Abstract Ossified ligamentum flavum (OLF) is an important surgically treatable cause of thoracic myelopathy, most commonly seen in East Asian countries. Dural ossification (DO) is observed in 10%–60% of cases and is a significant cause of surgery-related complications. The aim of the present report is to provide a detailed narrative review of the incidence, pathogenesis, and various radiological signs described for the diagnosis of DO in OLF. We intend to present a simple practical approach for the pre-operative diagnosis of DO. Online databases were searched to retrieve studies that have described radiological signs for the diagnosis of DO in OLF, from the earliest date to the present, in the English language. Since 2009, ten radiological signs have been described in nine studies. They were mostly reported from computed tomography scans and all were conducted in Asian countries, namely China and India. These signs include the tram-track sign (TTS), comma sign, bridge sign, T2 ring sign, TOLF-DO grading system, cross-sectional area (CSA) occupying ratio, cerebrospinal fluid cross-sectional ratio, DO-OLF risk classification, Banner cloud sign, and three-dimensional occupying ratio. Each of these signs has good sensitivity and specificity, but none of them are 100% diagnostic. Because of comparable sensitivities and specificities, it may be opined that a combination of TTS, T2 ring sign, and a tuberous type of OLF (if present) will be sufficient for the diagnosis of DO in the majority of cases, as most of the others require complicated calculations that are difficult in routine clinical practice.

Abstract Advances in surgical visualization have transformed spine and neurosurgery, with the exoscope (EX) emerging as a promising alternative to the operating microscope. Offering high-definition 3D, 4K imaging with light-emitting diode–based illumination, the EX enhances precision while reducing heat generation and surgeon fatigue. Its ergonomic design, compact camera head, and extended working distance improve workflow, minimize interference with instruments, and promote surgeon comfort during prolonged procedures. Educational benefits are notable as the surgical team and trainees can share the same high-quality view. Integration of EX with its endoscope allows seamless toggling between exoscopic and endoscopic views, enhancing access to hidden structures. Additionally, near-infrared spectroscopy enables real-time tumor identification, improving the safety and completeness of resection. Despite challenges such as adaptation to screen-based coordination and cost, the EX represents a significant advancement in surgical visualization.

Abstract Background: Effective pain management after lumbar laminectomy is crucial to improve functional outcomes. Limited evidence exists on using epidural gelfoam soaked in ropivacaine for acute postoperative pain management. This study aimed to evaluate the effect of ropivacaine-soaked epidural gelfoam on the duration of postoperative analgesia and opioid consumption in patients undergoing lumbar laminectomy under general anesthesia. Materials and Methods: A prospective, double-blind, randomized controlled trial was conducted. Fifty patients aged 18–60 years, undergoing elective single-level lumbar laminectomy, were randomized into two groups: group R received epidural gelfoam soaked in 0.25% ropivacaine, and group P received gelfoam soaked in normal saline. Postoperative pain was assessed using Visual Analog Scale (VAS) scores at different time points, and rescue analgesia (tramadol) was administered for VAS ≥ 4. The primary outcome was the duration of analgesia, and secondary outcomes included opioid consumption and patient satisfaction. Results: The mean duration of analgesia was significantly longer in group R compared with group P (1076.4 ± 253.77 min vs. 153.6 ± 55.38 min, P < 0.001). Group R also had significantly lower tramadol consumption (126.00 ± 21.01 mg vs. 275.00 ± 19.09 mg, P < 0.001). VAS scores were consistently lower in group R, and pain relief was rated higher. No significant differences in hemodynamic parameters or major complications were observed between groups. Conclusion: Epidural ropivacaine-soaked gelfoam significantly prolongs postoperative analgesia and reduces opioid consumption after lumbar laminectomy, suggesting an effective and safe method for managing postoperative pain.

Abstract Background: Iliosacral screw fixation is a standard method for posterior pelvic ring stabilization. However patients with sacral dysmorphism have a higher risk of cortical perforations and thereby of developing complications. However, no study has described the prevalence of sacral dysmorphism in the Indian population, and measurements regarding safe zone and safe surgical angles for iliosacral screw fixation are lacking. Materials and Methods: A total of 107 computed tomography (CT) scans and pelvic X-rays were analyzed for the features of dysmorphic sacral vertebrae. We reformatted the CT scans to true axial and true coronal sections by aligning with sagittal sections, and we measured the “safe zone distance” (shortest distance between the anterior alar cortex and neural foramina), “safe surgical angle” (angle from the ilium to safe zone distance through which screw passes) calculations for both S1 and S2 vertebrae in axial and coronal sections. We also calculated the sagittal body heights of S1 and S2 vertebrae. Results: Incidence of sacral dysmorphism in the Indian population was 26%. Average axial safe zone distance in dysmorphic S1 vertebrae (16.61 ± 2.73 mm) is 11% smaller compared to that in normal (18.71 ± 2.21 mm, P value < 0.001). Average coronal safe zone distance in dysmorphic S1 vertebrae (15.13 ± 2.77 mm) is 7.75% smaller compared to that in normal (16.40 ± 2.72 mm, P value 0.037). Mean safe surgical angle (18.23 ± 3.27 mm) in true axial sections was 16.57% smaller in dysmorphic individuals compared to normal ( P value < 0.001). The mean safe surgical angle in coronal sections (18.78 ± 3.55 mm) was 7.72% smaller in dysmorphic individuals compared to normal ( P value 0.030). In S2 vertebrae axial sections, average safe zone distance and safe surgical angle are smaller compared to normal S2. However, interestingly coronal safe zone distance and safe surgical angle were found to be bigger compared to normal. The mean sagittal height of dysmorphic S1 is 3.05% higher compared to normal S1 vertebrae and dysmorphic S2 is 9.63% taller than normal S2. Conclusion: Safe zone distance and safe surgical angle in first dysmorphic sacral vertebrae are much smaller compared to those of normal vertebrae. It precludes transverse screw placement in first dysmorphic sacral vertebrae; however, screws can be placed in oblique direction. S2 vertebrae have more or less the same safe zone distance in axial sections compared to normal S2 vertebrae. We found no difference between phenotypes and even significant more coronal safe surgical angle in dysmorphic S2 vertebrae compared to normal. It needs careful preoperative planning considering the higher prevalence and significant short safe zone distance and short safe surgical angle measurements in dysmorphic vertebrae.

Abstract Coccydynia is a painful condition arising from the lowermost part of the vertebra with a prevalence of around 2.7%. Coccygectomy has emerged as an effective surgical method. Type V (retroverted and posteriorly angulated apex) is a rare variant (5%). Coccygeal osteotomy to correct the Type V deformity and alleviate pain has not been described previously in the literature. This study aims to report a unique case of Type V coccyx deformity with severe coccydynia. He underwent osteotomy, correction of Type V deformity, and fusion with a good outcome. A 15-year-old boy presented with severe pain in the tailbone region for 6 months. Clinical examination revealed puckering of skin at the tip of the protruding coccyx. The surgical technique is described. Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) scores were recorded preoperatively and at the final follow-up. He had a preoperative VAS score of 6 and an ODI score of 24. X-ray imaging revealed a retroverted coccyx (with posterior angulation) and a magnetic resonance imaging scan suggested an elongated coccyx with outward concavity (posterior angulation). The retroverted coccyx was corrected by osteotomy and a small triangular piece of bone graft was placed at the sacrococcygeal disc space after removing the disc. Two 3.5 mm cortical screws on either side were used to transfix the coccyx to the distal sacrum. Clinical and radiological improvements were observed every 6 months. At a follow-up of 3 years, he remains pain-free with a VAS score of 0. His ODI score was 0. This unique case of corrective osteotomy and fusion of the Type V coccygeal deformity to a normal angulation resulted in a pain-free life in an adolescent. This type of corrective osteotomy and fusion has not been described before.

Abstract Background: Conventionally, OLIF is performed in the lateral decubitus position for the interbody cage placement, followed by repositioning the patient to the prone position for pedicle screw fixation. Intraoperative repositioning significantly increases the operative room utilization time and may increase complications. 3DCT-assisted navigation guidance enables posterior instrumentation in the lateral position, allowing completion of the procedure in a single position. We aimed to assess the accuracy of pedicle screw placement and the clinical efficiency of the single-position technique for OLIF using O-arm navigation. This study is a single-center prospective study. Materials and Methods: Consecutive patients presenting from July 2021 to February 2024, aged above 18 years, with single-level spondylolisthesis (L2–L5 levels) or stenosis who consented for the OLIF procedure were included in the study. The surgical details (blood loss, surgical timing, pedicle screw fixation time, and OLIF time) and complications were noted and analyzed. The pedicle screw accuracy was assessed using intraoperative 3DCT using O-arm. Results: Twenty-six patients with a mean age of 57 years (range: 33–70 years), including seven males and 19 females, underwent single-level OLIF in a single position. The mean surgical time was 182.53 ± 51.26 min (92–255 min). The mean OLIF time was 131.28 ± 44.02 (50–215 min), and the mean pedicle screw fixation time was 53.76 ± 22.06 (20–120 min). The mean blood loss during the surgery was 87.30 ± 98.65 mL (30–550 mL). The pedicle screw breach rate was 2.8% (3/104 screws), all <2 mm. Conclusion: Single-position OLIF performed with 3D navigation is a safe and efficient procedure.

Abstract Osteoporosis, characterized by reduced bone mineral density and compromised bone microstructure, significantly increases the risk of low-impact fragility fractures, particularly in the spine. As the global population ages, the incidence of osteoporotic spine fractures is on the rise. While pedicle screw (PS) instrumentation has become the standard for spinal fusion surgeries, the fragility of osteoporotic bones poses substantial challenges in maintaining spinal alignment and correction. Patients with osteoporosis face a markedly higher risk of complications from spinal instrumentation. The search for an optimal fixation technique like modifications in screw fixation strategies (bicortical purchase, cortical screw trajectories, and double screws augmentation with laminar wires) or cement augmented screws (vertebroplasty augmented screws/fenestrated screws) or modified screw designs (hydroxyapatite-coated screws, expandable screws/fenestrated screws/dual thread screws), for osteoporotic spines is complex, influenced by factors such as bone fragility, altered physiology in the elderly, comorbidities, cognitive impairments, polypharmacy, and pre-existing spinal conditions. This narrative review aims to explore the advancements in spinal fixation techniques for osteoporotic bones, examining their underlying principles, benefits, and limitations, and identifying the gaps that remain in optimizing fixation methods for osteoporotic spines.

Abstract Background: Compressive myelopathy due to thoracic ossified ligamentum flavum (TOLF) is a rare disorder of multifactorial etiology, and considerable ambiguity exists regarding several clinical and radiological indicators for prognosis following surgery. This study aims to analyze and compare the surgical outcomes from short-segment and long-segment involvement in patients with compressive myelopathy secondary to thoracic ossified ligamentum flavum and critically review the relevant literature. Materials and Methods: This is a retrospective, single-center study of 28 consecutive patients operated exclusively for TOLF divided into short-segment-TOLF (SSTOLF) (n = 15), having one or two contiguous levels of cord compression involvement, and long-segment-TOLF (LSTOLF) (n = 13), having three or more contiguous levels of involvement. The clinical features of these groups before and after surgery were analyzed and compared. Results: There were 20 males and eight females with a mean age of 53.2 years. Overall, there was a significant inverse correlation between the preoperative duration of symptoms and the Hirabayashi Recovery Rate (HRR) (r = -0.675, P = 0.001). The preoperative Japanese Orthopedic Association (JOA) score strongly correlated with the HRR (r = 0.715, P = 0.001). The mean preoperative JOA scores were 6.67 (0.72) and 4.08 (0.76), and the mean improvement in JOA scores for SSTOLF and LSTOLF following surgery were 2.26 (0.71) and 1.46 (1.13), respectively, which was statistically significant (P = 0.03). Conclusions: Patients with SSTOLF presented with symptoms relatively early, although with a better neurological profile and attained good functional status following surgical intervention. In contrast, patients with LSTOLF had a worse baseline clinical profile, and despite improvement with surgery, they had a poor functional status.

Abstract Hirayama disease (HD) is a rare neurological disorder. It is a focal, lower motor neuron disease, mainly affecting young males in their second and third decades. It is prevalent most commonly in Asian countries like Japan. Magnetic resonance imaging (MRI) of the cervical spine in flexion will reveal the hallmark features of Hirayama disease. A 22-year-old male presented with a history of insidious weakness of the left hand for 2 years. On examination, he had clawing of the left medial three fingers with wasting of left forearm muscles, which was progressive in nature. MRI showed thinning of the spinal cord from C3 to C7 level, suggestive of cord atrophy. Based on these features, a diagnosis of focal amyotrophy was made. As the patient was non-compliant with the use of the cervical collar, resulting in the progression of symptoms, C3–C6 lateral mass fixation without fusion was performed to stop the progression of the disease and to facilitate implant removal at a later stage and regain cervical motion. Early diagnosis is necessary as the use of a simple cervical collar, which will prevent neck flexion, has been shown to stop the progression in the majority of the cases.

Abstract Background: Surgical treatment in patients with adolescent idiopathic scoliosis (AIS) is primarily indicated for cosmesis. The assessment of the efficacy of this surgery by the patient and the surgeon may differ. The surgeon often relies on radiographic parameters, while the patient’s satisfaction is gauged by functional outcome measures. We aim to study the correlation between patient-reported outcome measures and radiographic deformity correction in patients with AIS. Materials and Methods: We included AIS patients who underwent deformity correction surgery at our institute between January 2010 and December 2019 with a minimum of 2-year follow-up. The curves were classified by the Lenke Classification preoperatively. Pre and postoperative radiographic parameters were calculated to determine the respective radiographic deformity score, and patients answered a postoperative outcome questionnaire, the Scoliosis Research Society revised (SRS)-22r. The radiographic parameters and outcome measures were then subjected to correlational analysis. Results: A total of 44 (7 males and 37 females) AIS patients with ages ranging from 10 to 18 years were included in our study. The average clinico-radiological follow-up period was 2 years and 7 months. The preoperative primary curve Cobb angle was 63.98 ± 21° and the postoperative primary curve Cobb angle was 29.28 ± 18°. The percentage of mean curve correction was 56.6%. The median SRS-22r score at the latest follow-up was 4.3. Our correlational analysis found no statistically significant correlation between postoperative radiographic scores and postoperative SRS-22r scores (r = 0.08, P = 0.58). We also found no significant correlation between coronal and sagittal radiographic scores and final SRS-22r scores. Conclusion: The radiographic parameters and patient-reported outcomes in our study did not correlate. This highlights the need for cognizance of the patient’s and surgeon’s differing vantage points when interpreting surgical outcomes.