MDR-TB of the spine is a different disease and is here to stay. There is an urgent need to include culture and drug susceptibility testing in the protocol for the treatment of tuberculosis of the spine.

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To compare the incidence of iatrogenic superior facet joint violation (SFV) in minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and open TLIF (OPEN-TLIF) at a single lower lumbar fusion level and to evaluate the patient and surgical factors influencing the outcome. Overview of Literature: Iatrogenic SFV is a significant risk factor for adjacent segment disease (ASD). Blind screw placement technique in MIS-TLIF contributes to the increasing incidence of iatrogenic SFV which can be influenced by several other potential factors. There are only limited studies comparing the incidence of iatrogenic SFV in MIS-TLIF and OPEN-TLIF. Methods: In total, 225 cases (450 top screws; MIS-TIFL, 120; OPEN-TILF, 105) undergoing single-level lower lumbar fusion were included in the study. Postoperative computed tomography grading system was used to evaluate iatrogenic SFV. Patient and surgical factors such as age, body mass index, top-screw level, side of the top screw, depth of the spine, and superior facet joint angle (SFA) were analyzed in iatrogenic SFV and non-violation groups to determine their influence on iatrogenic SFV. The clinical outcomes in both groups were assessed preoperatively and postoperatively. Results: The overall incidence of iatrogenic SFV and high-grade violations was higher in MIS-TLIF (41.25%) than in OPEN-TLIF (30.4%). In both groups, bivariate analysis showed a significantly greater incidence of the iatrogenic SFV in patients aged <60 years and those with obesity, top pedicle screws at L4, right-sided top screws, SFA >35°, and depth of the spine >50 mm. Conclusions: This study demonstrated that the incidence of iatrogenic SFV is greater in MIS-TLIF than in OPEN-TLIF at a single lower lumbar level. MIS-TLIF is effective for lumbar degenerative disease; however, the incidence of iatrogenic SFV was higher. Patient and surgical factors must be considered to protect the facet joints in both TLIF methods to avoid ASD.

Vertebroplasty provides excellent pain relief and functional restoration for osteoporotic fractures. Short-term complications such as cement leak and embolism are well described. Incident fractures are the only well-reported long-term complications. The authors describe the cases of 5 patients who presented with back pain caused by instability or worsening neurological status 13 months (range 8–17 months) after vertebroplasty. They further classify this postvertebroplasty instability into intervertebral instability and intravertebral instability, depending on the apex of abnormal mobility. One patient presented with cement migration and progressive collapse of the augmented vertebral body. Another patient presented with an additional fracture. Both cases were classified as intravertebral instability. The cases of 3 other patients presenting with adjacent endplate erosion, vacuum disc phenomenon, and bridging osteophyte formation were classified as having intervertebral instability. Long-term effect of cements on the augmented vertebral body and adjacent endplates and discs is a cause for concern. Vertebroplasty acts as a mechanical stabilizer and provides structural support but does not bring about union. Micromotion has been shown to persist for years after vertebroplasty. This study describes persistent instability after vertebroplasty in a series of 5 cases. The authors propose that postvertebroplasty instability occurs due to collapse of soft osteoporotic bone and endplates around cement. All 3 cases of intervertebral instability were associated with an intradiscal cement leak. With increased longevity and higher functional demands of the geriatric population, the durability of this “rock (cement) between cushions (of osteoporotic bone)” arrangement (as seen in vertebroplasty) will be increasingly challenged.

Study DesignProspective cohort study.PurposeTo compare intraoperative parameters, radiation exposure, and pedicle screw perforation rate in navigation-guided versus non-navigated fluoroscopy-assisted minimal invasive transforaminal lumbar interbody fusion (MIS TLIF).Overview of LiteratureThe poor reliability of fluoroscopy-guided instrumentation and growing concerns about radiation exposure have led to the development of navigation-guided instrumentation techniques in MIS TLIF. The literature evaluating the efficacy of navigation-guided MIS TLIF is scant.MethodsEighty-seven patients underwent navigation- or fluoroscopy-guided MIS TLIF for symptomatic lumbar/lumbosacral spondylolisthesis. Demographics, intraoperative parameters (surgical time, blood loss), and radiation exposure (sec/mGy/Gy.cm2 noted from C-arm for comparison only) were recorded. Computed tomography was performed in patients in the navigation and non-navigation groups at postoperative 12 months and reviewed by an independent observer to assess the accuracy of screw placement, perforation incidence, location, grade (Mirza), and critical versus non-critical neurological implications.ResultsTwenty-seven patients (male/female, 11/16; L4–L5/L5–S1, 9/18) were operated with navigation-guided MIS TLIF, whereas 60 (male/female, 25/35; L4–L5/L5–S1, 26/34) with conventional fluoroscopy-guided MIS TILF. The use of navigation resulted in reduced fluoroscopy usage (dose area product, 0.47 Gy.cm2 versus 2.93 Gy.cm2), radiation exposure (1.68 mGy versus 10.97 mGy), and fluoroscopy time (46.5 seconds versus 119.08 seconds), with p-values of <0.001. Furthermore, 96.29% (104/108) of pedicle screws in the navigation group were accurately placed (grade 0) (4 breaches, all grade I) compared with 91.67% (220/240) in the non-navigation group (20 breaches, 16 grade I+4 grade II; p=0.114). None of the breaches resulted in a corresponding neurological deficit or required revision.ConclusionsNavigation guidance in MIS TLIF reduced radiation exposure, but the perforation status was not statistically different than that for the fluoroscopy-based technique. Thus, navigation in nondeformity cases is useful for significantly reducing the radiation exposure, but its ability to reduce pedicle screw perforation in nondeformity cases remains to be proven.

Study Design. A cross-sectional observational study. Objective. This study aims to determine the diagnostic accuracy, sensitivity, and specificity of the Xpert MTB/RIF assay (Mycobacterium Tuberculosis/Rifampicin resistance) for the detection of spinal Tuberculosis (TB) and rifampicin (RIF) resistance. Summary of Background Data. The Spinal TB is often a paucibacillary extra pulmonary tuberculosis which gives a major challenge in early diagnosis and initializing the correct anti-tubercular treatment (ATT). Due to its rapidity and sensitivity, the dependence and reliability on the Xpert MTB/RIF assay has increased in the last few years. The studies describing accuracy of the Xpert MTB/RIF assay in spinal TB are scanty. Methods. This institutional review board-approved study included 360 diagnosed spinal TB patients. To determine the accuracy of the Xpert MTB/RIF assay, it was compared with other diagnostic tests like histopathology, acid fast bacilli (AFB) smear, culture, and drug sensitivity testing (DST). Results. The Xpert MTB/RIF assay showed 86.3% sensitivity and 85.3% specificity when compared with culture for the diagnosis of Spinal TB and showed 75.86% sensitivity, 96.12% specificity for RIF resistance when compared to DST. Four cases were false positive and 11 cases were false negative for RIF resistance on the Xpert MTB/RIF assay. Conclusion. The Xpert MTB/RIF assay is an efficient technique for the rapid diagnosis of spinal TB; however, a clinician should not solely rely on it for starting ATT. As there are false results also with this test which should be read cautiously and be well correlated with culture and DST pattern to guide the start of sensitive drug regimen only. The purpose is to prevent exposure of the second line drugs to false cases found on the Xpert MTB/RIF assay and avoid emergence of new acquired drug resistance. Level of Evidence: 4

The purpose of this study was to compare the clinical-radiological outcome and incidence of perioperative complications of MIS-TLIF at lower lumbar levels for elderly (Age >65 years) and younger patients (Age<65 years). Methods: A retrospective cohort study performed from 2011 to 2017. A total 138 patients who underwent MIS-TLIF were divided into two groups based on age (group A>65 years and group B<65 years). Perioperative clinical (co-morbidities, surgical time, blood loss, hospital stay, fusion level, VAS, ODI), radiological parameters (fusion, cage subsidence, implant failure), postoperative complications and satisfactory outcomes in the form of Wang's criteria were evaluated in both the groups. A statistical analysis between two matched groups was done with logistic regression analysis, chisquare and student t-test. Results: There was no statistical difference in blood loss, surgical time, mobilization and hospital stay between two groups however elderly patients took longer time to become pain free (p=0.001). Both groups showed significant improvement in ODI, VAS and Wang's outcome score however, no statistically significant difference noted in outcome between two groups at final follow up. General complications not affecting outcome were common in elderly group but no statistically significant difference noted among neurological events between both groups. Conclusion: MISS-TLIF surgery in elderly can produce successful clinical outcome and satisfaction after surgery in judiciously selected patients with proper preoperative risk assessment and optimization of medical co-morbidities. Elder age does not prove deterrent to outcome and should not be a contraindication to perform MISS-TLIF in lumbar degenerative diseases.

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