Ongoing Projects

Functional MRI (fMRI) is now also well established in many centres and uses similar imaging techniques and the same equipment as conventional MRI. fMRI relies on detecting small changes in the signals used to produce magnetic resonance images that are associated with neuronal activity in the brain, and it is producing unique and valuable information for applications in both basic and clinical neuroscience. fMRI is safe, non-invasive, and repeatable in adults and children and thus has widespread potential uses. fMRI detects the blood oxygen level–dependent (BOLD) changes in the MRI signal that arise when changes in neuronal activity occur following a change in brain state, such as may be produced, for example, by a stimulus or task. One of the underlying premises of many current uses of functional imaging is that various behaviours and brain functions rely on the recruitment and coordinated interaction of components of “large-scale” brain systems that are spatially distinct, distributed, and yet connected in functional networks. Thus, although the practice of phrenology is dead, identification of the neurobiological substrates associated with various specific functions of the brain is likely to shed light on how the brain determines behaviour. In addition, geographic maps identifying the locations of particularly critical areas, such as those involved in producing and understanding language, are of direct importance in clinical assessments and the planning of interventions. The physical origins of BOLD signals are reasonably well understood, though their precise connections to the underlying metabolic and electrophysiological activity need to be clarified further. It is well established that an increase in neural activity in a region of cortex stimulates an increase in the local blood flow in order to meet the larger demand for oxygen and other substrates. The change in blood flow actually exceeds that which is needed so that, at the capillary level, there is a net increase in the balance of oxygenated arterial blood to deoxygenated venous blood. Essentially, the change in tissue perfusion exceeds the additional metabolic demand, so the concentration of deoxyhaemoglobin within tissues decreases. This decrease has a direct effect on the signals used to produce magnetic resonance images. While blood that contains oxyhaemoglobin is not very different, in terms of its magnetic susceptibility, from other tissues or water, deoxyhaemoglobin is significantly paramagnetic (like the agents used for MRI contrast materials, such as gadolinium), and thus deoxygenated blood differs substantially in its magnetic properties from surrounding tissues (4). When oxygen is not bound to haemoglobin, the difference between the magnetic field applied by the MRI machine and that experienced close to a molecule of the blood protein is much greater than when the oxygen is bound. On a microscopic scale, replacement of deoxygenated blood by oxygenated blood makes the local magnetic environment more uniform. The longevity of the signals used to produce magnetic resonance images is directly dependent on the uniformity of the magnetic field experienced by water molecules: the less uniform the field, the greater the mixture of different signal frequencies that arise from the sample, and therefore the faster the decay of the overall signal.  The result of having lower levels of deoxyhaemoglobin present in blood in a region of brain tissue is therefore that the MRI signal from that region decays less rapidly and so is stronger when it is recorded in a typical magnetic resonance image acquisition. This small signal increase is the BOLD signal recorded in fMRI (2). It is typically around 1% or less, though it varies depending on the strength of the applied field; this variability is one reason why higher-field MRI systems are being developed. As can be predicted from the above explanation, the magnitude of the signal depends on the changes in blood flow and volume within tissue, as well as the change in local oxygen tension, so there is no simple relation between the signal change and any single physiological parameter. Thus fMRI does not report absolute changes such as the units of flow obtained with positron emission tomographic (PET) imaging. Furthermore, as neurons become more active, there is a time delay before the necessary vasodilation can occur to increase flow, and for the wash-out of deoxyhaemoglobin from the region to occur. Thus the so-called hemodynamic response detected by BOLD imaging is delayed and has a duration of several seconds following a stimulating event (6).

This proposal intends to develop an ultrasound bone scalpel which is a surgical tool that uses ultrasound technology to cut through bone or tissue. It is a relatively new technology, but it has the potential to offer a few advantages over traditional bone scalpels including precision, less pain, faster healing time and less blood loss.
As a nanoelectronics group, here we proposed a device where the ultrasonic energy is generated by a handpiece that is connected to a generator. The generator produces ultrasonic waves at a frequency of about 20 kHz. The ultrasonic waves are transmitted to the blade of the scalpel. The blade of the scalpel vibrates at the same frequency as the ultrasonic waves. This vibration creates friction that helps to cut the bone. The ultrasonic energy also creates cavitation bubbles in the bone. These bubbles collapse rapidly, creating shock waves that is used to cut or polish the bone or the target tissue. The ultrasonic bone scalpel would typically use with a continuous flushing system to wash away bone debris and cool the blade. 

Patients with SMA suffer from rapidly progressive spinal deformity which hampers their quality of life in the form of loss of independent function of the upper extremities secondary to the necessity to support the trunk, ischial bursitis with necrosis, fairly appreciable back pain, costo- pelvic impingement and severe cardiopulmonary problems which may even be fatal. Bracing is started early but fails to halt curve progression in most of them and surgery is expensive and complicated. Previous studies show the effectiveness of medical therapy with regard to improvement in quality of life and pulmonary functions. But no studies show the effect medical therapy has on curve progression. Aims and Objectives: To assess spinal deformity progression in patients of SMA on disease modifying medical treatment. To evaluate clinically and radiologically, spinal deformity patterns, deformity progression, pelvic obliquity and motor function & quality of life {Hammersmith Functional Motor Scale Expanded for SMA (HFMSE)} of newly diagnosed SMA patients who are on disease modifying medical (Risdeplam or Nusinersen).

Abstract
Study Design
Delphi survey.
Objectives 
To obtain an expert consensus on various dilemmas in the surgical treatment of adult spinal tuberculosis (TB) patients. 
Methods 
Stage I included a literature review, stage II the identification of 40 Key Opinion leaders (KOLs) and a set of 46 questions, stage III included analysis of 3 rounds of the Delphi survey, and stage IV had final analysis and recommendations. For each question, the level of agreement needed to reach a consensus was set at greater than or equal to 70.0%.  Results 
The first and second Delphi survey rounds received 62 and 58 responses, respectively, with 16 questions having more than 70% and two questions having 100% agreement in the first stage. The second stage saw a 70% agreement on six questions. Thus, a consensus was obtained on 22 questions. The recommendations that emerged were as follows: neurodeficit with corresponding radiology and neurological deficit appearing/deteriorating while on anti-tubercular chemotherapy(ATT) are absolute indications for surgery, duration of ATT before neurological deterioration need not be considered, epidural abscess does not need decompression unless concordant clinical neurological findings are present, pain not responding to medical management is not a surgical indication, active pulmonary TB, drug-resistant TB, and tubercular sacroiliitis are not considered as surgical indications, and hemoglobin and other health markers have little contribution to surgical indications. 
Conclusion 
In order to resolve several conundrums in the surgical treatment of adult spinal TB, this Delphi survey is the first to achieve a national consensus from spine experts. The final recommendations cover the serological, radiographic, and clinical aspects of spinal TB. 

Neck pain is common complaint in adult population, with an annual prevalence rate exceeding 30%. (1) Degenerative disc disease has strong correlation with neck pain and patients has spectrum of symptoms from neck pain to other neurological symptoms like radiculopathy and myelopathy which require treatment options range from conservative management to surgical decompression either from anterior as well as posterior approach. (2,3,4)
Cervical spine provides adequate function and range of motion like (flexion, extension, rotation, and side-bending) out of which upper cervical spine, C1 and C2 contributes significant ranges of motion, these movements are related to facetal orientation allowing for more rotation. (5)
Stability of cervical spine is maintained during range of motion with intervertebral disc (IVD) is found from the C2-C3 level down. Comparing to thoracic and lumbar vertebrae, the cervical vertebrae have a unique bony structure named uncinate process, which articulates with adjacent level and form the joint of Luschka or uncovertebral joint. This joint helps to reinforce the IVD and provides additional stability and motion. (6)
The IVD is complex structure having two parts, the annulus fibrosus (AF- peripherally located) and the nucleus pulpous (NP- centrally located) which helps in load distribution in cervical spine. Other surrounding ligamentous structure like anterior and posterior longitudinal ligaments reinforce the IVD. (7)
NP consists at central part of IVD having gel-like consistency composed mainly of type II collagen and proteoglycans. A unique proteoglycan in the NP is aggrecan, which, helps to conserve water in the NP, and helps to distribute pressure evenly across the disc, but the amount of water reduces with age, contribute degenerative cascade in cervical spine. (8)  AF consist of type I collagen mostly in concentric layers (lamellae) and proteoglycans, glycoproteins, and extracellular matrix (ECM) secreting cells. These collagen layers are uniquely positioned to form a strong shell which can withstand compressive forces and provides greater strength.
In first few years of life, IVD is vascular, by the time it becomes the largest avascular structure 8 in the body. Most of the nutrition delivery is via vertebral end plates. (9)
Over time, the IVD begins to lose its water content and proteoglycan content leads to a more fibrotic consistency of the NP and subsequent fissuring and start IVD Degeneration. (10)
Disc degeneration involves alteration in microstructure which leads to failure of load distribution capacity of nucleus pulposus and annulus fibrosus which ultimately leads to loss of disc height and neural compression. (11)
Degenerative process of cervical spine occurs in 3 stages- (i) Dysfunction (ii) Instability (iii) Stabilization. In Dysfunction phase, annular tear take place along with facet joint synovitis. Instability phase is characterized by annulus disruption and progressive resorption and facet joint degeneration. Stabilization phase causes hypertrophic bone around facet joint and disc, leads to stiff and ankylosed spine.
  There are 3 methods of Disc Degeneration- 
1. Biomechanical- Alteration in spine motion segment causes Degeneration. (12) 
2. Genetic - Genetic factors are critical contributors to the onset and progression of IDD. (13) 
3. Infective - In last few years studies it’s found the Role of sub-clinical infections in disc disorders and investigate the existence of microbiome in intervertebral discs (IVD).  Purpose of my thesis to evaluate microbiome in cervical intervertebral disc and their association with Disc degeneration.

Cervical spondylotic myelopathy (CSM) is a slowly progressive disease of the cervical spine and the world’s most common cause of chronic spinal cord injury (1). CSM, which is more prevalent with aging, is caused by degenerative or congenital alterations to the discs and soft tissues of the cervical spine, which results in chronic compression of the spinal cord (2). The increased recruitment and excessive activation of different immune cells (activated microglia/macrophages, T cells and neutrophils), accompanied by the production of inflammatory cytokines in the spinal cord, have been shown to contribute to the progression of CSM (3,4).
CSM shows intermittent exacerbations of symptoms often followed by periods of static, or only slightly worsening function. (5) Myelopathic symptoms are largely irreversible, and the limited degree of recovery depends on the severity of the myelopathy at the time of intervention in addition to other factors such as the duration of symptoms and patient age.[6] The literature suggests that surgical decompression may alter the natural history of this disease most typically by halting progression. (7,8)
Decisionmaking for the treatment of CSM can be challenging for treating spinal surgeons. A number of studies with contradictory results are seen in the literature and guidelines are yet to be developed. (9) Evidence for the efficacy of conservative treatment is scarce, and in moderatetosevere myelopathy, surgery is generally the only treatment option, given its progressive nature. (10,11) In about 20 to 60% of patients with CSM, a neurologically symptomatic deterioration occurs if no surgical intervention is performed. (12) About 50% of patients show a neurologic improvement postoperatively; however, the severity and duration of the disease are currently regarded as the predictors that determine outcome. (13)   The current treatment, particularly with moderate to severe impairment (14), consists of surgical decompression [15]. However, approximately 4% of patients who undergo 8
  decompression develop perioperative neurological complications, including worsening of myelopathy and delayed C5 palsy (15). Moreover, while most patients show neurological recovery with decompressive surgery, approximately 20% of patients fail to show neurological improvement, with a minority exhibiting continued neurological decline.
Surgical cervical decompression and fusion causes tissue damage and triggers a systemic proinflammatory response. Among other mediators such as interleukin (IL)-1β and tumour necrosis factor α, IL-6 was correlated with the extent of surgical trauma (16). Several studies have reported that steroid administration reduces surgical trauma, as measured by serum IL-6 in patients undergoing elective thoracoabdominal surgery. (17) It seems that a preoperative administration of steroids modifies the systemic inflammatory response and prevents iatrogenic deficits. (18) Glucocorticoid anti-inflammatory effects result from their ability to inhibit the expression of collagenase and proinflammatory cytokines. (18) Glucocorticoids decrease inflammation by stabilizing the lysosomes in neutrophils that prevent degranulation and the resulting inflammatory response. (19)
A degenerative cervical myelopathy (DCM) mouse model has demonstrated that post-decompression neurological decline is associated with the presence of an ischemia-reperfusion injury (IRI) and increased activation of the immune system (20,21). Thus, neuroprotective or neuroregenerative strategies, like perioperative steroid administration, which complement surgical decompression and rehabilitation approaches, would enhance the management of patients with DCM.  
In the present study, we hypothesize that reducing neuroinflammation by steroid administration following decompression for CSM would attenuate perioperative neurological decline and promote enhanced neural recovery. To examine this hypothesis, we administered methylprednisolone (MP), an anti-inflammatory glucocorticoid, which has long-standing use in clinical practice as an anti-inflammatory and neuroprotective treatment for traumatic spinal cord injury (SCI) (22). Patients with cervical SCI and low baseline severity of injury have 9  
  been shown to benefit the most from MP treatment (23); however, the use of MP for SCI has been questioned by some clinicians due to heterogeneous findings reported in the literature (24). In addition to its use in SCI, the use of perioperative corticosteroids as a complementary approach to decompressive surgery has been shown to reduce pain as well as the duration of postoperative hospitalization in patients with lumbar and cervical radiculopathy due to degenerative conditions (25, 26). Given this background, we sought to examine the repurposing of MP as a potential neuroprotective treatment for DCM as a complement to surgical decompression. The aim of this study will be to investigate the influence methylprednisolone administration on Surgical site infections, and clinical outcomes in patients with cervical decompression for CSM.  3. Responses of surgical team, Recovery patterns and de-novo neurological deficits associated with intraoperative neuromonitoring (IONM) alerts in cord level severe spinal deformity surgeries - Results from an international multicentre prospective Spinal Deformity Intraoperative Monitoring (SDIM) study.  
  Purpose  
  To report on the recovery patterns during surgery and the de-novo neurological deficits at discharge associated with IONM alerts during severe spinal deformity surgeries. 

Purpose  
To report on the recovery patterns during surgery and the de-novo neurological deficits at discharge associated with IONM alerts during severe spinal deformity surgeries.

Spinal deformity in neurofibromatosis, when associated with dystrophic change, is a major treatment challenge. The surgical management of severe rigid dystrophic neurofibromatosis curves is a demanding procedure with uncertain results. Several difficulties are present in such patients including a poor bone stock, sharp angulation of these dystrophic curves and dural thinning or ectasia. There are still many unanswered questions regarding the time of surgical intervention, an approach for surgery, and length of the fusion and safety and efficacy of surgical procedures. By this retrospective study involving three centers, we will try to assess the demographic details, clinical and radiographic findings and operative outcomes of severe rigid neurofibromatosis curves.  
The aim of this work was to review the demographics and clinical and radiographic outcomes operative outcomes of severe rigid neurofibromatosis curves analysing its efficacy, safety and possible complications. 

Lumbar disc herniation is one of the most common causes of back and lower extremity pain that can eventually require surgical intervention (1). There are many approaches to treat lumbar disc herniations and the type of surgery is mainly dependent on the type of herniation, level of herniation and symptomatology. The most commonly used surgical method is lumbar discectomy (2). Complications related to discectomy occur in 5-20 % patients, of which recurrent disc herniation is one of the common complications (3–7).  
Recurrent disc herniation is one of the most common causes of reoperation after primary discectomy. Recurrent disc herniation is defined as disc herniation occurring at the same level, regardless of ipsilateral or contralateral herniation in a patient after a definite pain-free period of at least six months from initial surgery (8,9). Incidence of recurrent disc herniation (rDH) has been reported to be between 3 % and 25% (10,11). There are numerous risk factors and theories for recurrent disc herniations but no one factor has been identified consistently in the literature. Some of these proposed risk factors include obesity, smoking, male gender, diabetes, weight lifting, the size of the annular tear, type of disc space and type of primary operation (12–17). However, sex, age, smoking status, level of herniation and duration of symptoms were not associated with higher rates of recurrence (8,10,18,19). The recurrence of back or sciatic pain after primary discectomy can be caused by a true recurrence of disc herniation, new disc herniation at a different disc, epidural fibrosis, local adhesive arachnoiditis, segmental instability, symptomatic arthritis of the small intervertebral joints (facet syndrome), secondary spinal stenosis, and spondylitis or spondylodiscitis (3,20). 
The management of postoperative recurrent lumbar disc herniation remains controversial. There are no clear guidelines or significant comparative studies to assist surgeons in their approach to managing recurrent disc herniation (22). Without clear 3 guidelines there are significant differences in treatment plans among spine surgeons, which was evaluated in a survey among spine surgeons (23). Surgical options include repeat discectomy either via a conventional or minimally invasive technique, or discectomy with instrumented spinal fusion (8,10,21,24–27). Some surgeons consider discectomy alone as major source of disability (20). When determining the optimal approach, surgeon preference, presenting symptoms, presence of axial low back pain, radiographic evidence of instability or deformity, and number of prior herniations must be considered (28). With the prognosis of repeated back surgery being relatively poor with regards to pain relief and return to work (29), identifying the appropriate treatment for recurrent disc herniation is important to improve outcome. However, a repeat discectomy is generally more difficult due to scar tissue from the primary surgery, and there is an increased risk of Dural tears or nerve injury (30). Furthermore, using a minimally invasive percutaneous endoscopic method was determined to be effective in decreasing the chance of fusion and bleeding with reoperation in comparison to conventional revision discectomy (30). A recent recommendation is to perform a discectomy in patients with rDH and radiculopathy (22). Additionally, fusion has been recommended if the patient has associated lumbar instability, radiographic degenerative changes, and/or chronic axial lower back pain (21). However, it is still unclear which method has shown to be more effective for reoperation.  
The goal of this systematic review is to compare the two treatment options for rDH and determine if one intervention provides better outcomes than the other. More specifically, is there a difference in outcomes from surgery with and without fusion. So we retrospectively compared, clinical outcomes of surgical treatment for recurrent lumbar disc herniation by either discectomy alone or discectomy with fusion. 

Comparing the efficacy of QCT vs DEXA vs MRI scan in the diagnosis of osteoporosis and their correlation with pedicle screw insertional torque and bone histomorphometry in patients undergoing spinal decompression and fixation surgeries for lumbar degenerative disorders 
Osteoporosis is defined as ‘a skeletal disease, characterized by low bone mass and micro-architectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture’ (1). Noninvasive techniques for measuring bone mineral density (BMD) play an important role in the clinical diagnosis of osteoporosis and in monitoring its progression. Dual Energy X-ray Absorptiometry (DEXA) and Quantitative Computed Tomography (QCT) are the most common tools for measuring BMD. Quantitative computed tomography (QCT) was introduced in the mid-1970s. The technique is most commonly applied to 2D slices to measure trabecular bone mineral density (BMD) (2),(3). With the introduction of DEXA in the late 1980s, with its lower ionizing radiation doses and wide use in epidemiological and pharmaceutical studies, it is used in diagnosis of Osteoporosis (4).  
Precise evaluation of vertebral osteoporosis is critical in the management of spinal disorders. As pedicle screws, the principal workhorses of spine instrumentation, obtain their maximum stability from purchase in trabecular bone (5) (6). Ultimately, the long-term surgical outcomes are highly dependent on trabecular bone stock. It is recognized that poor bone quality increases risk of osteoporotic fractures in all affected patients, and places operative spine patients at further risk of mechanical complications, such as proximal junctional kyphosis and hardware failure like screw pull out, loosening and loss of correction (7)  
However, the role of DEXA in the diagnosis of osteoporosis can be put into question over its efficacy, a number of studies have been done earlier regarding the same (8). DEXA measures a two-dimensional ‘areal’ bone mineral density, and so is size dependent. DEXA measures integral (cortical and trabecular) BMD which may not give the exact severity of osteoporosis. BMD measured by DEXA was significantly influenced by degenerative joint disease giving higher BMD values (9),(10). DEXA might also be fallacious in postoperative cases with the usage of hardware and cement as well as in spinal deformities. 10  
  With the evolution of CT scan modalities, QCT also has improved in the form of decreased scan times, better resolution and spiral MDCT has resulted in images of volumes of tissue being acquired very rapidly. QCT measures true volumetric bone mineral density (11), and so is not size dependent. QCT allows separate measures of BMD of the trabecular and cortical bone. BMD by QCT is not influence by degenerative joint disease changes, and abdominal aortic calcifications, giving precise values of the BMD (69) (70). The only drawback of QCT over DEXA is QCT radiation dose of approximately 90μSv which is higher than that associated with DEXA (1–6μSv), but lesser than the routine X-ray based investigations (e.g. spinal radiographs 700–2000μSv) (12).  
Opportunistic bone quality screening has been explored using lumbar MRIs (13),(14),(15). One recently described, novel technique for assessing bone quality is the vertebral bone quality (VBQ) score, which uses non contrast, T1-weighted lumbar spine magnetic resonance imaging (MRI) (16). The VBQ has been shown to both correlate with DEXA-measured BMD scores (16) and predict vertebral compression fracture risk. Unlike DEXA and QCT it has the advantage of imaging that spares patients from radiation.  
Conventional radiological investigations that are mentioned above can measure only the mineral content of the bone, ignoring the fact that bone matrix/mass is also an important component of solid bone strength. Decreased in measured BMD values can be due to loss of bone mass or a decrease in mineral content per bone volume or a combination of both, however biopsy is the only available investigation that can provide information about both the parameters (17). As procurement of biopsy samples requires an invasive procedure and paucity of widely accepted literature backed guidelines to score/grade the osteoporosis they are rarely used to diagnose or manage patients with osteoporosis. Over the years, the iliac crest has been the site of choice which may cause further morbidity to patient due to a second procedure. 11  
  Hence we planned to procure the biopsies directly from the pedicle screw tract before screw insertion and performing histomorphometric analysis (18),(19).  
Previous biomechanical research has found that pedicle screw fixation is strongly related to BMD (20) (21), and that the torque required to insert a screw is strongly related to its pull-out strength (22). Given that insertional torque is a better predictor of fixation strength than pullout strength, and that in patients with osteoporosis, the BMD of the instrumented vertebrae was strongly and positively correlated with the maximum torque generated during screw insertion (23), we planned on measuring insertional torque with a torque measuring device to determine fixation strength.  
There is a wide gap between the established standards considering DXA as a gold standard for bone density (24), (25). It is surprising that in spite of the well-known drawbacks of DXA and the availability of newer and better modalities, the screening of spinal osteoporosis has not changed the standards of practice. There is a need for reconsidering osteoporosis evaluation with a site specific and patient specific inclination.  
A number of studies have been conducted to compare the efficacy of QCT, DEXA and MRI scan in assessing BMD, but none of them correlated their findings with the biopsy parameters and magnitude of torque required to insert the pedicle screw. 

Osteoporosis is a metabolic bone disease characterised by decreased amount of normally mineralised bone per unit volume resulting in skeletal fragility and increased risk of fracture. It is estimated affect 200 million worldwide [1]. The most important consequence of osteoporosis is an increased risk of fractures, resulting in more than 8.9 million fractures annually worldwide [2]. These  fractures usually occur in thoracolumbar segment of spine and hips [3].  With the aging of the population, increasing numbers of elderly persons  are sustaining vertebral compression fractures due to osteopenia. OVCF patient  suffers from severe back pain, pulmonary dysfunction, spinal deformity,  abdominal limitation, impaired mobility and clinical depression, which have an  impact on the quality of life of patients [4]. Vertebral fracture may result in pain  about the fracture site, loss of height caused by vertebral collapse, spinal  instability, and in many cases, kyphotic deformity [5]. External bracing,  analgesics, and observation may be all that is necessary for pain control in some  patients, but in others, a constant requirement for narcotics can be as life-altering  as the fracture itself. OVCF has traditionally been treated with bed rest, physical  therapy an antiosteoporotic medications [6]. Patients with multiple systemic  complications and conservative treatment in form of bed rest further aggravate  osteoporosis and induce complications such as respiratory and urinary infection.  Vertebroplasty was first reported by Galibert et al [7] in 1987 for  treatment of hemangiomas. Gradually it has been adapted for use in the treatment  of intractable, focal, intense pain localized to a vertebral fracture. However,  recent studies have questioned its efficacy and deemed it necessary to investigate  2 the complications induced by vertebral augmentation, such as new vertebral  fractures, cement leakage, and pulmonary and cerebral embolism [8].  New vertebral fracture following vertebral augmentation is one of the  most serious postoperative complications and can greatly reduce therapeutic  effectiveness. The frequency of new OVCF varied, ranging from 8% to 52% and  most of these reported fractures occurred at adjacent levels [9]. The new  osteoporotic vertebral fracture are natural progression of disease pathology or a  sequelae of augmentation procedure is still a controversy. Number of studies  have supported this observation [10, 11, 12]. 
There are other variables like bone mineral density and vertebral height  restoration which are not clearly established. The goal of this study is to analyse  multicentric vertebroplasty data regarding age, gender, comorbidities, cement  leakage, change of kyphotic angle, BMD and their association with subsequent  vertebral Fractures. 

Corrective surgeries for scoliosis commonly target patients during their growth period. Although the trend in scoliosis surgery suggests selective fusion of spinal segments, there are reports of disc degeneration occurring in unfused segments adjacent to fused area. These adjacent segment disc degeneration can be evaluated only with long term, post growth followup1. With long segment constructs proximal junction kyphosis is also seen, defined as a kyphotic deformity 15 degrees in the spinal motion segments immediately cephalad to the instrumented segments 2. In the past, patients who underwent corrective surgery with Harrington instrumentation experienced disc degeneration at distal unfused segments3. Evaluation of the relationship of Lower instrumented vertebrae(LIV) with the existence of instability or low back pain in those patients were done previously through data obtained from X ray images.3,4,5,6.In addition such surgeries ignored the physiological sagittal contour of the spine and flat back. The advent of MR imaging has opened new avenues for evaluating disc degeneration. Studies with the Cortrel Dobusset (CD) system suggest that there is little correlation between back pain and the number of unfused spinal segments below the LIV in comparison to control groups, whereas others suggest that frequency of low back pain increases when LIV is placed below L4. 3,4,5 Suk et al. reported the use of segmental pedicle screws in 1995, and corrective surgeries using pedicle screws became a standard treatment protocol. 7 They reported excellent results in patients who underwent such treatments after a 10-year followup7 .Different correction methods may have a different impact on the spontaneous correction of unfused lumbar curve. The mechanical stress on the lumbar vertebra may differ with the type of instrumentation used, in a long term follow up.7 The incidence of proximal junction kyphosis(PJK) increases slightly in patients treated with all pedicle screw/hybrid constructs in comparison to hook alone constructs. Increased PJK might be secondary to increased rigidity of the construct8. Comparing anterior and posterior instrumentation techniques in AIS, Rhee et al9 noted an increase of 7 degrees PJK with posterior instrumentation and proposed that difference was related to posterior tension band disruption, posterior compression and decreased thoracic kyphosis. Our study focuses on degenerative discs occurring in unfused lumbar segments in patients who underwent corrective surgery using anterior or posterior instrumentations with a postoperative follow up period of at least 5 years. Degenerative discs were evaluated on MRI and Xray. In addition, the coronal and sagittal balance were considered to investigate factors that may affect the onset of disc degeneration. It also investigates the incidence of PJK and proximal adjacent segment degeneration above the Upper Instrumented Vertebra (UIV). Our study wishes to evaluate the adjacent segment disease and proximal junction kyphosis after instrumented fusion and deformity correction for Adolescent Idiopathic Scoliosis.

The thoracolumbar region is one of the most common areas of injury to the spine (about 90%), due to the fulcrum of increased motion at the T12-L1 junction. Burst fractures account for about 10-20% of these injuries.1-4 The majority (50–78%) of patients are neurologically intact, but may develop complications, such as paralysis and kyphotic deformities. 
In fracture treatment, the primary aim is to obtain and maintain a stable reduction that leads to early mobilisation and ultimately, union as well as satisfactory function. A secondary aim is to restore sagittal alignment. 
It is important to consider various clinical factors when treating a thoracolumbar injury, such as age of the patient, the extent of spinal canal compromise by retropulsed fragments, angle of sagittal index, anterior body height, degree of integrity of the posterior elements, and presence of neurologic deficit. 
It remains controversial how to treat thoracolumbar fractures, particularly in patients without neurologic deficits. A variety of options are available for treating a spinal injury, including conservative method, posterior reduction and fixation, anterior decompression and fixation.8-10 The choice is largely determined by an evaluation of the stability of the injured spine.  The literature has many studies describing internal fixation for this injury, but to our knowledge, most of them studied the open procedure and most of them included spinal fusion as part of the stabilizing procedure, via an anterior or posterior approach. This study includes patients with post traumatic and osteoporotic thoracolumbar fractures who underwent percutaneous pedicle screw and rod fixation with or without vertebroplasty. 
The hypotheses of this study were that the fusion of the spine could be achieved on the anterior or posterior columns in form of anterior bridging callus or facetal fusion, with percutaneous pedicle screws - rod fixation without adding any primary fusion technique in form of interbody or posterolateral fusion at the time of operative procedure and that non-fusion would not lead to a greater loss of correction or poor clinical outcome. 
The aim of this study was to assess spinal fusion after percutaneous minimally invasive spinal internal fixation with pedicle screw rod system for traumatic and osteoporotic fractures. 
We are unaware of any literature reports on the assessment of fusion following thoracolumbar fracture who were treated with minimally invasive percutaneous fixation without fusion, a method of treatment we consider to hold significant potential advantages.

Bracing constitutes the most widely practiced treatment method for nonoperative management of adolescent idiopathic scoliosis  (AIS). Brace treatment has undergone a large number of variations from the time of its inception, and it has led to a number of available options to choose from in present times. The evidence for bracing has also evolved tremendously in the last few years from single-center cohort studies to multicenter randomized controlled trials. For bracing to be successful, proper patient selection is an important prerequisite. A coordinated team effort from the patient, parents, family, the surgeon, and orthotist is also essential for ensuring compliance and treatment success. This article is a narrative review and focuses on the role of bracing in the management of AIS in terms of the brace history, types, indications, results, and drawbacks with relevant literature. 

Langerhans cell histiocytosis (LCH) is a common disease in the pediatric population with a peak incidence between 5 and 10 years of age. Eosinophilic granuloma (EG) accounts for less than 1% of all primary bone tumors primarily affecting the skull, pelvis, ribs and metaphyses of long bones and is a benign localized form of LCH. It is extremely rare in adults, more so in the spine, with a predilection for the thoracic spine than the lumbar and cervical region. A 35-year-old gentleman presented with transitional mid back pain for two months radiating to the right flank which worsened at night. There was no history of fever or trauma. Physical examination revealed right dorsolumbar tenderness without any neurological deficit. Serological parameters were normal and C-reactive protein (CRP) was  negative. X-ray showed radiolucency in the right D12 pedicle with CT scan showing a lytic lesion in D12 body extending into the right pedicle. Magnetic resonance imaging (MRI) showed a hypointense lesion on T1 and hyperintense lesion on T2. Transpedicular biopsy was done and histopathology revealed Langerhans cell with abundant basophilic cytoplasm and a centrally placed nucleus with a groove. On further confirmation with IHC, a diagnosis of LCH was made. He then received radiotherapy for 12 days. PET CT done one year after diagnosis revealed near-total metabolic response of the tumor after comparing the PET CT done prior to diagnosis. 
The patient has reported complete relief since 2 years with recent radiological evidence of no recurrence. A precise diagnosis of LCH largely relies on biopsy and histopathology and once definitive diagnosis is established, EG can be managed by chemotherapy and/ or radiotherapy in patients with no neurological deficit. Despite its rarity, EG should be considered as an important differential for solitary osteolytic lesions at the thoracolumbar junction in the adult spine. 

Purpose: Cement distribution in spinal stabilization with fenestrated screws is unpredictable in patients with osteoporosis. The objective of our study was an assessment of cement distribution while using fenestrated screws and to establish an association between cement distribution and the Dual Emission X-ray Absorptiometry (DEXA) scan T scores. Materials and Methods: Osteoporotic patients who underwent spinal stabilization with fenestrated screws by a single surgeon with a minimum follow-up of one year were included. 
Cement distribution (four zones comprising the vertebral body and the pedicle), a pattern of distribution (concentrated or scattered) and cement leakage were assessed on CT scans. Patients were categorized into two groups based on their DEXA scan T scores to test an association between the pattern of distribution of cement and the scores. Clinical improvement was determined using visual analogue scale and Oswestry disability index scores. Results: A total of 126 screws were analyzed in 20 patients with a mean age of 69 years and a mean follow-up of 18 months. Out of 126 screws, 114 (90.47%) had cement in Zones 1 and 2. In total, 58 screws had  a concentrated pattern of distribution of cement, whereas 68 screws had a scattered distribution, and the odds ratio of a scattered pattern of distribution was 6.31:1 if the DEXA scan T score was “below (−)3.0.” Clinical improvement was calculated in percentage  of change from the preoperative value (mean % visual analogue scale change = 65.13 ± 7.59 and mean % Oswestry disability index change = 43.14 ± 7.24). Conclusion: The pattern of cement distribution in fenestrated screws relates well with the DEXA scan T scores and their usage should be strongly considered in patients with poorer scores. However, there is no relevant difference between the pattern of distribution and the clinical outcome. 

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. 

The impact of the pandemic on the practice of spine surgery has been huge, and this impact is beyond geographic, economic, and social barriers. Spine surgical procedures dropped by more than 50%,[3] and continued to drop further in the extended lockdown policy adopted by most of the countries affected by this deadly virus.
The largest drop occurred in relation to the degenerative spine pathologies, especially those of lumbar stenosis or prolapsed intervertebral disc (PID). Additionally in a country like ours where road traffic accidents are a regular phenomenon, the incidence of spinal trauma is expected to come down because of the massive travel restrictions imposed by the government in an attempt to combat the spread of this highly infectious disease. This gives the spinal community a self-pondering window to assess whether some “elective surgery” is avoidable and if at all necessary.[4] This opportunity to understand the natural history of various degenerative pathologies might not be available for possibly the next few decades or generations of spine specialists. Elective surgery for spinal deformities has obviously nose-dived though all surgeries focusing on prevention or treatment of major neurological deficits have been reasonably spared.

The objectives were to review the evidence on whether intraoperative neurophysiological monitoring (IONM) sensitively and  specifically detects intraoperative neurologic injury during spine surgery and whether it reduces neurological complications in spine surgery. A systematic literature review and meta-analysis were conducted using the Preferred Reporting Items for Systematic Reviews  and Meta-Analyses (PRISMA) guidelines, and studies spanning 1990–2022 were searched. The diagnostic accuracy of somatosensory evoked potentials (SSEPs) and motor-evoked potential (MEP) in predicting postoperative neurologic outcomes in spine surgery was assessed. We also analyzed clinical comparative studies that compared patients who underwent spine surgery with and without IONM to determine the rate of new neurologic events. Fifty studies that provided exact SSEP or MEP changes and postoperative neurological outcomes were analyzed. The features of SSEP changes included low sensitivity (67.7%), high specificity (94.1%), and strong negative predictive value (NPV) (92.1%). For the assessed alarm criteria of a 50% reduction, a 65% reduction, an 80% reduction in amplitude, and a total signal loss, the sensitivity and specificity values for MEP were 87.4%, 100%, 100%, and 100%, and 94.8%, 97%, 94.5%,  and 90.5%, respectively. A random effects model was used to assess six research that compared neurological events with and without the use of IONM. The pooled Odds ratio was 0.5746 (confidence interval = 0.48; 0.67), z = 6.637, and the P value was 0.0001. The usefulness of IONM in detecting neurological events during spine surgery is well demonstrated by a growing body of research. 
However, prospective trials with high-level data are lacking to establish its efficacy in preventing new neurological deficits. 

Spinal osteochondromas with neurological deficits are rare. Only 0.5% to 1% of spinal osteochondromas present with neurological dysfunction. We hereby present a case of osteochondroma of the C2 lamina with neurological deficit and unique presentation. A 10-year-old female presented with a history of severe weakness of all four limbs after a fall. Weakness had spontaneously improved  over initial three days and she presented to us with mild weakness of the right upper limb about two weeks after the fall. On examination, neck movements were full and painless with spastic quadriparesis and a motor power of grade 4/5 in all four limbs with extensor plantars.  On radiology, CT scan of the cervical spine showed an osseous outgrowth from the C2 lamina in the midline projecting into the spinal canal, directed superiorly toward the dens. An MRI showed spinal-cord compression with cord deformation and signal changes. She underwent en bloc excision of the tumor mass, which was severely impinging on the spinal cord. Histopathology confirmed a diagnosis of osteochondroma. At four-year follow-up, there was complete recovery with no signs of recurrence. 
Spinal osteochondroma is a rare but potential cause of spinal-cord compression in a child with varied presentation. 

Background: Incidence of postoperative deep wound infection (PODWI) after lumbar surgery varies from 2.1% to 6.7%.Studies looking into the effect of postoperative infection on functional recovery of the patient have thrown conflicting results. The aim of this study is to evaluate 2‑year functional and radiological outcome of patients with PODWI. This was a retrospective, matched cohort study. Materials and Methods: A total of 23 patients developing acute PODWI (<3 months) after instrumented posterior spinal fusion (IPSF) from 2005 to 2013 were treated by debridement along with antibiotics for 6 weeks (3 weeks intravenous and 3 weeks oral). Their preoperative and postoperative (6 months and 2 years) functional scores in the form of Oswestry Disability Index (ODI) and visual analog scale (VAS) were queried from the electronic database. Fusion was assessed at 2 years using radiograph and computed tomography scan. A noninfected control group (CG) was identified  matching indication, type and number of levels of fusion, ODI, and Charlson Age‑matched Comorbidity Index. Unpaired t‑test was used for statistical analysis. Results: Out of 23 patients, 21 underwent posterior spinal fusion, and two had additional anterior surgery. Mean lag time before the diagnosis of infection was 4.7 weeks. Most common pathogenic organism was Staphylococcus aureus. All patients except one had documented fusion at 2‑year follow‑up. Four patients developed discharging sinuses. Implant removal had to be done in three patients.  The mean ODI difference at 6 months from baseline was higher in the CG (33) as compared to infected group (19) (P < 0.001). Difference at 2 years was comparable for the two groups (P = 0.4). No significant difference was found in the VAS scores between the two groups. Small  sample size and retrospective nature are the potential limitations of this study. Conclusions: Patients with acute PODWI after IPSF treated appropriately have comparable long‑term outcome to patient with noninfected surgery; however, initial short‑term worsening in functional  status was seen in infected patients. Fusion was a predictable outcome. 

Cosmesis and self-image perception are important aspects of adolescent idiopathic scoliosis (AIS). Shoulder balance plays an important role in this aspect. In this article, we provide a broad narrative review of the clinical and radiological assessment of shoulder balance along with various factors affecting the postoperative shoulder imbalance (PSI). Systematic literature search was done using specific keywords, and studies were screened using PRISMA flowchart. Concept of medial and lateral shoulder balance, which are two distinct and independent entities, has been discussed. The trapezial angle and area are medial shoulder parameters, and are of more concern as they directly affect the cosmesis. Choice of the upper instrumented vertebra (UIV), behavior of the proximal thoracic curve, and preoperative levels of shoulder are important determinants of PSI. The relative correction of middle and distal curves also plays an important role to prevent imbalance and adding-on, especially in type 5 and 6 curves. Hooks at the UIV may provide a soft  landing and help in the adjustment of any PSI.

This section of the symposium brings to the reader seven case scenarios with regard to adolescent idiopathic scoliosis (AIS). These are the common curve patterns which a spine surgeon encounters in his practice. They have been contributed by different spine surgeons and highlight the varied approaches taken by them to achieve a satisfactory outcome. Each scenario highlights the proper workup required for such cases along with planning of the levels of fusion. 

Purpose Spinal Cord Society (SCS) and Spine Trauma Study Group (STSG) established a panel tasked with reviewing management and prognosis of acute traumatic cervical central cord syndrome (ATCCS) and recommend a consensus statement for its management. 
Methods A systematic review was performed according to the PRISMA 2009 guidelines. Delphi method was used to identify key research questions and achieve consensus. PubMed, Scopus and Google Scholar were searched for corresponding keywords. The initial search retrieved 770 articles of which 37 articles dealing with management, timing of surgery, complications or prognosis of ATCCS were identified. The literature review and draft position statements were compiled and  circulated to panel members. The draft was modified incorporating relevant suggestions to reach consensus. 
Results Out of 37 studies, 15 were regarding management strategy, ten regarding timing of surgery and 12 regarding prognosis of ATCCS. 
Conclusion There is reasonable evidence that patients with ATCCS secondary to vertebral fracture, dislocation, traumatic disc herniation or instability have better outcomes with early surgery (< 24 h). In patients of ATCCS secondary to extension injury in stenotic cervical canal without fracture/fracture dislocation/traumatic disc herniation/instability, there is requirement of high-quality prospective randomized controlled trials to resolve controversy regarding early surgery versus conservative management and delayed surgery if recovery plateaus or if there is a neurological deterioration. Until such time decision on surgery and its timing should be left to the judgment of physician, deliberating on pros and cons relevant to the particular patient and involving the well-informed patient and relatives in decision making. 

Purpose Management of vertebral and discovertebral lesions depends on highly specific modalities like biopsy and histopathology. The transpedicular and transforaminal routes have gained popularity for obtaining samples for diagnosing these lesions. Sample inadequacy plays an important part in lowering the diagnostic accuracy. Present study introduces a technical modification by using a kyphoplasty cannula and pituitary forceps through it thus improving sample adequacy and diagnostic accuracy. 
Methods Seventy-one patients with radiological evidence of spinal lesions from T1 to S1 were included. After obtaining samples via the transpedicular route they were sent for aerobic, anaerobic, acid fast bacilli & fungal cultures, Mycobacterium Tuberculosis/Radio Immuno Frequency (MTB/RIF) Assay and histopathological examination. In lesions with minimal  vertebral erosions the transforaminal route was used to obtain samples from the disc space.  Results Sixty-eight patients (95.8%) had a definite diagnosis of which 37 patients (54.4%) tested positive for vertebral osteomyelitis/discitis. All the samples were found to be adequate on histopathological examination. The remaining 3 patients showed chronic inflammation and responded to oral and intravenous antibiotics. None of the patients underwent repeat biopsy.  There were no perioperative complications. 
Conclusions Percutaneous transpedicular biopsy has evolved as the intervention of choice in diagnosing radiologically proven vertebral body lesions. Our technique of using a pituitary forceps through a cannula is highly effective in getting an adequate representative sample with excellent accuracy in diagnosis. This procedure is beneficial for soft tissue lesions and for infective pathology especially discitis. 

Background and objective: Lower back pain in humans has become a major risk. Classical approaches fol- low a non-invasive imaging technique for the assessment of spinal intervertebral disc (IVDs) abnormal- ities, where identification and segmentation of discs are done separately, making it a time-consuming phenomenon. This necessitates designing a robust automated and simultaneous IVDs identification and segmentation of multi-modality MRI images. Methods: We introduced a novel deep neural network architecture coined as ‘RIMNet’ , a Region-to-Image Matching Network model, capable of performing an automated and simultaneous IVDs identification and segmentation of MRI images. The multi-modal input data is being fed to the network with a dropout strategy, by randomly disabling modalities in mini-batches. The performance accuracy as a function of the testing dataset was determined. The execution of the deep neural network model was evaluated by computing the IVDs Identification Accuracy, Dice coefficient, MDOC, Average Symmetric Surface Distance, Jaccard Coefficient, HausdorffDistance and F1 Score. Results: Proposed model has attained 94% identification accuracy, dice coefficient value of 91 . 7 ±1 % in seg- mentation and MDOC 90 . 2 ±1 % . Our model also achieved 0 . 87 ±0 . 02 for Jaccard Coefficient, 0 . 54 ±0 . 04 for ASD and 0 . 62 ±0 . 02 mm HausdorffDistance. The results have been validated and compared with other methodologies on dataset of MICCAI IVD 2018 challenge. Conclusions: Our proposed deep-learning methodology is capable of performing simultaneous identifica- tion and segmentation on IVDs MRI images of the human spine with high accuracy.  

Study Design: An expert-panel consensus-based content validation and case-based clinical validation study Objective: To develop a novel scoring system for diagnosing instability in tuberculosis (TB) spine using an expert-panel consensus followed by clinical validation for validating the content. Summary of Background Data: Currently, diagnosis of instability is primarily experiencebased which may lead to considerable variability and misdiagnosis in the hands of a relatively in-experienced spine surgeon. Considering the potential complications this entity entails, a universally accepted scoring criteria is very important for accurate and uniform diagnosis of instability in TB spine. 
Methods: The development of TB spine instability score (TSIS) followed a two-step process,  one designing the instrument and the other obtaining judgemental evidence. For judgemental  evidence a panel of experts was appointed to make appropriate modifications and content  validation for finalizing the scoring instrument. This score was applied on 30 patients of TB  spine and ROC curves were drawn for sensitivity and specificity analysis. 
Results: The comprehensive scoring criteria to diagnose instability in TB spine was approved  after three rounds of expert panel discussions with an index of content validation more than  0.75 after final round of panel discussion. On case-based validation after plotting ROC  curves, sensitivity and specificity for diagnosing stable and potentially unstable lesions at a  cut-off score of 6 was 92.9% and 86.8% respectively whereas for diagnosing potentially  unstable and unstable lesions at a cut-off score of 10 was 94.3% and 81.9% respectively.
Conclusions: TSIS is a comprehensive scoring system integrating demographic, anatomical,  clinical and radiological factors aimed at diagnosing instability in TB spine. The  classification determines indications for surgical stabilization in patients with TB spine, with no or little neurological deficit. 

Objectives The objectives of this study were to study the long-term results of one-stage single and multiple level posterior hemivertebrectomies and to find out the safety and efficacy of the procedure. 
Method Twenty patients (9 male and 11 female) with mean age of 9.2 years (2 years 4 months–14 years 10 months) with congenital scoliosis (hemivertebrae) were treated with posterior hemivertebrectomy with intraoperative neuromonitoring. Posterior exposure and transpedicular fixation of the adjoining vertebrae was done. The hemivertebra was approached from the convex side, and transpedicular decancellation followed by complete excision was done. Controlled compression at the convexity was done after a cantilever manoeuvre was done for  rod capturing on the convexity to achieve the reduction. 
Results Average number of hemivertebra removed was 1.46 (1–3). Mean pre-op and post-op coronal Cobb angle was 48.8° (range 22 to 80) and 24.2° (range 7 to 41), respectively (p < 0.001). Mean pre-op and post-op sagittal Cobb angle was 32.1° (range 7 to 76) and 13.6° (range 0 to 23) respectively, (p < 0.005). Mean coronal and sagittal Cobb correction percentage achieved was 50.2 and 51.8%, respectively. Mean follow-up was 62.4 months (range 24–73 months). Mean loss  of coronal and sagittal correction at final follow-up was 2.26° (0–8) and 1.55° (0–5), respectively. Maximum correction in both coronal (p = 0.167) and sagittal (p = 0.095) planes was achieved in thoracolumbar vertebrae. Maximum correction was achieved in 3 level hemivertebrae in sagittal (p = 0.9) and 2 level hemivertebrae in coronal plane (p = 0.740). Conclusions Posterior hemivertebrectomy is a safe and effective procedure for congenital scoliosis. Not only single but up to 3 level hemivertebrae can be safely removed with good  correction of deformity. Long-term follow-up reveals good maintenance of correction. 

Purpose The purpose of this work is to describe normal spino-pelvic parameters for pediatric and adolescent Indian population (and compare it with a cohort of different ethnicity) and to find out the correlation of pelvis incidence (PI) and lumbar lordosis (LL) Methods 129 asymptomatic subjects (66 males, 63 females) with age 4–15 years were studied. Pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and lumbar lordosis (LL) were measured on lateral whole-spine standing radiographs using computer software and compared in relation to age, sex, and ethnicity. Using correlation and regression analysis, the association and predictability of LL with PI was studied within the entire sample and then among age groups 4–10 and 11–15 years. 
Results Mean PI was 42° ± 8.1°, whereas PT and SS were 12.9° ± 7.8° and 29.3° ± 9.62°, respectively. PI and SS were lower (p < 0.0001), but PT was higher than Caucasians. Overall PI remained unchanged in the age group > 10 years in comparison to the younger age. Mean PT was lower (p = 0.0020), but SS and LL were higher (p = 0.0027 and p = 0.0002 respectively). Angular spino-pelvic parameters were similar between sex groups. Overall correlation between PI and LL was 0.4 (p < 0.0001) which was 0.1 (p = 0.2345) and 0.5 (p < 0.0001) for ages 4–10 and 11–15 years, respectively. Overall, the prediction of PI based on LL is not very accurate with a simple linear term between PI and LL (R2 = 0.1) and only improve marginally with a restricted cubic spline function. 
Conclusions In pediatric and adolescent’ population, ethnicity and age-related variations of normal sagittal spino-pelvic parameters exist and should be considered in patient management. 

Purpose To document baseline cervical sagittal characteristics in Lenke 1 adolescent idiopathic scoliosis (AIS) patients and assess the alteration in these parameters with surgery. 
Methods Pre-operative and 2-year postoperative radiographs of 82 Lenke 1 AIS patients recruited from five hospitals were analysed. Selected radiographic parameters capturing regional and global sagittal alignment were measured. Comparison was made between groups based on baseline thoracic kyphosis (TK: TK < 20°, TK ≥ 20°). Pre-operative and postoperative values were compared—the change in each radiographic parameter was correlated with the degree of sagittal and coronal correction. Results At baseline, TK was 29.8° } 16°, cervical lordosis (CL) was − 1° } 14°, lumbar lordosis (LL) was − 57.1° } 21°, C2–C7 sagittal vertical axis (SVA) was 16 } 14 mm and C7–S1 SVA was − 15 } 28 mm; 44% of patients had cervical kyphosis. Patients with thoracic hypokyphosis had a significantly lower LL and more kyphotic cervical spine compared to those with thoracic normohyperkyphosis. The effect of surgery on TK depended on pre-operative thoracic sagittal alignment— TK increased in patients with thoracic hypokyphosis, but decreased in patients with thoracic normohyperkyphosis. 
Neither CL nor C2–C7 SVA changed significantly with surgery; 46% of patients still had cervical kyphosis postoperatively. 
Conclusion There is a high incidence of cervical kyphosis at baseline in AIS patients—more so in those with pre-operative thoracic hypokyphosis. Unlike TK, CL is not significantly altered with surgery—improvement in CL correlates weakly with sagittal correction of the structural curve. 

Purpose. To review treatment outcomes of 19 patients with delayed presentation of cervical facet dislocations. 
Methods. Records of 17 men and 2 women aged 21 to 63 (mean, 39) years who presented with unilateral (n=14) or bilateral (n=5) cervical facet dislocation after a delay of 7 to 21 (mean, 14) days were reviewed. The most common level of dislocation was C5-C6 (n=9), followed by C4-C5 (n=6), C3- C4 (n=2), and C6-C7 (n=2). The neurological status was graded according to the Frankel classification. One patient (with bilateral facet dislocation) had complete quadriplegia (grade A), 11 had incomplete spinal cord injury (grades C and D), and 7 had nerve  root injury. Closed reduction using continuous skull traction for 2 days was attempted. In patients achieving closed reduction, only anterior discectomy and fusion was performed. Those who failed closed reduction underwent posterior partial/complete facetectomy and fixation. If there was traumatic disk prolapse, anterior decompression and fusion was then performed. 
Results. The mean follow-up was 46 (range, 12– 108) months. 10 of 14 patients with unilateral facet dislocation were reduced with traction and then underwent anterior discectomy and fusion. The remaining 4 patients who failed closed reduction underwent posterior facetectomy and fixation; 3 of them had traumatic disk prolapse and thus also underwent anterior discectomy and fusion with cage and plate. Four of the 5 patients with bilateral facet dislocations failed closed reduction and underwent posterior facetectomy and lateral mass fixation, as well as anterior surgery. The remaining patient achieved reduction after traction and hence  underwent only anterior discectomy and fusion. All patients achieved pain relief and sufficient neck movement for normal activities. All 7 patients with nerve root injury improved completely; 9 of the 11 patients with incomplete spinal cord injury improved by one Frankel grade, and the remaining 2 by 2 grades. The patient with complete quadriplegia showed no improvement. 
Conclusion. Preoperative traction is a safe and effective initial treatment for neglected cervical facet dislocation, as it reduces the need for extensive (anterior and posterior) surgery. If closed reduction is successful, anterior discectomy and fusion is the surgery of choice. If not, posterior facetectomy and fusion followed by anterior surgery is preferred. 

Purpose To evaluate the incidence and risk factors associated with the unplanned return to OR in EOS.
  Methods Medical records of 51 patients of EOS operated at three different centres using various types of GSCs were evaluated for complications requiring unplanned surgeries. Data were analysed to find out rate of unplanned surgeries in relation to the aetiology, age and Cobb angle at index surgery, type of implant, cause of unplanned surgery, and management required. Results Out of 51 patients, three did not meet inclusion criteria. Forty-eight patients of EOS operated by GSCs with a mean age of 6.7 years (range 2–12 years) with an average follow-up of 67.3 months were studied. There were 30 congenital, 10 idiopathic, 4 syndromic, and 4 neuromuscular cases. Thirty-nine out of 48 patients had one or more unplanned surgeries on  follow-up (81.25%). Out of total 248 surgeries following index procedure, 82 were unplanned surgeries (33.06%), including 53 implant revisions, 12 implant-removal, 14 debridement, and 2 flaps. The common complications were 24.14% rod/ screw breakage, 42.53% anchor pull-out, 16.09% infections, 6.90% wound dehiscence, and 4.6% neuro deficits. Unplanned surgeries were significantly higher in syndromic (58.8%) and neuromuscular (52.9%) than congenital (27.2%) and idiopathic (37.8%) cases (p < 0.05). Age at index procedure < 5 years had higher unplanned surgeries than age > 5 years (2.5 and 1.23 per patient, respectively, p < 0.05). Type of implant and initial Cobb angle did not significantly affect the rate of unplanned surgeries (p > 0.05) 
Conclusion GSCs in EOS require a frequent revisit to operation room which should be well understood by the surgeon and parents. ct

Purpose Determine impact of metal density on curve correction and costs in thoracic adolescent idiopathic scoliosis  (AIS). Ascertain if increased metal density is required for larger or stiffer curves. 
Methods Multicentre retrospective case series of patients with Lenke 1-2 AIS treated with single-stage posterior only surgery using a standardized surgical technique; constructs  using[80 % screws with variable metal density. All cases had [2-year follow up. Outcomes measures included coronal and sagittal radiographic outcomes, metal density (number of instrumented pedicles vs total available), fusion length and cost. 
Results 106 cases included 94 female. 78 Lenke 1. Mean age 14 years (9–26). Mean main thoracic (MT) Cobb angle 63_ corrected to 22_ (66 %). No significant correlations were present between metal density and: (a) coronal curve correction rates of the MT (r = 0.13, p = 0.19); (b) lumbar curve frontal correction (r = -0.15, p = 0.12); (c) correction index in MT curve (r = -0.10, p = 0.32); and (d) correction index in lumbar curve (r = 0.11, p = 0.28). Metal density was not correlated with change in thoracic kyphosis (r = 0.22, p = 0.04) or lumbosacral  lordosis (r = 0.27, p = 0.01). Longer fusions were Abstract Purpose Determine impact of metal density on curve correction and costs in thoracic adolescent idiopathic scoliosis (AIS). Ascertain if increased metal density is required for larger or stiffer curves. 
Methods Multicentre retrospective case series of patients with Lenke 1-2 AIS treated with single-stage posterior only surgery using a standardized surgical technique; constructs  using[80 % screws with variable metal density. All cases had [2-year follow up. Outcomes measures included coronal and sagittal radiographic outcomes, metal density (number of instrumented pedicles vs total available), fusion length and cost. 
Results 106 cases included 94 female. 78 Lenke 1. Mean age 14 years (9–26). Mean main thoracic (MT) Cobb angle 63_ corrected to 22_ (66 %). No significant correlations were present between metal density and: (a) coronal curve correction rates of the MT (r = 0.13, p = 0.19); (b) lumbar curve frontal correction (r = -0.15, p = 0.12); (c) correction index in MT curve (r = -0.10, p = 0.32); and (d) correction index in lumbar curve (r = 0.11, p = 0.28). Metal density was not correlated with change in thoracic kyphosis (r = 0.22, p = 0.04) or lumbosacral  lordosis (r = 0.27, p = 0.01). Longer fusions were 

Objectives: The purpose of this study is to study the safety and efficacy of single-stage transpedicular decompression/debridement and instrumented posterior spinal fusion for single-level thoracic spinal tuberculosis with myelopathy without anterior column reconstruction. 
Summary of Background Data: Existing literature has many reports of transpedicular decompression/debridement and instrumented posterior spinal fusion with anterior column reconstruction. The quoted loss of correction is around 2_, but there is no strong evidence  analyzing the loss of kyphosis correction, assessment of fusion in the same, without anterior column reconstruction. 
Study Design: Retrospective study. 
Methods: Study consisted of 57 patients of single-level thoracic tuberculosis with myelopathy from a single center who fulfilled the selection criteria. All underwent pedicle screw-rod instrumentation (2 up and 2 down), bilateral transpedicular decompression/debridement  of granulation tissue/abscess, followed by instrumented posterior spinal fusion with local bone/B-tri-calcium phosphate. Patients were analyzed clinically (ASIA scoring) and radiologically by radiographs for kyphosis correction and CT scans at 2 years (for assessment of fusion). The grade of destruction was correlated with loss of kyphosis correction and neurologic improvement. 
Results: There are 43 female and 14 male patients with a mean age of 46.7 years (18.4-74.2), mean follow-up of 3.4 years (2.1-8.4). The mean pre-op Cobb angle is 26.4_ and mean correction obtained is 12.6_ (47.8%). The mean loss of kyphosis after 2 years’ follow-up is 3.6_ (13.6%).  The mean American Spinal Injury Association (ASIA) grade improvement after surgery is 1.05 (p 5 .001). There is no correlation observed between neurologic recovery and grade of destruction (R 5 _0.11). There is no correlation between the improvement in kyphosis and neurologic recovery (R 5 _0.05). Two-year postoperative CT scan showed solid interbody (55 patients) and posterior fusion (57 patients). 
Conclusion: Significant neurologic recovery, kyphosis correction, and posterior/interbody bony fusion can be obtained by transpedicular decompression/debridement and instrumented posterior spinal fusion (without anterior reconstruction) with maintained correction at 2 years. 

Purpose Symptomatic adult spinal deformity (ASD) with an extremely variable presentation with pain, with and without neurogenic leg pain, and/or disturbed sagittal and coronal balance, causes a significant societal burden of disease. It is an important consequence of the aging adult population, generating a plethora of spine-related interventions with variable treatment efficacy and consistently high costs. Recent years have witnessed more than a threefold increase in the prevalence and treatment of ASD, and further increases over the coming decades are expected with the growing elderly population worldwide. The ability to monitor and assess clinical outcomes has not kept pace with these developments. This paper addresses the pressing need to provide a set of common outcome metrics for this growing group of patients with back pain and other disabilities due to an adult spinal deformity. 
Methods The standard outcome set was created by a panel with global representation, using a thorough modified Delphi procedure. The three-tiered outcome hierarchy (Porter) was used as a framework to capture full cycle of care. The standardized language of the International Classification of Functioning, Disability and Health (WHO-ICF) was used. 
Results Consensus was reached on a core set of 25 WHO-ICF outcome domains (‘What to measure’); on the accompanying globally available clinician and patient reported measurement instruments and definitions (‘How to measure’), and on the timing of the measurements (‘When to measure’). The current work has brought to light domains not routinely reported in the spinal literature (such as pulmonary function, return to work, social participation), and domains for which no adequate instruments have yet been identified (such as how to clinically quantify in routine practice lumbar spinal stenosis, neurogenic claudication, radicular pain, and loss of lower extremity motor function). 
Conclusion A standard outcome set was developed for patients undergoing treatment for adult spinal deformity using globally available outcome metrics. The current framework can be considered a reference for further work, and may provide a starting point for routine methodical and systematic monitoring of outcomes. Post-COVID e-health may accelerate the routine capture of these types of data. 

About 5% of spinal injuries occur in children – however the consequences to the society are devastating, all the more so because the cervical spine is more commonly affected. 
Anatomical differences with adults along with the inherent elasticity of the pediatric spine,  makes these injuries a biomechanically separate entity. Hence clinical manifestations are  unique, one of which is the Spinal Cord InjuryWithout Radiological Abnormality.With the  advent of high quality MRI and CT scan along with digital X-ray, it is now possible to exactly  delineate the anatomical location, geometrical configuration, and the pathological extent  of the injury. This has improved the management strategies of these unfortunate children  and the role of surgical stabilization in unstable injuries can be more sharply defined. However  these patients should be followed up diligently because of the recognized long term  complications of spinal deformity and syringomyelia. 

Study Design: Prospective matched cohort study Objective: To evaluate the sensitivity and specificity of Gene Xpert in the diagnosis of spinal tuberculosis.  Methods: From January 2016 to August 2018, Gene Xpert results were prospectively studied in 68 patients of clinicoradiologically suspected spinal tuberculosis (STB) and a control group (CG) of 92 patients, all of whom underwent computed tomography–guided/C-arm-guided/open surgical biopsy. Sensitivity, specificity, positive predictive value, and negative predictive  value are obtained using standard equations. 
Results: Out of 68 cases of STB, Gene Xpert was positive in 62 (true positive: 62/68) and negative in 6 (false negative: 6/68). Gene Xpert was negative for all 92 cases of CG (true negative: 92/92, false positive 0/92). Thus, in our series, sensitivity of Gene Xpert is  91.18%, specificity is 100%, positive predictive value is 100%, and negative predictive value is 93.88%. Out of all cases of STB, 62/68 (91.18%) were Gene Xpert positive, but only 35/64 (54.69%) was acid-fast bacilli (AFB) culture positive and 53/60(88.33%) was histopathologically conclusive of TB. Also, Gene Xpert was positive in 7/7 (100%) cases of STB in which histopathology were inconclusive and 25/29 (86.21%) cases of STB in which AFB culture was negative. 
Conclusion: In STB, Gene Xpert clearly outperforms AFB culture and histopathology due to its high sensitivity and specificity apart from being rapid in diagnosis. Hence it is justified to diagnose spinal tuberculosis by Gene Xpert though histopathology is confirmative and AFB culture remains the gold standard.