width, pedicle angle and maximum chord length in both convex and concave sides of the curve and were analyzed in the software (Renaissance) used for robotic guidance. Results We reviewed charts of 23 patients with an average age of 14.9 years. Average Cobb angles of the major curve measured 48.4° (Range 27.7° to 82.8°). There were 7 type 5 Lenke curves, 6 type 3 and type 1, and 4 cases of type 6. On the concave side 247 pedicles were measured, of which 104 (42%) were hypoplastic (i.e., transverse pedicle width <4 mm). Of the 249 convex pedicles measured, 74 (30%) were hypoplastic (p < 0.005). Mean concave pedicle angle was 15.6 ± 3.8° and maximum chord length was 40.9 ± 7.1 mm, while the convex pedicle angle was 16.1 ± 3.9° (p = 0.22) and maximum chord length was 40.8 ± 6.4 mm (p = 0.82). Conclusion Knowledge of patient-specific anatomical variances is critical when instrumenting scoliotic vertebrae. Based on our findings, despite the patient's added exposure to radiation, we advocate the use of CT-based preoperative planning to maximize safety of the instrumentation and emphasize the importance of Surgeon familiarity with patient specific anatomic variances in instrumentation of scoliotic vertebrae.

Introduction Cobb's angle in scoliosis has been widely accepted to analyze the extent of deformities and can be used as an indicator of the degree of correction obtained following a corrective surgery. Measurement has traditionally been manual using a pencil and protractor on radiographs. Smartphones have changed the way we live in every field of life. Use of apps in smartphones with accelerometers aids to measure the angle quickly. This study analyzes the accuracy and efficiency of the inclinometer app in smartphones to measure cobb's angle in scoliosis. Material and Methods We analyzed cobb's angle in scoliotic patients who underwent robotic guided corrective surgery at our center over the past 2 years. The Cobb angle measure tool in the software used in robotic surgery (Renaissance, Mazor robotics) was used as the gold standard (GS) as it was software based analysis. Clinometer app was used in the smartphone by the primary observer over the computer screen to measure the cobb angle and then manual method was used. Time taken to measure using both the techniques was noted by other observers. Another two observers then independently measured the angle using their smartphones to assess the interobserver variability. Data was tabulated and analyzed by a biostatistician. Results Cobb angle of 25 patients with mean age of 14.1 years were analyzed for primary and secondary curves separately. The mean Cobb angle of all measured X-rays was 48.9 degrees in the manual set and 47.9 degrees in the smartphone set as compared with 48.2 degrees as per GS. The mean time consumed was 13.5 seconds for the smartphone set, significantly shorter than that of the manual set which was 36.2 seconds (statistically significant – p < 0.05). 95% confidence intervals for inter-observer variability using smartphones were ±1.5degrees. Conclusion Cobb angle measurement using the smartphones was more accurate than the manual methods in our study. With significant time difference between the methods indicating the simplicity of the use of apps in our daily use and the minimal interobserver variability, smartphones indeed can replace the manual methods and can be a reliable tool in the hands of spinal deformity surgeons.

Introduction Lumbar fusion in degenerative conditions has universally provided good results. However, adjacent segment degeneration, either afresh or worsening of a low grade degeneration in the segment above has been indicated for the pain and low functional outcome on long term follow-ups. Interspinous implants have been used to off load the facets and prevent spinal canal narrowing in stenosis with good results. This paper analyses the novel idea of using an interspinous device above the level of fusion to decelerate the physiologic process and reduce the incidence of adjacent segment degeneration (ASD). Material and Methods 12 patients were analyzed in the study. The inclusion criteria for the study was degeneration of the disc above the level of intended fusion with no or less than 50% disc height reduction and no nerve root compression. Patients with more than 50% height reduction or severe arthritic facet joints underwent fusion at two levels and were excluded from the study. Patients with failed back syndrome and significant osteoporosis were also excluded from the study. Coflex (Paradigm) interspinous device was used in the level above the fusion in all cases. Clinical and radiographic criteria for ASD was assessed at the latest followup. VAS and ODI functional outcome was analyzed. Results 12 patients with mean age of 63 years who underwent surgery between September 2012 and March 2014 were analyzed in the study. Mean followup was 27 months (Range 18–36 months). Single level fusion was performed in 9 cases and Two level fusion in 3 cases. Coflex device was implanted at L3–4 in 8 cases and L4–5 in 4 cases. All 12 patients had a good fusion in the 6 months radiograph. Disc height improvement was seen in the level above, with no evidence of stenosis or listhesis at the latest followup. Worsening of already existant ASD in one patient was noticed but did not require surgical intervention. VAS and ODI showed significant (p < 0.05) improvement postoperatively. No infection or reoperation was needed in any of the 12 patients. Conclusion ASD remains a significant reason causing failed back syndrome requiring reoperations in lumbar fusion. Use of interspinous device not only preserves a motion segment from fusion, but also shows promise in reducing the incidence of degeneration above the level of fusion. Further studies with larger sample size and long term followup is necessary to support the conclusion.