Study Design: Review article. Objectives: A review of literature on the epidemiology, diagnosis, and management of spinal tuberculosis (TB). Methods: A systematic computerized literature search was performed using Cochrane Database of Systematic Reviews, EMBASE, and PubMed. Studies published over the past 10 years were analyzed. The searches were performed using Medical Subject Headings terms, and the subheadings used were “spinal tuberculosis,” “diagnosis,” “epidemiology,” “etiology,” “management,” “surgery,” and “therapy.” Results: Tissue diagnosis remains the only foolproof investigation to confirm diagnosis. Magnetic resonance imaging and Gene Xpert help in early detection and treatment of spinal TB. Uncomplicated spinal TB has good response to appropriately dosed multimodal ambulant chemotherapy. Surgery is warranted only in cases of neurological complications, incapacitating deformity, and instability. Conclusions: The incidence of atypical clinicoradiological presentations of spinal TB is on the rise. Improper dosing, inadequate duration of treatment, and inappropriate selection of candidates for chemotherapy has not only resulted in the resurgence of TB but also led to the most dreadful consequence of multidrug resistant strains. In addition, global migration phenomenon has resulted in worldwide spread of spinal TB. The current consensus is to diagnose and treat spinal TB early, prevent complications, promote early mobilization, and restore the patient to his or her earlier functional status.

Randomized clinical trial (level I evidence). To compare the accuracy of non-navigation and Iso-C based navigation in pedicle screw fixation in thoracic spine deformities. Thoracic pedicle screw insertion for spinal deformity correction can be associated with increased pedicle breaches. Iso-C based navigation has been reported to improve the accuracy of pedicle screw placement, but its use in the presence of deformity has not been reported. Twenty-seven patients with scoliosis and 6 patients with kyphosis had a total of 478 thoracic pedicle screws. The average Cobb angle was 58.4° ± 8° (range 50°–80°), and the mean kyphotic angle was 54.6° ± 4° (range 51°–76°). By random allocation, 17 patients had screw insertion under navigation (242 screws) and 16 under fluoroscopic control (236 screws). The 2 groups were compared for accuracy of screw placement, time for screw insertion, and the number of times the C-arm had to be brought into the field. Two independent blinded observers determined accuracy using postoperative computed tomography assessments. There were 54 (23%) pedicle breaches in the non-navigation group as compared to only 5 (2%) in the navigation group (P < 0.001). Thirty-eight screws (16%) in the non-navigation group had penetrated the anterior or lateral cortex compared to 2 screws (0.8%) in the navigation group. Average screw insertion time in the non-navigation group was 4.61 ± 1.05 minutes (range 1.8–6.5) compared to 2.37 ± 0.72 minutes (range 1.16–4.5) in navigation group (P < 0.01). The C-arm had to be moved into the operation field on an average of 1.5 ± 0.25 times (range 1–3) per screw. With single screening data, an average of 11.4 pedicles (range 9–14) could be visualized without necessity to bring the C-arm into operating field again. Iso-C navigation increases accuracy, and reduces surgical time and radiation in thoracic deformity correction surgeries.

Limb-injury severity scores are designed to assess orthopaedic and vascular injuries. In Gustilo type-IIIA and type-IIIB injuries they have poor sensitivity and specificity to predict salvage or outcome. We have designed a trauma score to grade the severity of injury to the covering tissues, the bones and the functional tissues, grading the three components from one to five. Seven comorbid conditions known to influence the management and prognosis have been given a score of two each. The score was validated in 109 consecutive open injuries of the tibia, 42 type-IIIA and 67 type-IIIB. The total score was used to assess the possibilities of salvage and the outcome was measured by dividing the injuries into four groups according to their scores as follows: group I scored less than 5, group II 6 to 10, group III 11 to 15 and group IV 16 or more. A score of 14 to indicate amputation had the highest sensitivity and specificity. Our trauma score compared favourably with the Mangled Extremity Severity score in sensitivity (98% and 99%), specificity (100% and 17%), positive predictive value (100% and 97.5%) and negative predictive value (70% and 50%), respectively. A receiver-operating characteristic curve constructed for 67 type-IIIB injuries to assess the efficiency of the scores to predict salvage, showed that the area under the curve for this score was better (0.988 (± 0.013 sem)) than the Mangled Extremity Severity score (0.938 (± 0.039 sem)). All limbs in group IV and one in group III underwent amputation. Of the salvaged limbs, there was a significant difference in the three groups for the requirement of a flap for wound cover, the time to union, the number of surgical procedures required, the total days as an in-patient and the incidence of deep infection (p < 0.001 for all). The individual scores for covering and functional tissues were also found to offer specific guidelines in the management of these complex injuries. The scoring system was found to be simple in application and reliable in prognosis for both limb-salvage and outcome measures in type-IIIA and type-IIIB open injuries of the tibia.

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Study Design. A prospective multimodal study including clinical, radiological, serial postcontrast magnetic resonance imaging, intraoperative findings, and histopathological study. Objective. To document in vivo, the site of anatomical failure in lumbar disc herniation (LDH). Summary of Background Data. Although in vitro mechanical disruption studies have implicated both the endplate junction (EPJ) and the annulus fibrosus (AF) as the site of failure in LDH, there are no in vivo human studies to document the exact anatomy of failure. Methods. One hundred eighty-one consecutive patients requiring microdiscectomy at a single level formed the study group. The status of the endplate and AF in the operated level (study discs) and the other discs (control) were evaluated by plain radiograph, thin slice computed tomographic scan, plain and contrast magnetic resonance imaging, intraoperative examination, and histopathological analysis. Results. LDH due to EPJ failure (EPJF- type I herniation) was more common (117; 65%) than annulus fibrosis rupture. Herniated discs had a significantly higher incidence of EPJF than control discs (P < 0.0001). The EPJF was evident radiologically as vertebral corner defect in 30 patients, rim avulsion in 46, frank bony avulsions in 24, and avulsion at both upper and lower EP in 4. Thirteen discs with normal EP radiologically had cartilage or bone avulsion intraoperatively. Sixty-four discs (35%) had intact EP of which annular high intensity zone was found in 21 (11%), suggesting a disruption of AF (type II herniation). Postcontrast magnetic resonance image of 20 patients showed dye leak at the EPJ proving EPJF as main cause of LDH. Conclusion. Our study provides the first in vivo evidence that LDH in humans is more commonly the result of EPJF than AF rupture and offers clinical validation of previous in vitro mechanical disruption studies. Future research must focus on the EPJ as a primary area of interest in LDH. Level of Evidence: N/A