Monthly Archives: June 2023
Hypothesis on the Surgical Management and Outcomes of Terrible Triad Injuries around the Elbow
Vol 9 | Issue 1 | January-June 2023 | page: 21-24 | Haroon Ansari, Chetan Pradhan, Atul Patil, Chetan Puram, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2023.v09.i01.202
Author: Haroon Ansari [1], Chetan Pradhan [1], Atul Patil [1], Chetan Puram [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Haroon Ansari,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
E-mail: ansariharoon045@gmail.com
Abstract
Background: The terrible triad of the elbow—radial-head fracture, coronoid fracture and posterolateral dislocation—creates a mechanically unstable joint that commonly leads to pain, stiffness and impaired daily activities when not reconstructed properly. Modern surgical care aims to restore the anterior bony buttress by fixing the coronoid, to preserve or replace the radial head to maintain radiocapitellar contact, and to repair the lateral collateral ligament to regain stability and permit early controlled motion.
Hypothesis: We hypothesize that a disciplined, anatomy-focused operative sequence—fixation or repair of the coronoid, reconstruction or arthroplasty of the radial head as determined by fracture morphology, repair of the lateral collateral ligament, and selective medial-sided repair only if residual instability persists—combined with early supervised mobilisation will restore joint stability, reduce pain and result in meaningful functional gains in adult patients with terrible-triad injuries. Functional success will be measured by improvements in the Mayo Elbow Performance Score, restoration of a functional flexion-extension arc commonly greater than 100 degrees, recovery of near-normal forearm rotation, and acceptable pain scores, while monitoring complications and reoperation rates.
Clinical importance: For surgeons, applying this reproducible protocol improves the likelihood of a stable, functional elbow. Repairing even small coronoid fragments, selecting radial-head replacement when reconstruction is impractical, and reserving medial repair for persistent instability reduce recurrent instability and need for salvage operations. Close follow-up, clear patient counselling about expected recovery and complications, and a structured physiotherapy programme are essential to manage stiffness and restore strength.
Future research: Large multicentre prospective cohorts and randomized trials comparing radial-head fixation versus arthroplasty for defined fracture types, head-to-head comparisons of coronoid fixation techniques, and standardised rehabilitation protocols with long-term follow-up are needed to refine indications and reduce complications. Biomechanical work linking fragment morphology to fixation choice would further reduce practice variability. Studies should include validated patient-reported outcome measures, cost-effectiveness analyses, and subgroup analyses by age and bone quality, and implant survivorship.
Keywords: Terrible triad, Elbow, Coronoid, Radial head, Lateral collateral ligament, Arthroplasty, Fixation, Rehabilitation.
Background
The “terrible triad” of the elbow — a combination of radial-head fracture, coronoid fracture and posterolateral elbow dislocation — was named because, left untreated or treated poorly, it frequently led to pain, recurrent instability and poor function. Early descriptions emphasized that the triad disrupts both the bony constraints (radial head and coronoid) and the soft-tissue stabilizers (lateral collateral ligament complex), producing a mechanically unstable elbow that is difficult to manage without surgery. Hotchkiss popularized the term and highlighted the poor natural history without adequate reconstruction; Regan and Morrey provided the familiar coronoid classification that helps guide fixation decisions; Mason’s classification of radial-head fractures remains central to choosing fixation versus replacement. [1–3]
Biomechanical and clinical work shows that the coronoid is the primary anterior buttress against posterior translation, while the radial head contributes to valgus and radiocapitellar stability. Cadaveric and finite-element studies indicate that even relatively small coronoid tip fragments can be functionally important because they carry capsular and ligamentous attachments that affect stability; conversely, large coronoid defects (type III) reliably require fixation to avoid late instability. The radial head, particularly when comminuted, cannot always be reconstructed — in those cases arthroplasty is used as a spacer to re-establish height and radiocapitellar contact. [4–6]
Contemporary operative practice has therefore adopted a principle-based, stepwise approach: restore the anterior bony buttress (coronoid), restore the radial head (fixation when feasible; arthroplasty when not), repair the lateral collateral ligament (LUCL/LCL) and reassess stability — repairing the medial collateral ligament only when residual instability persists; a hinged external fixator is a salvage option for persistent instability. Studies reporting this sequence show better maintenance of concentric reduction, permit early controlled motion and achieve satisfactory functional scores in most patients, though complication rates remain meaningful. [7–12]
Surgical technique is adapted to fragment size and location: small coronoid tip fractures are commonly stabilized with suture lasso or anchors while larger fragments require screws or buttress plating; anteromedial facet fractures often need medial exposure and buttress fixation because they act as a varus/medial buttress. For radial-head fractures, attempts at reconstruction are reasonable in younger patients when fragments can be anatomically restored; for severely comminuted heads, modular metallic arthroplasty more reliably restores length and radiocapitellar mechanics and avoids proximal migration. Approaches vary (lateral-only versus combined medial and lateral exposures) and each has tradeoffs related to soft-tissue dissection and neurovascular risk. [13–16]
Despite improvements in technique, the literature documents a substantial complication burden — heterotopic ossification, stiffness, nerve palsies and a nontrivial reoperation rate for stiffness, instability or implant problems. Outcomes are better when reconstruction is performed early, when the reconstruction restores radiocapitellar contact and coronoid buttress, and when early supervised rehabilitation is begun once a stable construct is confirmed. Published series show a majority achieving good to excellent results on validated scores (for example MEPS), but with
Complication and reoperation rates that demand careful patient counselling and meticulous surgical technique. [17–20]
Hypothesis
Primary hypothesis:
When surgeons apply a systematic, anatomy-focused operative sequence — restore coronoid (repair/fixation) → restore radial head (fix or replace) → repair lateral collateral ligament → reassess and address the medial side only if needed — and begin early controlled rehabilitation, patients with terrible-triad injuries will gain significant functional improvement (as measured by MEPS, range of motion and pain scores) with acceptable complication rates. [21]
Secondary hypotheses:
1. Radial-head arthroplasty is more reliable than attempted fixation in severely comminuted radial-head fractures within the terrible-triad pattern, producing more consistent restoration of radiocapitellar contact and reducing late instability or need for secondary procedures. [22]
2. Repair of even small coronoid tip fragments (with a suture lasso or anchor) materially improves early stability compared with leaving them untreated, because capsular and ligamentous insertions on small fragments contribute disproportionately to joint restraint. [23]
3. Routine medial collateral ligament (MCL) repair is unnecessary; selective MCL repair only for persistent instability after anterior and lateral reconstruction minimizes surgical morbidity while addressing instability when indicated. [24]
4. A stepwise algorithm (coronoid → radial head → LCL → reassess → MCL/hinge if needed) results in a majority of patients achieving a functional arc of motion and good/excellent MEPS scores at medium-term follow-up, while keeping reoperation rates within published expectations. [25]
Rationale and plan for measurement:
These hypotheses rest on the mechanical role of the coronoid and radial head and the central role of the lateral collateral complex in resisting posterolateral rotatory and varus-posteromedial failure. Practically, the study measures pre- and post-operative MEPS, active flexion/extension and forearm rotation (goniometer), VAS pain, radiographic maintenance of reduction and evidence of heterotopic ossification. Success is operationalized as a clinically meaningful rise in MEPS category and restoration of a functional arc of motion (commonly >100° flexion-extension and near-normal pronation/supination) with no recurrent dislocation. Complications including HO, nerve palsy, implant failure and need for reoperation are recorded and compared with historical series. [21–25]
Discussion
This series and the thesis literature support the central idea that a disciplined, anatomy-first operative approach converts a once “terrible” injury into one that frequently yields useful function. Restoring the coronoid — even when the fragment appears small — is important because it re-establishes the anterior buttress and the capsular attachments that restrain posterior translation; repair by suture lasso/anchors for tip fragments or screws/plates for larger or anteromedial facet fractures prevents varus collapse and later arthrosis. [1–5]
When the radial head is reconstructable, fixation preserves native anatomy and is reasonable in younger patients. However, when the head is severely comminuted, arthroplasty more predictably restores length and radiocapitellar contact and avoids problems such as proximal migration and late valgus deformity that were seen historically with simple excision. Several comparative series in the thesis point toward lower instability and improved short-term function with arthroplasty in the appropriate setting. [6–9]
Repair of the lateral collateral ligament complex is essential to control posterolateral rotatory instability; the MCL need only be repaired if the elbow remains unstable after reconstituting bony anatomy and repairing the lateral side. Selective MCL repair avoids unnecessary additional medial dissection and its attendant risks. If residual instability persists despite soft-tissue repair, a hinged external fixator offers a temporary stabilizing strategy that allows early motion while soft tissues heal. [10–14]
Outcomes reflect this logic: most patients reach a functional arc of motion and report reduced pain and improved MEPS, but the complication rate remains substantial — heterotopic ossification, nerve symptoms (radial or ulnar neuropraxia), stiffness requiring adhesiolysis, and occasional implant problems are reported across multiple series. Timely surgery, careful reconstruction of coronoid and radial head, judicious use of arthroplasty, meticulous ligament repair and early supervised rehabilitation together reduce but do not eliminate these risks. [15–20]
Clinical importance
For surgeons, this work clarifies a reproducible pathway: restore the coronoid buttress, preserve or replace the radial head depending on reconstructability, repair the lateral collateral ligament, and only address the medial side if residual instability remains. Applying this sequence allows early controlled motion and yields useful elbow function in most patients while recognizing and mitigating common complications through careful technique and dedicated rehabilitation. The practical benefit is fewer recurrent instabilities and better early function compared with historical non-operative care.
Future direction
Future research should aim for larger, multicentre prospective cohorts or randomized comparisons of radial-head fixation versus arthroplasty in defined fracture patterns, and head-to-head trials of coronoid fixation techniques (suture lasso/anchor vs screws vs medial buttress plating for anteromedial facets). Standardized, protocolized rehabilitation regimens and longer-term follow-up will help define drivers of late arthritis and hardware-related problems. Biomechanical studies that link fragment morphology to a specific fixation strategy would also reduce practice variability.
References
1. Hotchkiss RN. Fractures and dislocations of the elbow. In: Rockwood CA, Green DP, Bucholz RW, Heckman JD, editors. Rockwood and Green‘s fractures in adults. 4th ed. Philadelphia: Lippincott-Raven; 1996. p. 980–981.
2. Regan W, Morrey B. Fractures of the coronoid process of the ulna. J Bone Joint Surg Am. 1989; 71:1348–1354.
3. Mason ML. Some observations on fractures of the head of radius with a review of one hundred cases. Br J Surg. 1954; 42:123–132.
4. Miyazaki AN, Checchia CS, Fagotti L, Fregoneze M, Santos PD, Andrade L, et al. Evaluation of the results from surgical treatment of the terrible triad of the elbow. (May/June 2014) Vol 49 No.3.
5. Broberg MA, Morrey BF. Results of treatment of fracture-dislocations of the elbow. Clin Orthop Relat Res. 1987; 216:109–119.
6. Hong-wei Chen, Guo-dong Liu, Shan Ou, Jun Fei. Operative treatment of terrible triad of the elbow via posterolateral and anteromedial approaches. Apr 2015.
7. Guanyi Liu, Weihu Ma, Ming Li, Jianxiang Feng, Rongming Xu, Zhijun Pan. Operative treatment of terrible triad of the elbow with a modified Pugh standard protocol.
8. Armstrong AD. The terrible triad injury of the elbow. Curr Opin Orthop. 2005; 16:267–270.
9. Hildebrand KA, Patterson SD, King GJ. Acute elbow dislocations: simple and complex. Orthop Clin North Am. 1999; 30:63–79.
10. Armstrong AD, Dunning CE, Faber KJ, et al. Rehabilitation of the medial collateral ligament-deficient elbow: an in vitro biomechanical study. J Hand Surg. 2000; 25:1051–1057.
11. Closkey RF, Goode JR, Kirschenbaum D, et al. The role of the coronoid process in elbow stability: a biomechanical analysis of axial loading. J Bone Joint Surg Am. 2000; 82A:1749–1753.
12. Wake H, Hashizume H, Nishida K. Biomechanical analysis of the mechanism of elbow fracture–dislocations by compression force. J Orthop Sci. 2004; 9:44–50.
13. Pugh DMW, McKee MD. The terrible triad of the elbow. (2002) 6(1):21–29.
14. Ring D, Jupiter J, Zilberfarb J. Posterior dislocation of the elbow with fractures of the radial head and coronoid. (2002) 84(4):547–551.
15. Bain GI, Ashwood N, Baird R, Unni R. Management of Mason type 3 radial head fractures with a titanium prosthesis, ligament repair and early mobilisation. (2004) Vol. 86-A: 274–280.
16. Doornberg JN, van Duijn J, Ring D. Coronoid fracture height in terrible triad injuries. J Hand Surg. 2006; 31A:794–797.
17. Ring D, Doornberg JN. Fracture of the anteromedial facet of the coronoid process: surgical technique. J Bone Joint Surg Am. 2007; 89:267–283.
18. Forthman C, Henket M, Ring DC. Elbow dislocation with intra-articular fracture: results of operative treatment without repair of the medial collateral ligament. 2007.
19. Ring D. Displaced, unstable fractures of the radial head: fixation vs replacement — what is the evidence? 2008.
20. Clarke SE, Lee SY, Raphael JR. Coronoid fixation using suture anchors. 2008.
21. Lindenhovius ALC, Jupiter JB, Ring D, McKee MD. Comparison of acute versus subacute treatment of terrible triad injuries of the elbow. J Hand Surg. 2008; 33A:920–926.
22. Johnson J, King G. The effect of anteromedial facet fractures of the coronoid and lateral collateral ligament injury on elbow stability and kinematics. 2008.
23. Seijas R, Ares-Rodriguez O, Orellana A, Albareda D, Collado D, Llusa M. Terrible triad of the elbow. J Orthop Surg. 2009; 17(3):335–339.
24. Pollock JW, Brownhill J, Ferreira L, McDonald CP, Johnson J, King G. The effect of anteromedial facet fractures of the coronoid and lateral collateral ligament injury on elbow stability and kinematics. 2009.
25. Micic I, Kim S-Y, Park Me-H, Kim P-T, Jeon I-H. Surgical management of unstable elbow dislocation without intra-articular fracture. Int Orthop (SICOT). 2009; 33:1141–1147.
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2020
| How to Cite this Article: Ansari H, Pradhan C, Patil A, Puram C, Sonawane D, Shyam A, Sancheti P. Hypothesis on the Surgical Management and Outcomes of Terrible Triad Injuries around the Elbow. Journal of Medical Thesis. January-June 2023; 9(1):21-24. |
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Spondylodiscitis: Prospective Analysis of Clinical Presentations and Surgical Outcomes
Vol 9 | Issue 1 | January-June 2023 | page: 17-20 | Vijay Karthek, Shailesh Hadgaonkar, Ajay Kothari, Siddhart Aiyer, Pramod Bhilare, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2023.v09.i01.200
Author: Vijay Karthek [1], Shailesh Hadgaonkar [1], Ajay Kothari [1], Siddhart Aiyer [1], Pramod Bhilare [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Vijay Karthek,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
E-mail: karthek555@gmail.com
Abstract
Background: Spondylodiscitis is infection of the vertebral bodies and intervertebral disc that can progress to abscess formation, deformity and neurological compromise when recognition and treatment are delayed. Early identification of the causative organism and prompt, targeted therapy — medical or surgical — reduce the risk of permanent disability.
Methods: This prospective study enrolled fifty-three adults diagnosed between October 2017 and October 2018. All patients had clinical assessment, laboratory tests including ESR and CRP, plain radiography and MRI for anatomic definition, and image-guided or open biopsy for microbiology, histopathology and molecular testing. Management was culture-directed antibiotics for pyogenic infections and standard antitubercular therapy where indicated. Surgical debridement with decompression and posterior instrumented stabilization was performed for neurological deficit, marked instability, large collections or failure of conservative care. Functional outcomes were measured with the Oswestry Disability Index and SF-36 at baseline, six months and one year.
Results: The cohort was predominantly older adults with mainly single-level lumbar disease. Combining culture, histology and GeneXpert PCR increased diagnostic yield. ESR and CRP trended down with effective therapy. Surgically treated patients showed meaningful improvement in function at follow up.
Conclusion: Early imaging, targeted tissue diagnosis and pathogen-directed therapy, with timely surgery for defined indications, produce favourable functional outcomes in spondylodiscitis.
Keywords: Spondylodiscitis,Vertebral osteomyelitis, Magnetic resonance imaging (MRI) GeneXpert Mycobacterium tuberculosis, Posterior instrumented stabilization, Oswestry Disability Index (ODI)
Introduction
Spondylodiscitis refers to infection of the vertebral body and intervertebral disc. The condition commonly presents with persistent axial back pain, sometimes accompanied by radicular symptoms, fever or progressive neurological deficits. Because the onset is often subtle, patients may wait weeks or months before seeking specialist assessment, and this delay allows the infection to extend into adjacent soft tissues or cause structural collapse. In adults the usual route of infection is hematogenous seeding of the vertebral endplates; haematogenous spread is favored by the vertebral vascular anatomy and the rich blood supply of the endplates. Risk factors include advanced age, diabetes, renal disease, immunosuppression and recent invasive procedures or bacteremia. These comorbidities increase both the risk of infection and the risk of complications. Imaging and laboratory tests are central to early detection. Plain radiographs can show late osseous changes, but MRI is the preferred modality because it detects marrow edema, disc involvement and paraspinal or epidural abscesses early and delineates the full extent of disease for planning sampling or surgery. Raised inflammatory markers — ESR and CRP — are common and provide useful objective measures to follow response to therapy. Microbiological confirmation is important: while aerobic culture remains the standard for pyogenic organisms, culture may be negative, especially after prior antibiotics or in granulomatous disease; histopathology and molecular assays such as nucleic acid amplification tests improve diagnostic yield and shorten time to a definitive diagnosis. Treatment goals are consistent: eradicate infection, preserve or restore neurological function, and maintain or reestablish spinal stability. Many patients with limited disease respond to prolonged, targeted medical therapy, while those with neural compression, marked instability or large collections benefit from debridement and stabilization. Individualized, multidisciplinary decision-making is therefore essential to achieve the best possible outcome. [1-7]
Review of literature
Classic and modern series underline the difficulty in diagnosing spinal infection early and stress the importance of integrating clinical suspicion with imaging and laboratory data. Early reports noted frequent diagnostic delay and showed that elevated ESR and CRP should prompt further evaluation in older adults with unexplained back pain. Numerous studies have since confirmed MRI as the imaging modality of choice because of its sensitivity for marrow and disc abnormalities and its ability to demonstrate paraspinal and epidural collections that plain films miss. Comparative studies describe differences between pyogenic and tuberculous spondylodiscitis: tuberculosis more often produces contiguous multilevel involvement and progressive vertebral destruction with deformity, while pyogenic infections frequently present with a more acute systemic picture and focal vertebral involvement. Microbiological diagnosis remains central to management; culture guides antibiotic selection but can be negative, particularly after prior empirical therapy or in granulomatous infections. To address that, several investigators have advocated combining culture with histopathology and molecular diagnostics — for example, nucleic acid amplification tests that detect Mycobacterium tuberculosis DNA — to increase the speed and reliability of diagnosis in endemic settings. Outcome studies comparing conservative and surgical management show that selected patients with stable anatomy and no neurologic deficit do well with medical therapy, but patients with neurologic compromise, instability or large, unresolving collections benefit from surgical debridement and stabilization, which often produces more rapid symptom relief and earlier functional recovery. Consensus statements and clinical practice guidelines recommend a multidisciplinary approach, prolonged culture-directed antibiotics for pyogenic infections and standard antitubercular regimens for TB, with individualized timing and extent of surgery to control infection, decompress neural elements and restore alignment when necessary. [8-16]
Methods and materials
This prospective single-center study enrolled fifty-three consecutive adult patients with clinico-radiological features consistent with spondylodiscitis between October 2017 and October 2018. Patients with prior instrumentation at the affected level or who declined consent were excluded. After informed consent each patient underwent standardized clinical evaluation to record duration and character of pain, radicular features, systemic symptoms and neurological status. Baseline laboratory tests included complete blood count, ESR and CRP. Radiographic assessment began with plain films of the symptomatic region and proceeded to MRI for detailed evaluation of vertebral body marrow, disc involvement, and prevertebral, paravertebral and epidural soft tissue extension; whole-spine MRI screening was performed when multifocal disease was suspected.
Tissue diagnosis was attempted by percutaneous image-guided biopsy when feasible; open biopsy was performed when sampling occurred at the time of surgical intervention. Specimens were processed for Gram stain and aerobic culture, Ziehl–Neelsen staining and mycobacterial culture, histopathological examination and molecular testing with GeneXpert PCR for Mycobacterium tuberculosis when clinically indicated. Aerobic cultures were incubated and observed for growth; mycobacterial cultures were maintained for extended incubation periods. Empirical therapy was tailored once culture or molecular results were available. Pyogenic infections received culture-directed intravenous antibiotics for an initial phase followed by oral therapy as per institutional protocol. Confirmed tuberculous cases were treated with standard antitubercular regimens according to national guidelines.
Indications for surgery were predefined and included progressive or severe neurological deficit, frank mechanical instability or vertebral collapse, large prevertebral or paraspinal collections not amenable to percutaneous drainage, and clinical deterioration despite appropriate medical therapy. Surgical techniques varied according to pathology and included debridement, neural decompression and posterior instrumented stabilization with fusion to restore alignment and support. Outcome measures were the Oswestry Disability Index and SF-36 recorded at baseline, six months and one year. ESR and CRP were measured serially to monitor inflammatory response. Complications and need for reoperation were recorded. Data were captured on a predefined proforma and analyzed descriptively. [17-20]
Results
Fifty-three patients met inclusion criteria and completed one-year follow up. The majority were aged between fifty and seventy years; both sexes were represented. Symptom duration before specialist evaluation varied widely, with many patients reporting several weeks to months of axial back pain before referral. The lumbar spine was the most frequently involved region and single-level disease was more common than multi-level involvement. At presentation most patients had elevated ESR and CRP; both markers declined progressively with effective therapy in responding patients. Microbiological assessment identified a mixture of pyogenic and tuberculous aetiologies: several cases yielded pyogenic organisms on culture, while histopathology and GeneXpert PCR increased diagnostic yield for tuberculosis where cultures were negative or slow to grow. Open biopsy secured diagnosis in cases not amenable to percutaneous sampling. Surgical management was employed in patients with neurological deficits, marked instability or large collections; posterior instrumented stabilization combined with decompression and debridement was the common operative strategy. Patients who underwent surgery typically experienced more rapid pain relief and earlier mobilization, and showed sustained improvement on ODI and SF-36 at six months and one year. Perioperative complications were infrequent and manageable; reoperation was required in a small minority.
Discussion
This prospective cohort echoes findings from previous series: older adults are commonly affected and lumbar single-level involvement predominates. The indolent onset of symptoms observed here accounts for the frequent delays in specialist referral and diagnosis; that delay permits more extensive local disease before treatment begins. MRI proved indispensable for defining the extent of vertebral and soft tissue involvement and for identifying collections that require drainage, and it guided decisions on percutaneous versus open sampling. ESR and CRP were reliable markers of active disease in most patients and provided practical metrics to follow response to treatment.
Microbiological confirmation was enhanced by combining culture with histopathology and molecular diagnostics. Culture positivity allowed targeted antibiotic stewardship, but culture negativity occurred in some cases, particularly when granulomatous inflammation suggested tuberculosis or after prior antibiotic exposure. In those cases, GeneXpert PCR offered rapid confirmation of Mycobacterium tuberculosis and permitted earlier initiation of appropriate antitubercular therapy. Surgical intervention remains an important option for those with neurological compromise, mechanical instability or large collections. Posterior instrumented stabilization provided dependable mechanical support in lumbar disease and facilitated mobilization and rehabilitation
Limitations of the study include single-center design and modest sample size, which restrict generalizability. Nevertheless, the prospective protocolized assessment and uniform follow up strengthen the findings. The balance between conservative and operative management should be individualized: reserve surgery for progressive neurological deficit, significant instability, or unresolving collections, and use culture and molecular diagnostics to guide medical therapy and reduce unnecessary broad-spectrum antibiotic exposure.
Conclusion
In this prospectively followed cohort, spondylodiscitis most commonly involved older adults and predominantly affected a single lumbar level. MRI combined with targeted biopsy and a combination of culture, histopathology and molecular testing improved the chances of identifying the responsible organism. Culture-directed antibiotics for pyogenic infections and standard antitubercular therapy for tuberculosis, together with timely surgical decompression and posterior instrumented stabilization for patients with neurological compromise, instability or large collections, produced durable functional improvement. Serial monitoring of ESR and CRP provided a practical method to assess response to therapy. An individualized, multidisciplinary approach that integrates rapid imaging, definitive tissue diagnosis and appropriate selection for surgery offers the best opportunity to limit morbidity and restore function to patients with vertebral infection. Early intervention preserves function and reduces long-term disability risk, consistently achieved.
References
1. Sobottke R, Seifert H, Fätkenheuer G, Schmidt M, Goßmann A, Eysel P. Current diagnosis and treatment of spondylodiscitis. Dtsch Arztebl. 2008; 105(10):181–7.
2. Park KH, Cho OH, Jung M, Suk KS, Lee JH, Park JS, et al. Clinical characteristics and outcomes of hematogenous vertebral osteomyelitis caused by gram-negative bacteria. J Infect. 2014; 69(1):42–50.
3. Kaufman DM, Kaplan JG, Litman HE. Infectious agents in spinal epidural abscesses. Neurology. 1980; 30(8):844–50.
4. Hematogenous Pyogenic Spinal Infections and Their Surgical M... : Spine [
5. Lee KY. Comparison of pyogenic spondylitis and tuberculous spondylitis. Asian Spine J. 2014; 8(2):216–23.
6. Grammatico L, Baron S, Rusch E, Lepage B, Surer N, Desenclos JC, et al. Epidemiology of vertebral osteomyelitis (VO) in France: analysis of hospital-discharge data 2002–2003. Epidemiol Infect. 2008 Apr; 136(5):653–60.
7. Krogsgaard MR, Wagn P, Bengtsson J. Epidemiology of acute vertebral osteomyelitis in Denmark. 137 cases in Denmark 1978–1982, compared to cases reported to the National Patient Register 1991–1993. Acta Orthop Scand. 1998; 69(5):513–7.
8. Gouliouris T, Aliyu SH, Brown NM. Spondylodiscitis: update on diagnosis and management. J Antimicrob Chemother. 2010; 65(SUPPL. 3):11–24.
9. Hadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ. Hematogenous pyogenic spinal infections and their surgical management. Spine (Phila Pa 1976). 2000; 25(13):1668–79.
10. Kern RZ, Houpt JB. Pyogenic vertebral osteomyelitis: diagnosis and management. Can Med Assoc J. 1984 Apr 15; 130(8):1025–8.
11. Torda AJ, Gottlieb T, Bradbury R. Pyogenic vertebral osteomyelitis: analysis of 20 cases and review. Clin Infect Dis. 1995; 20(2):320–8.
12. Chelsom J, Solberg CO. Vertebral osteomyelitis at a Norwegian university hospital 1987–97: clinical features, laboratory findings and outcome. Scand J Infect Dis. 1998; 30(2):147–51.
13. Ma H, Kim I. Clinical outcomes of spinal epidural abscess. Korean J Spine. 2012; 9(1):6.
14. Blizzard DJ, Hills CP, Isaacs RE, Brown CR. Extreme lateral interbody fusion with posterior instrumentation for spondylodiscitis. J Clin Neurosci. 2015; 22(11):1758–61.
15. Berbari EF, Kanj SS, Kowalski TJ, Darouiche RO, Widmer AF, Schmitt SK, et al. 2015 Infectious Diseases Society of America (IDSA) clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis in adults. Clin Infect Dis. 2015; 61:e26–46.
16. Khan IA, Vaccaro AR, Zlotolow DA. Management of vertebral diskitis and osteomyelitis. Orthopedics. 1999; 22:758–65.
17. Oliver J. Discitis. J Chem Inf Model. 2013; 53(9):1689–99.
18. Cottle L, Riordan T. Infectious spondylodiscitis. J Infect. 2008; 56:401–12.
19. Herren C, Jung N, Pishnamaz M, Breuninger M, Siewe J, Sobottke R. Spondylodiscitis: diagnosis and treatment options — a systematic review. Dtsch Arztebl Int. 2017; 114(51–52):875–82.
20. Guerado E, Cerván AM. Surgical treatment of spondylodiscitis. An update. Int Orthop. 2012; 36(2):413–20.
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2020
| How to Cite this Article: Karthek V, Hadgaonkar S, Kothari A, Aiyer S, Bhilare P, Sonawane D, Shyam A, Sancheti P. Spondylodiscitis: Prospective Analysis of Clinical Presentations and Surgical Outcomes. Journal of Medical Thesis. January-June 2023; 9(1):17-20. |
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Prospective Evaluation of Femoral Head Containment Following Shelf Acetabuloplasty in Late-Stage Legg–Calvé–Perthes Disease
Vol 9 | Issue 1 | January-June 2023 | page: 13-16 | Udit Vinayak, Sandeep Patwardhan, Vivek Sodhai, Rahul Jaiswal, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2023.v09.i01.198
Author: Peeyush Belsare [1], Rajeev Joshi [1], Sahil Sanghavi [1], Mahavir Dugad [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Udit Vinayak,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
E-mail: uditvinayak@gmail.com
Abstract
Background: Legg–Calvé–Perthes disease leads to femoral head deformity from ischemic osteonecrosis; containment within the acetabulum preserves sphericity. This study reports early results of lateral shelf acetabuloplasty using a slotted corticocancellous autograft.
Methods: We prospectively enrolled consecutive children with unilateral Perthes disease suitable for shelf augmentation between August 2018 and December 2020. Inclusion required reducible extrusion and a mobile hip. A single surgeon performed slotted lateral shelf grafting, harvesting corticocancellous strips from the iliac crest and seating them into an acetabular slot. Patients followed a protected weight-bearing protocol and were reviewed at set intervals with AP pelvis and frog-lateral radiographs. Outcomes included radiographic indices (centre–edge angle, acetabular depth, acetabular–head quotient, subluxation measures) and clinical scores (CHOHES, WOMAC, modified Sundt).
Results: Thirty-five hips were treated. By three months most grafts had incorporated and radiographs demonstrated increased acetabular depth and centre–edge angle with reduced lateral subluxation. Acetabular–head coverage indices improved and clinical scores showed meaningful gains overall. No major intraoperative complications or early conversions to salvage procedures occurred.
Conclusion: In selected children with reducible extrusion, lateral shelf acetabuloplasty produced reliable graft incorporation, improved radiographic containment and early clinical improvement while avoiding femoral shortening.
Keywords: Perthes disease, Shelf acetabuloplasty, Containment, Femoral head, Graft incorporation.
Introduction
Legg–Calvé–Perthes disease is a childhood condition that begins with a loss of blood supply to the femoral head, followed by collapse and gradual healing by repair and remodelling. The disease is most commonly seen in boys and typically presents in early school years, though older children may be affected and often do worse. The vulnerable phase after the initial insult is when the femoral head is soft and prone to flattening under normal loads and muscle forces. Because loss of spherical shape is the key problem that leads to long-term hip dysfunction, treatment focuses on protecting the femoral head while it remodels and on preserving motion and comfort.
The central therapeutic idea is containment: keeping the femoral head well seated under the acetabular roof so it remodels into a rounder shape. A variety of containment strategies exist — from conservative measures and braces, to corrective osteotomies of the femur or pelvis. The lateral shelf acetabuloplasty is a pelvic procedure that augments the acetabular roof by placing a corticocancellous graft along the lateral rim. This graft acts as an extended roof that improves coverage of an extruded or enlarged femoral head without shortening the femur or altering proximal femoral geometry.
Because the shelf does not require femoral shortening and is technically less demanding than some pelvic osteotomies, it is useful particularly in older children with reducible extrusion or when femoral procedures alone may fail to achieve adequate containment. The technique aims to increase the weight-bearing surface and resist lateral displacement while permitting natural remodelling. In this series we describe indications, a consistent slotted-graft technique, and early radiographic and clinical outcomes following lateral shelf augmentation. [1-6]
Review of Literature
Early authors described the natural history of Perthes disease and drew attention to how variable the outcome can be depending on the amount of epiphyseal involvement and patient age. Classification systems such as Catterall, Herring (lateral pillar) and others helped clinicians predict prognosis by quantifying how much of the femoral head is involved and the expected remodelling. These systems made clear that preserving the lateral epiphysis from extrusion early in the disease improves the chance of a round head later.
Containment as a guiding principle grew from these observations. If the femoral head can be maintained beneath an adequate acetabular roof during the repair phase, deforming forces are less likely to produce permanent flattening. Historically, containment was achieved with bracing or with osteotomies on the femur or pelvis; each approach has pros and cons. femoral varus osteotomy can improve coverage but alters limb alignment and may shorten the limb, while pelvic osteotomies can reorient the acetabulum but are more invasive.
Shelf arthroplasty evolved out of practice treating residual dysplasia and was adapted for Perthes. The technique places corticocancellous bone along the lateral acetabular rim to extend the roof, improving lateral coverage without changing femoral length or alignment. Midterm reports and series have documented increases in centre–edge angle and measures of lateral coverage after shelf procedures, and many series show acceptable clinical and radiographic results when the operation is timed before advanced collapse. Patient selection — particularly assessing reducibility and remaining growth potential — is repeatedly emphasized in the literature as a determinant of success. Standardized surgical technique and follow-up protocols are recommended to reduce variability between series and to allow meaningful comparison of outcomes. [7 -13]
Materials and Methods
This study is a prospective single-centre cohort of consecutive children treated with lateral shelf acetabuloplasty between August 2018 and December 2020. Inclusion criteria were age appropriate for the procedure, unilateral disease, a mobile hip with reducible extrusion on assessment, and modified Elizabethtown stage IIa or greater. Patients with prior pelvic or femoral realignment, bilateral disease, or grossly irreducible collapse were excluded. The institutional review board approved the study and informed consent was obtained from guardians.
All operations were performed by one senior surgeon using a slotted corticocancellous autograft technique. Through a limited lateral approach, corticocancellous strips were harvested from the outer table of the iliac crest. A slot was prepared along the lateral acetabular margin and the graft was seated into this slot; the periosteum and soft tissues were closed snugly over the graft to secure it. No routine spica or rigid postoperative immobilization was used. Patients were mobilized with protected weight bearing using crutches; partial weight bearing began at around six weeks and full weight bearing was allowed after radiographic evidence of graft incorporation, typically by three months.
Radiographic follow-up included AP pelvis and frog-lateral views at set intervals: immediate postoperative, six weeks, three months, six months and one year. Outcome measures combined objective radiographic indices — acetabular depth, centre–edge angle, acetabular–head quotient and lateral subluxation measures — with clinical assessments using CHOHES, WOMAC and modified Sundt criteria to capture pain, function and motion. Data collection was done by a dedicated trainee under consultant oversight. Statistical analysis used repeated measures techniques for continuous measures and chi-square for categorical outcomes, with significance at p<0.05.
Results
Thirty-five patients met inclusion criteria and completed early follow-up. The group included twenty-eight boys and seven girls. Mean age at disease onset and at surgery reflected the older childhood group in which shelf procedures are commonly considered. Most hips were Herring lateral pillar types B or C and presented in mid-stage disease. Radiographically, centre–edge angle and acetabular depth increased after the shelf procedure, with measurable change by three months and maintenance at one year. Lateral coverage indices improved and lateral subluxation diminished, indicating better containment of the femoral head. Graft incorporation into the iliac margin was seen on follow-up radiographs by approximately three months in most patients. Clinically, there were improvements in CHOHES and WOMAC scores and the majority of hips achieved good or fair results by modified Sundt criteria. There were no major intraoperative complications and no conversions to salvage surgery during the follow-up period.
Discussion
The results here mirror other series that show the lateral shelf can reliably increase acetabular coverage and help contain a vulnerable femoral head during remodelling. Mechanically, the grafted shelf lengthens the lateral roof and redistributes load across a broader surface, resisting lateral extrusion and allowing the femoral head to remould under more favourable conditions. Because this approach augments acetabular support without shortening or changing the geometry of the femur, it avoids some gait and limb-length consequences seen after varus femoral osteotomy.
Patient selection is critical. The shelf is most helpful when extrusion is reducible and when there is still potential for remodelling; it is less useful in hips with severe collapse and irreversible loss of sphericity. Dynamic assessment of reducibility and careful preoperative imaging inform this choice. Technique also affects outcome: creating an accurate acetabular slot, harvesting appropriately sized corticocancellous strips, and snug soft tissue closure all aid graft stability and incorporation. Our use of a standardized slotted autograft method aimed to reduce variability and promote consistent radiographic incorporation.
Comparative data remain limited, but the shelf offers an attractive compromise in selected older children — offering structural support with lower technical morbidity than complex pelvic osteotomies and without femoral shortening. Early clinical score improvements seen in this cohort align with the observed radiographic gains, supporting the link between better containment and improved function. The single-surgeon, single-centre design helped maintain consistency in technique and follow-up but limits generalizability. Longer follow-up to skeletal maturity will be necessary to confirm whether these early gains translate into better long-term joint shape and reduced degenerative change. [14-20]
Conclusion
In this series lateral shelf acetabuloplasty gave consistent early improvements in acetabular coverage and clinical scores in selected children with Perthes disease. When applied to hips with reducible extrusion and reasonable remodelling potential, a slotted corticocancellous autograft shelf provides predictable graft incorporation and improved containment while avoiding femoral shortening. These early outcomes support the shelf as a valuable option for older children or those in whom femoral procedures may be insufficient. Continued follow-up to skeletal maturity is required to determine the procedure’s influence on final hip shape and long-term function.
References
1. Koob TJ, Pringle D, Gedbaw E, Meredith J, Berrios R, Kim HKW. Biomechanical properties of bone and cartilage in growing femoral head following ischemic osteonecrosis. J Orthop Res. 2007; 25(6):750-757. doi:10.1002/jor.20350
2. Catterall A. Legg-Calve-Perthes syndrome. Clin Orthop Relat Res. 1981; NO.158 (158):41-52.
3. Atsumi T, Yamano K, Muraki M, Yoshihara S, Kajihara T. The blood supply of the lateral epiphyseal arteries in Perthes’ disease. J Bone Jt Surg - Ser B. 2000; 82(3):392-398. doi:10.1302/0301-620X.82B3.10193
4. Joseph B, Varghese G, Mulpuri K, Rao KLN, Sreekumaran Nair N. Natural evolution of Perthes disease: A study of 610 children under 12 years of age at disease onset. J Pediatr Orthop. 2003; 23(5):590-600. doi:10.1097/01241398-200309000-00005
5. Legg AT. An obscure affection of the hip joint. 1910. Clin Orthop Relat Res. 2006; 451:11-13. doi:10.1097/01.BLO.0000238798.05338.13
6. Calvé J. On a particular form of pseudo-coxalgia associated with a characteristic deformity of the upper end of the femur. 1910. Clin Orthop Relat Res. 2006; 451:14-16. doi:10.1097/01.blo.0000238799.05338.5a
7. Perthes GC. Concerning arthritis deformans juvenilis. 1910. Clin Orthop Relat Res. 2006; 451:17-20. doi:10.1097/01.blo.0000238800.12962.b2
8. Guille JT, Lipton GE, Szöke G, Bowen JR, Harcke HT, Glutting JJ. Legg-Calve-Perthes disease in girls. A comparison of the results with those seen in boys. J Bone Jt Surg - Ser A. 1998; 80(9):1256-1263. doi:10.2106/00004623-199809000-00002
9. Kim HKW. Legg-Calve-Perthes disease: Etiology, pathogenesis, and biology. In: Journal of Pediatric Orthopaedics. Vol 31. J Pediatr Orthop; 2011. doi:10.1097/BPO.0b013e318223b4bd
10. Moens P, Defoort K, Vancampenhout A, Peerlinck K, Fabry G. Thrombophilia and Legg-Calvé-Perthes disease: Is it a causative factor and does it affect the severity of the disease? Acta Orthop Belg. 2007; 73(5):612-617.
11. Vosmaer A, Rodrigues Pereira R, Koenderman JS, Rosendaal FR, Cannegieter SC. Coagulation abnormalities in Legg-Calvé-Perthes disease. J Bone Jt Surg - Ser A. 2010; 92(1):121-128. doi:10.2106/JBJS.I.00157
12. Bahmanyar S, Montgomery SM, Weiss RJ, Ekbom A. Maternal smoking during pregnancy, other prenatal and perinatal factors, and the risk of Legg-Calvé-Perthes disease. Pediatrics. 2008; 122(2). doi:10.1542/peds.2008-0307
13. Wynne-Davies R, Gormley J. The aetiology of Perthes’ disease: genetic, epidemiological and growth factors in 310 Edinburgh and Glasgow patients. J Bone Jt Surg - Ser B. 1978; 60 B (1):6-14. doi:10.1302/0301-620x.60b1.564352
14. Faraj AA, Nevelos AB. Ethnic factors in Perthes disease: A retrospective study among white and Asian population living in the same environment. Acta Orthop Belg. 2000; 66(3):255-258.
15. Norlin R, Hammerby S, Tkaczuk H. The natural history of Perthes’ disease. Int Orthop. 1991; 15(1):13-16. doi:10.1007/BF00210525
16. Kamegaya M. Nonsurgical treatment of Legg-Calvé-Perthes disease. In: Journal of Pediatric Orthopaedics. Vol 31. J Pediatr Orthop; 2011. doi:10.1097/BPO.0b013e318223b4a6
17. Thompson GH. Salter osteotomy in Legg-Calvé-Perthes disease. In: Journal of Pediatric Orthopaedics. Vol 31. J Pediatr Orthop; 2011. doi:10.1097/BPO.0b013e318223b59d
18. Copeliovitch L. Femoral varus osteotomy in Legg-Calvé-Perthes disease. In: Journal of Pediatric Orthopaedics. Vol 31. J Pediatr Orthop; 2011. doi:10.1097/BPO.0b013e318223b55c
19. Sergio KS, Alvin CH. Comparison between Salter’s Innominate Osteotomy and Augmented Acetabuloplasty in the treatment of Patients with Severe Legg-Calvé-Perthes disease. J Paediatr Orthop. 2002; 11(1).
20. Kruse RW, Guille JT, Bowen JR. Shelf arthroplasty in patients who have Legg-Calvé-Perthes disease. J Bone Jt Surg - Ser A. 1991; 73(9):1338-1347. doi:10.2106/00004623-199173090-00008
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2021
| How to Cite this Article: Vinayak U, Patwardhan S, Sodhai V, Jaiswal R, Sonawane D, Shyam A, Sancheti P. Prospective Evaluation of Femoral Head Containment Following Shelf Acetabuloplasty in Late-Stage Legg–Calvé–Perthes Disease. Journal of Medical Thesis. January-June 2023; 9(1):13-16. |
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Determinants of Health-Related Quality of Life Post Primary Total Joint Arthroplasty
Vol 9 | Issue 1 | January-June 2023 | page: 9-12 | Peeyush Belsare, Rajeev Joshi, Sahil Sanghavi, Mahavir Dugad, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2023.v09.i01.196
Author: Peeyush Belsare [1], Rajeev Joshi [1], Sahil Sanghavi [1], Mahavir Dugad [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Peeyush Belsare,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
E-mail: peeyushbelsare.03@gmail.com
Abstract
Background: Osteoarthritis and related degenerative joint conditions are major causes of pain and disability. In India, local data on patient-centred outcomes after primary total hip and knee arthroplasty are limited. The aim of this prospective study was to describe change in pain, function and health-related quality of life during the first postoperative year after primary total hip (THR) or total knee replacement (TKR).
Methods: Consecutive adults undergoing elective primary THR or TKR were evaluated with validated instruments preoperatively and at 3, 6 and 12 months. Disease-specific tools and a generic health measure captured pain, stiffness, function and broader quality-of-life domains. Demographic and clinical variables including age, body mass index and range of motion were recorded.
Results: Two hundred and sixty-eight patients (118 THR, 150 TKR) with complete one-year follow-up were analysed. Both groups showed rapid pain reduction by three months and continued functional gains to twelve months. The THR group had a marked rise in hip scores by one year. Higher age and BMI were associated with smaller functional gains; greater preoperative range of motion predicted better outcomes.
Conclusion: Primary joint arthroplasty produced meaningful improvements in pain, function and quality of life within the first year. These results offer realistic benchmarks for counselling and perioperative optimisation in similar settings.
Keywords: Total hip arthroplasty, Total knee arthroplasty, Health-related quality of life, Osteoarthritis, Patient-reported outcome measures, Prospective cohort
Introduction
Worldwide population ageing has increased the burden of chronic degenerative joint disease, notably osteoarthritis of weight-bearing joints; in India the true prevalence is under-reported [1]. Pain from hip and knee osteoarthritis is the dominant symptom that drives disability, frequently accompanied by progressive loss of range of motion and difficulty performing daily tasks such as stair climbing and walking [2]. Activity avoidance and reduced muscle strength magnify disability and lower quality of life, limiting independence for many patients [3]. Avascular necrosis of the femoral head adds to the burden of hip pain and disability; in India it is increasingly recognised among younger adults and has been linked with steroid exposure and alcohol use [4,5]. Total hip and knee replacement are established operations to relieve pain, restore joint function and improve health-related quality of life for appropriately selected patients [6]. Historically success after arthroplasty was judged by implant survival and complication rates, but contemporary practice emphasises patient-reported outcomes to capture the personal and social benefits of surgery [7]. Validated instruments — disease-specific tools such as WOMAC and Oxford scores, joint measures like the Harris Hip Score, and generic surveys such as the SF-36 — together provide a rounded assessment of surgical benefit and recovery trajectory. The timing of intervention, individual expectations and local activity demands (for example squatting or cross-legged sitting) influence perceived recovery and satisfaction. This study uses repeated, validated measures to describe the course of improvement in pain, function and quality of life after primary THR and TKR and to explore which demographic and clinical variables predict greater or lesser benefit in our local practice [1–7]. The goal is to provide culturally relevant benchmarks that support patient counselling and perioperative planning.
Aims and Objectives
The primary aim was to measure change in health-related quality of life following primary total hip or knee arthroplasty in an Indian tertiary-care population. Secondary objectives were to document pain relief and functional improvement at 3, 6 and 12 months, compare recovery patterns between THR and TKR groups, and examine associations between outcomes and patient factors (age, sex, body mass index, range of motion, baseline function). Validated instruments (WOMAC, Oxford hip/knee, Harris Hip Score, SF-36 and VAS) captured joint-specific and general health domains. Through repeated assessments, the study sought to provide practical, locally relevant evidence to help clinicians set expectations, guide perioperative optimisation and plan rehabilitation tailored to patient needs.
Review of Literature
Quality-of-life outcomes after total joint arthroplasty have been extensively studied and most series report substantial improvement in pain and function, especially during the first postoperative year [8]. Systematic reviews and prospective cohorts describe early reductions in pain within weeks to months and progressive functional gains thereafter [9]. Outcome instruments capture complementary aspects of recovery: WOMAC addresses pain, stiffness and function; Oxford hip and knee scores offer concise patient-focused assessment; the Harris Hip Score evaluates hip pain and function; and SF-36 provides a broader view of physical and mental health domains [10,11]. Comparative and methodological reviews emphasise combining disease-specific and generic measures to characterise recovery comprehensively [12,13]. Preoperative functional status is consistently identified as a major predictor: patients with poorer baseline scores often have larger absolute improvements but may still have lower absolute function compared with those who started in better health [14,15]. Age and comorbidity affect outcomes and support using physiological reserve rather than chronological age alone when advising patients [14]. Prior reports note that study design, timing of measurements and choice of instruments influence conclusions; longitudinal studies with multiple follow-up points better delineate early versus late gains [12,13]. Obesity is frequently cited as a potentially modifiable factor associated with less favourable recovery after knee arthroplasty and is an important target for optimisation [15]. Cultural expectations and activity demands shape perceived success and satisfaction, arguing for regionally relevant outcome data when counselling patients [13]. Overall, the literature supports prospective, repeated-measure studies using validated instruments to produce practical guidance for clinicians, patients and families considering arthroplasty [8–15].
Materials and Methods
This prospective observational study was conducted at a tertiary joint replacement centre. Consecutive adults scheduled for elective primary total hip or total knee arthroplasty between August 2018 and December 2019 were enrolled after written informed consent and institutional ethics approval. Inclusion criteria were elective primary THR or TKR for degenerative or related indications. Exclusion criteria comprised active infection, metastatic disease, neurological conditions limiting valid questionnaire completion and revision procedures. Baseline evaluation recorded demographics, diagnosis, radiographic severity and joint range of motion; height and weight were measured to calculate body mass index.
Standardised validated outcome measures were administered preoperatively and at 3, 6 and 12 months: the WOMAC index, Oxford hip or knee scores, Harris Hip Score for hip patients, SF-36 for generic health-related quality of life and a visual analogue scale for pain. Questionnaires were explained in the local language when necessary and assistance provided for completion. Perioperative care followed institutional protocols including antibiotic prophylaxis, thromboprophylaxis as indicated, standard wound management and early mobilisation; procedure-specific rehabilitation emphasised progressive range of motion and strengthening. Data were recorded on a predesigned proforma and entered into a master chart for analysis.
Statistical analysis summarised mean scores and standard deviations at each time point. Within-group changes were tested using paired t-tests or Wilcoxon signed-rank tests according to distribution. Associations between postoperative outcomes and variables (age, BMI, gender, range of motion) were examined using Pearson or Spearman correlation as appropriate; significance was set at p<0.05. Missing interval data were handled by casewise deletion with sensitivity checks. The repeat-measure design and assessment timing were chosen to capture early and later phases of recovery described in prior longitudinal joint replacement studies, and interpretation accounted for patient satisfaction dynamics reported in related work [16–18]. Safety monitoring was performed throughout.
Results
The results include 268 patients in total: 118 underwent total hip replacement (THR) and 150 underwent total knee replacement (TKR). The mean age was approximately 49.6 years in the THR group and 64.0 years in the TKR group. In the THR group the mean Harris Hip Score rose from 33.08 ± 13.65 preoperatively to 82.51 ± 6.99 at one year (p < 0.001). Disease-specific and generic quality-of-life instruments (WOMAC, Oxford scores and SF-36) showed statistically significant improvement across the 3-, 6- and 12-month assessments (multiple domains p < 0.05), with the largest gains typically present by three months and incremental improvement thereafter. Pain measured on the visual analogue scale declined markedly across intervals. Correlation analyses revealed that increasing age and higher body-mass index were associated with smaller functional gains (negative correlations, p < 0.01), whereas greater preoperative range of motion correlated positively with better postoperative scores. Gender did not show a consistent relationship with outcome. Overall, the majority of patients in both cohorts achieved clinically meaningful improvement in pain relief and daily function by one year, and complications were infrequent and did not materially alter these group-level results.
Discussion
This study documents clear and sustained improvement in pain, function and health-related quality of life during the first postoperative year after primary total hip and knee arthroplasty. Pain relief was commonly evident by three months while functional recovery and gains in broader quality-of-life domains continued over subsequent months, consistent with earlier longitudinal reports [12,13]. Preoperative functional status remained a strong determinant of postoperative outcome: patients with poorer baseline scores achieved larger absolute improvements but often did not reach the same absolute function as those who started at a higher level [14,15]. In our cohort, increasing age and higher body mass index were associated with smaller functional gains on several measures; this aligns with analyses that relate patient factors to changes in satisfaction and perceived benefit after arthroplasty [19]. Using both disease-specific and generic instruments allowed a fuller view of recovery: physical domains and pain improved markedly, while mental and social domains improved more slowly, underscoring that physical restoration does not always produce instant psychosocial recovery [12,11]. Cultural expectations and common activities in this setting—such as squatting and cross-legged sitting—affect perceived success and should inform rehabilitation goals and counselling. Studies from Asian populations report similar correlations between functional outcomes and quality-of-life domains, supporting the need for region-specific benchmarks [20]. Strengths of this work include a prospective design, validated repeated measures and a sizeable cohort with complete one-year follow-upEmphasis on preoperative education, shared decision-making and multidisciplinary care may enhance recovery [8,9,10]. Such measures improve outcomes.
Conclusion
In this prospective cohort from a tertiary referral centre, primary total hip and knee arthroplasty produced marked improvements in pain, joint-specific function and overall health-related quality of life within the first postoperative year. Most patients experienced meaningful pain relief by three months with continued functional gains to twelve months. Higher age and greater body mass index were associated with smaller improvements, while better preoperative range of motion predicted superior postoperative function.. The repeated use of validated joint-specific and generic outcome measures provided a clear depiction of recovery trajectories and offers a practical benchmark for clinicians counselling patients in similar settings. Local adaptation of care pathways, attention to modifiable risks such as weight, and clear preoperative education can further improve outcomes and patient satisfaction, and long-term follow-up is recommended.
References
1. Pal CP, Singh P, Chaturvedi S, Pruthi KK, Vij A. Epidemiology of knee osteoarthritis in India and related factors. Indian J Orthop. 2016 Sep;50(5):518–22.
2. Neogi T. The Epidemiology and Impact of Pain in Osteoarthritis. Osteoarthritis Cartilage. 2013 Sep;21(9).
3. Pisters MF, Veenhof C, van Dijk GM, Dekker J, CARPA Study Group. Avoidance of activity and limitations in activities in patients with osteoarthritis of the hip or knee: a 5 year follow-up study on the mediating role of reduced muscle strength. Osteoarthritis Cartilage. 2014 Feb;22(2):171–7.
4. Vardhan H, Tripathy SK, Sen RK, Aggarwal S, Goyal T. Epidemiological Profile of Femoral Head Osteonecrosis in the North Indian Population. Indian J Orthop. 2018 Mar;52(2):140–6.
5. Osteo-necrosis of femoral head in North Indian population: Risk factors and clinico-radiological correlation. Clin Epidemiol Glob Health. 2019 Sep;7(3):446–9.
6. Shihora U, Modi B. Clinical and functional outcome of total knee replacement in patients with osteoarthritis: a prospective study. Int J Res Orthop. 2017 Oct 25;3(6):1148–51.
7. Patel NG, Waterson HB, Phillips JRA, Toms AD. 50 years of total knee arthroplasty. Bone & Joint 360. 2019;8:3–7.
8. Feng JE, Novikov D, Anoushiravani AA, Schwarzkopf R. Total knee arthroplasty: improving outcomes with a multidisciplinary approach. J Multidiscip Healthc. 2018 Jan 25;11:63–73.
9. Slover J, Alvarado C, Nelson C. Shared Decision Making in Total Joint Replacement. JBJS Rev. 2014 Mar 4;2(3).
10. Barlow T, Griffin D, Barlow D, Realpe A. Patients’ Decision Making in Total Knee Arthroplasty: A Systematic Review of Qualitative Research. Bone Joint Res. 2015 Oct;4(10).
11. Edusei E, Anoushiravani AA, Slover J. Modern clinical decision-making in total joint arthroplasty. Ann Joint. 2017 Jun 9;2:29–29.
12. Shan L, Shan B, Suzuki A, Nouh F, Saxena A. Intermediate and Long-Term Quality of Life After Total Knee Replacement. J Bone Joint Surg. 2015;97:156–68.
13. Bruyère O, Ethgen O, Neuprez A, Zégels B, Gillet P, Huskin J-P, et al. Health-related quality of life after total knee or hip replacement for osteoarthritis: a 7-year prospective study. Arch Orthop Trauma Surg. 2012 Nov;132(11):1583–7.
14. Dowsey MM, Choong PFM. The Utility of Outcome Measures in Total Knee Replacement Surgery. Int J Rheumatol. 2013 Oct 31;2013.
15. Fortin PR, Clarke AE, Joseph L, Liang MH, Tanzer M, Ferland D, et al. Outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery. Arthritis Rheum. 1999 Aug;42(8):1722–8.
16. Nilsdotter A-K. Age and waiting time as predictors of outcome after total hip replacement for osteoarthritis. Rheumatology. 2002;41:1261–7.
17. Neuprez A, Neuprez AH, Kaux J-F, Kurth W, Daniel C, Thirion T, et al. Early Clinically Relevant Improvement in Quality of Life and Clinical Outcomes 1 Year Postsurgery in Patients with Knee and Hip Joint Arthroplasties. Cartilage. 2018 Apr;9(2):127–39.
18. Galea VP, Rojanasopondist P, Connelly JW, Bragdon CR, Huddleston JI 3rd, Ingelsrud LH, et al. Changes in Patient Satisfaction Following Total Joint Arthroplasty. J Arthroplasty. 2020 Jan;35(1):32–8.
19. Tan DW, Teh DJW, Hamid Rahmatullah Bin, Tan AHC. Improvement in Health-Related Quality of Life after Unilateral Total Knee Arthroplasty in Patients with Bilateral Knee Osteoarthritis. J Orthop Surg. 2016;24:294–7.
20. Thiam WD, Teh J-WD, Hamid Rahmatullah Bin, Tan H-CA. Correlations Between Functional Knee Outcomes and Health-Related Quality of Life After Total Knee Arthroplasty in an Asian Population.
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2021
| How to Cite this Article: Belsare P, Joshi R, Sanghavi S, Dugad M, Sonawane D, Shyam A, Sancheti P. Determinants of Health-Related Quality of Life Post Primary Total Joint Arthroplasty. Journal of Medical Thesis. January-June 2023; 9(1):9-12. |
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Epidemiology and Demographics of Spinal Tumors: Insights from a Tertiary Spine Care Center in India
Vol 9 | Issue 1 | January-June 2023 | page: 5-8 | Rakesh Gosavi, Shailesh Hadgaonkar, Ajay Kothari, Siddharth Aiyer, Pramod Bhilare, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2023.v09.i01.194
Author: Rakesh Gosavi [1], Shailesh Hadgaonkar [1], Ajay Kothari [1], Siddharth Aiyer [1], Pramod Bhilare [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Rakesh Gosavi,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
E-mail: rakesh.mbbsrocks@gmail.com
Abstract
Background: Spinal tumours — primary and metastatic — present with a range of symptoms and require tailored diagnostic and therapeutic strategies. This retrospective study describes the demographic profile, presenting features, anatomical level distribution and histological diagnoses of consecutive patients with spinal and vertebral tumours treated at a tertiary spine centre.
Methods: Hospital records of consecutive patients seen between January 2011 and December 2015 were reviewed for age, sex, presenting complaints, neurologic status, tumour level and compartment, imaging findings and histology where obtained. Contrast-enhanced MRI was the principal imaging modality used to define tumour extent.
Results: One hundred and one patients met inclusion criteria; primary tumours comprised the majority while metastatic disease formed a substantial subgroup. Extradural lesions were the most common compartment and the lumbar spine was the most frequently involved level. Pain was the near-universal presenting symptom and neurological deficit was seen in a substantial number. Multiple myeloma and nerve-sheath tumours were prominent among primaries, while lung and breast were common primaries for metastases.
Conclusion: Metastatic disease constitutes a large component of spinal tumours in tertiary referral practice. Early MRI-based assessment and histological confirmation where indicated support timely, pathology-directed management and multidisciplinary care.
Keywords: Spinal tumour, Metastasis, Myeloma, Schwannoma, MRI
Introduction
Spinal neoplasms may arise within the vertebrae, the epidural space, the intradural compartment or the spinal cord itself. They are broadly classified as primary or metastatic and by dural relation as extradural, intradural-extra medullary or intramedullary; these distinctions carry practical implications for presentation and management. Pain is the most common initial complaint, with radicular pain and axial mechanical pain frequently prompting imaging and clinic review. Progressive motor weakness, sensory disturbance and sphincter dysfunction occur when neural elements become compromised. Contrast-enhanced magnetic resonance imaging is the cornerstone of diagnostic work-up, supplemented selectively by CT or bone scintigraphy to characterise bony involvement and to stage systemic disease when needed. Histological diagnosis, obtained by biopsy or resection, remains essential to distinguish haematological malignancies, primary bone tumours and metastatic deposits and to guide oncological therapy. Institutional series from tertiary centres show that extradural lesions, most often metastatic, make up a major part of clinical caseloads and that benign intradural-extramedullary tumours such as schwannomas and meningiomas continue to be frequent surgical diagnoses. Understanding the local case mix — the relative proportions of primary versus metastatic disease, the common histologies encountered and the typical presenting features — helps tailor diagnostic pathways, plan operative services and coordinate multidisciplinary care. This study presents a consecutive series managed at our centre between January 2011 and December 2015, summarising demographic features, level distribution, presenting complaints and histological patterns to inform local clinical practice and resource allocation. [1–3]
Aims & Objectives
Aim: To describe demographic features, presenting symptoms, anatomical level and dural compartment distribution, and histological diagnoses of patients with spinal and vertebral tumours presenting to a tertiary spine centre between January 2011 and December 2015. Objectives: To inform diagnostic pathways and local service planning.
Review of Literature
Large institutional series and registry analyses provide complementary perspectives on spinal tumours. Institutional reports commonly show that extradural lesions — largely metastatic — are the single largest category encountered in clinical practice, while intradural-extramedullary tumours such as schwannomas and meningiomas account for many benign presentations. Intramedullary tumours are less common but pose significant management challenges because of their location within the cord substance. Haematological malignancies such as multiple myeloma and primary bony tumours are repeatedly reported among extradural primaries and are notable for causing vertebral collapse and pathological fracture. Several series document diagnostic delays, particularly for benign extramedullary lesions that may present with slowly progressive radicular symptoms, whereas more aggressive intramedullary lesions often prompt earlier investigation. Magnetic resonance imaging with contrast is universally recommended for lesion characterisation and to plan the surgical approach, while CT and bone scan are useful adjuncts for assessing cortical destruction and disease burden when necessary. Histological diagnosis by percutaneous biopsy or open sampling is the definitive method for differentiating among myeloma, primary bony tumours and metastatic disease and for guiding definitive oncological therapy. Management strategies range from observation for asymptomatic benign lesions to microsurgical resection for symptomatic or progressive lesions, radiotherapy for radiosensitive tumours, and systemic therapy for disseminated malignancy. Stabilisation with instrumentation is frequently required when vertebral body collapse threatens alignment or neural elements, and combined approaches may be necessary for tumours that extend through neural foramina. Outcomes depend on tumour pathology, preoperative neurological status and extent of resection or decompression; benign extramedullary tumours generally show better functional recovery than malignant or intramedullary processes. Multidisciplinary pathways that include spine surgeons, medical and radiation oncologists and rehabilitation teams are emphasised repeatedly in the literature to optimise functional outcomes and resource use. Institutional series enrich registry data by providing granular clinical detail such as symptom duration, neurological grade and decision-making rationale, which are crucial for tailoring local care pathways. [4–11]
Materials and Methods
This retrospective observational study included consecutive patients with spinal and vertebral tumours treated at the Department of Spine, Sancheti Institute for Orthopaedics and Rehabilitation, Pune, from January 2011 to December 2015. Inclusion criteria captured primary and metastatic tumours involving vertebral bodies, epidural, intradural and intramedullary compartments. Data were abstracted from outpatient records, inpatient charts, radiology reports, operative notes and pathology reports. Extracted variables included age, sex, presenting complaint, duration of symptoms, neurological examination findings, tumour level and compartment, imaging characteristics and histologic diagnosis when available. Contrast-enhanced MRI was the primary imaging modality for delineating lesion extent and relation to neural structures; CT and bone scan were employed selectively to assess bony destruction or to stage systemic disease. Indications for biopsy included radiological uncertainty, suspected haematological malignancy or need to plan adjuvant oncological therapy. Treatment decisions — observation, biopsy, and decompression with or without instrumentation, radiotherapy, or systemic therapy — were made by the treating team based on pathology, imaging and patient factors. Data were summarised descriptively with counts and proportions to characterise case mix, level distribution and histological patterns. Institutional retrospective audit approval and local ethical procedures were followed and patient confidentiality preserved during data handling. [12–14]
Results
Over the five-year period, 101 consecutive patients met inclusion criteria. Of these, 68 patients (67%) had primary spinal tumours and 33 patients (33%) presented with metastatic disease. Extradural lesions made up approximately 70 cases (≈69% of the cohort), while intradural-extramedullary tumours accounted for about 31 cases (≈31%). The lumbar spine was the most commonly involved region, with 40 of 101 patients (39.6%) affected; thoracic and thoracolumbar levels together represented roughly 35 patients (≈35%), and the remaining cervical and sacral cases numbered about 26 (≈25.4%). The series included 66 males and 35 females (male:female ≈1.89:1). Among primary histologies, multiple myeloma was frequent (26 cases) and schwannoma was the leading benign nerve-sheath tumour (17 cases). In metastatic presentations the lung was the most frequent primary site, followed by breast. Pain was the presenting complaint in 98 of 101 patients (≈97%), and 48 patients (≈47.5%) exhibited neurological deficit at presentation. Vertebral compression fractures or pathological collapse occurred in 38 patients (≈37.6%), most often associated with myeloma or metastatic deposits. Recorded management included biopsy, decompression with or without instrumentation, radiotherapy and systemic therapy, with specific choices driven by pathology and clinical status; follow-up documentation was variable across the cohort.
Discussion
The numeric profile of this series mirrors common patterns seen in tertiary referral practices: extradural lesions form the larger proportion of cases and metastatic deposits make up a substantial component of the workload. The preponderance of lumbar involvement likely reflects the combination of regional pain symptomatology prompting investigation and the anatomical load-bearing vulnerability of the lumbar vertebrae to destructive processes. Male predominance in this cohort may reflect local referral patterns and the demographic distribution of underlying primaries in the population served. The notable representation of multiple myeloma among primary diagnoses emphasises the need to include haematological malignancy in the differential of vertebral destructive lesions and to obtain timely serum and imaging-based evaluations. The high rate of vertebral compression fractures and structural compromise underlines the biomechanical consequences of neoplastic disease; these cases often necessitate surgical stabilisation to relieve pain and protect neurological function. Pain as the dominant presenting complaint highlights the need for clinicians to maintain a low threshold for advanced imaging when red flags or progressive deficits are present. Outcomes in spinal neoplasia hinge on pathology, preoperative neurological status and the extent of decompression or resection achieved; benign extramedullary tumours generally have more favourable functional recoveries than high-grade or intramedullary lesions. Limitations of this work include its retrospective design, possible referral bias inherent to a tertiary centre and variable follow-up documentation. Nevertheless, detailed institutional data contribute clinical nuance to registry-based incidence reports and inform local service planning. Future prospective collection of functional and quality-of-life outcomes will better delineate the impact of different interventions and guide resource allocation. [15–19]
Conclusion
Over the five-year period reviewed, metastatic tumours formed a substantial portion of spinal neoplasms managed at this tertiary centre; primary tumours including multiple myeloma and schwannoma were also frequently encountered. Extradural disease predominated and the lumbar spine was the most common anatomical level affected. Pain was the predominant presenting complaint and nearly half the patients had neurological deficits at the time of presentation, underlining the clinical burden of spinal tumours. Early MRI assessment and histological diagnosis where indicated are central to planning definitive therapy. A multidisciplinary approach spanning surgical, oncological and rehabilitation services is essential to address pain, protect or restore neurological function and manage spinal stability. Institutional series such as this help prioritise diagnostic pathways and resource allocation for improved patient care.
References
1. Hatrick NC, Lucas JD, Timothy AR, et al. The surgical treatment of metastatic disease of the spine. Radiother Oncol. 2000; 56:335–339.
2. Bailar JC III, Gornik HL. Cancer undefeated. N Engl J Med. 1997; 336:1569–1574.
3. Jacobs WB, Perrin RG. Evaluation and treatment of spinal metastases: an overview. Neurosurg Focus. 2001; 11: article 10.
4. Ibrahim AG, Crockard HA, Antonetti P, et al. Does spinal surgery improve the quality of life for those with extradural (spinal) osseous metastases? An international multi-centre prospective observational study of 223 patients. J Neurosurg Spine. 2005; 8:271–278.
5. Gerszten PC, Welch WC. Current surgical management of metastatic spinal disease. Oncology. 2000; 14(7):1013–1024.
6. Boriani S, Biagini R, De Iure FD, et al. Primary bone tumors of the spine: a survey of the evaluation and treatment at the Instituto Ortopedico Rizzoli. Orthopedics. 1995; 18(10):993–1000.
7. Jacobs W, Fehlings M. Primary vertebral column tumors. In: Dickman C, Fehlings M, Gokaslan Z, editors. Spinal Cord and Spinal Column Tumors: Principles and Practice. New York: Thieme; 2006:369–386.
8. Mechtler LL, Nandigam K. Spinal cord tumors: new views and future directions. Neurol Clin. 2013; 31(1):241–268.
9. Grimm S, Chamberlain MC. Adult primary spinal cord tumors. Expert Rev Neurother. 2009; 9(10):1487–1495.
10. Duong LM, McCarthy BJ, McLendon RE, et al. Descriptive epidemiology of malignant and nonmalignant primary spinal cord, spinal meninges, and cauda equina tumors, United States, 2004–2007. Cancer. 2012; 118(17):4220–4227.
11. Harrop JS, Ganju A, Groff M, Bilsky M. Primary intramedullary tumors of the spinal cord. Spine (Phila Pa 1976). 2009; 34:S69–S77.
12. Schoenberg BS, Christine BW, Whisnant JP. The descriptive epidemiology of primary intracranial neoplasms: The Connecticut experience. Am J Epidemiol. 1976; 104:499–510.
13. Claus EB, Abdel-Wahab M, Burger PC, Engelhard HH, Ellison DW, Gaiano N, et al. Defining future directions in spinal cord tumor research: Proceedings from the National Institutes of Health workshop. J Neurosurg Spine. 2010; 12:117–121.
14. Kurland LT, Schoenberg BS, Annegers JF, Okazaki H, Molgaard CA. The incidence of primary intracranial neoplasms in Rochester, Minnesota, 1935–1977. Ann N Y Acad Sci. 1982; 381:6–16.
15. Segal D, Lidar Z, Corn A, Constantini S. Delay in diagnosis of primary intradural spinal cord tumors. Surg Neurol Int. 2012; 3:52.
16. Hirano K, Imagama S, Sato K, Kato F, Yukawa Y, and Yoshihara H, et al. Primary spinal cord tumors: Review of 678 surgically treated patients in Japan. Eur Spine J. 2012; 21:2019–2026.
17. Wen-qing H, Shi-ju Z, Qing-sheng T, Jian-qing H, Yu-xia L, Qing-zhong X, et al. Statistical analysis of central nervous system tumors in China. J Neurosurg. 1982; 56:555–564.
18. Bansal S, Ailawadhi P, Suri A, Kale SS, Sarat Chandra P, Singh M, et al. Ten years’ experience in the management of spinal intramedullary tumors in a single institution. J Clin Neurosci. 2013; 20:292–298.
19. Chandy MJ, Babu S. Management of intramedullary spinal cord tumours: Review of 68 patients. Neurol India. 1999; 47:224–228.
| How to Cite this Article: Gosavi R, Hadgaonkar S, Kothari A, Aiyer S, Bhilare P, Sonawane D, Shyam A, Sancheti P. Epidemiology and Demographics of Spinal Tumors: Insights from a Tertiary Spine Care Center in India. Journal of Medical Thesis. January-June 2023; 9(1):5-8. |
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2017
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Comparative Outcomes of Simultaneous Versus Staged Decompression in Tandem Spinal Stenosis: A Retrospective–Prospective Analysis
Vol 9 | Issue 1 | January-June 2023 | page: 01-04 | Aparmeya Joshi, Shailesh Hadgaonkar, Ajay Kothari, Siddharth Aiyer, Pramod Bhilare, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2023.v09.i01.192
Author: Aparmeya Joshi [1], Shailesh Hadgaonkar [1], Ajay Kothari [1], Siddharth Aiyer [1], Pramod Bhilare [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Aparmeya Joshi
Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
E-mail: aprameyajsh@gmail.com
Abstract
Background: Tandem spinal stenosis — symptomatic narrowing at both the cervical and lumbar levels — often produces a confusing mix of arm and leg symptoms and walking difficulty. Deciding whether to operate on both regions in one sitting or in separate staged procedures is a common clinical dilemma, especially in older patients with other medical problems.
Methods: We reviewed 23 patients treated for clinically and radiologically confirmed tandem cervical and lumbar stenosis between August 2015 and August 2016. Pre- and postoperative assessment used standard tools (JOA for cervical and lumbar function, European myelopathy score and SF-36). Eighteen patients had simultaneous cervical and lumbar decompression; five had staged procedures. Perioperative data, complications and functional outcomes were recorded up to one year.
Results: Most patients showed clear, sustained improvement in neurological function and quality of life after surgery. There was no statistically significant difference in the main outcome measures between the staged and simultaneous groups in this series. Younger patients (≤60 years) tended to regain better function and higher SF-36 scores at one year. Serious complications were uncommon; when they occurred they were manageable with standard care.
Conclusion: Both simultaneous and staged decompression provided meaningful benefit when treatments were matched to the patient’s condition. The operative approach should be chosen individually, considering symptom dominance, overall fitness and surgical risk.
Keywords: Tandem spinal stenosis, Simultaneous decompression, Staged decompression, JOA score, SF-36, Whole-spine MRI.
Introduction
Tandem spinal stenosis (TSS) denotes the coexistence of spinal canal narrowing at two anatomically separate regions — most commonly the cervical and lumbar spine. Patients with TSS often present with a confusing mixture of lower-extremity symptoms (neurogenic claudication, pain and paresthesia) and upper-motor-neuron signs (hand numbness, weakness, and gait imbalance). This mixed clinical picture may obscure the site primarily responsible for functional impairment, delaying diagnosis and complicating surgical planning. Historically, early clinical series described the natural history and outcomes after decompression in combined cervical and lumbar disease and emphasized the need for careful selection of the dominant symptomatic level when planning surgery. [1–4]
Several radiological studies subsequently documented frequent radiographic overlap between cervical and lumbar stenotic disease and highlighted that radiological cervical cord compression may be asymptomatic in a substantial proportion of patients presenting with lumbar stenosis; routine whole-spine imaging was advocated in patients with discordant clinical findings.[3,5 ]Such observations led to evolving surgical strategies: some authors recommend simultaneous decompression of both regions in selected patients, whereas others favor staged procedures that target the symptom-dominant level first.[2,6] The choice depends on patient factors (age, comorbidity), the pattern and severity of stenosis on imaging, and the treating team’s experience. The remainder of this thesis summarizes clinical presentation, operative choices, outcomes and perioperative safety for patients managed for TSS at our centre.
Review of literature
Early reports described cases of combined cervical and lumbar stenosis and reported variable outcomes following surgical decompression. Dagi and colleagues documented the natural history and highlighted prognostic indices that influenced recovery after surgery.4 Kikuike et al. reported favorable mid-term outcomes after one-stage combined cervical and lumbar decompression in selected patients, noting careful patient selection and postoperative rehabilitation were important for patient satisfaction[.1] Eskander and co-workers compared simultaneous and staged decompressions and emphasized the need to weigh operative time and perioperative risks against the benefits of a single hospitalization.[2 ]Lee and coworkers provided anatomical and radiological insights into TSS that aid interpretation of whole-spine imaging.
Subsequent cohort and population studies refined prevalence estimates and demonstrated that radiographic tandem stenosis is common among older adults and frequently asymptomatic at one region despite significant imaging change at another.[5,7,8] The Wakayama population MRI study and similar series documented the prevalence and anatomical characteristics of TSS in a community cohort.[9] Systematic reviews and meta-analyses summarized available observational data and concluded that both staged and simultaneous decompressions can be effective; however, differences in complication rates, operative parameters and recovery patterns depend on whether the pathology involves cervical-lumbar or cervical-thoracic segments.[10,11]
More recent series examined outcomes after selective (target the dominant region) versus nonselective or combined approaches and noted that selective decompression of the symptom-dominant level often achieves comparable functional gains with potentially fewer early complications.[12–15] Studies addressing tandem ossification (OPLL/OLF) and other complex presentations described technical nuances, perioperative risks and the importance of intraoperative neurophysiological monitoring to minimize neurological deterioration.[13,14 ]Across the literature the message is consistent: detailed clinical evaluation and whole-spine imaging are essential to tailor the surgical plan for each patient
Methods and Materials
This retrospective analysis included patients with clinical features consistent with TSS and radiological confirmation on whole-spine magnetic resonance imaging or computed tomography. Inclusion required clear documentation of both cervical and lumbar canal compromise and correlation with presenting symptoms and neurological examination. Exclusion criteria included prior multiregional spine surgery that precluded assessment of native anatomy and cases with active infection or neoplasm. Demographic data, comorbid conditions, duration of symptoms, neurological status, and dominant clinical complaints were recorded.
Preoperative assessment included detailed neurological examination, gait and balance assessment, JOA (Japanese Orthopaedic Association) or equivalent functional scores as available, and standardized whole-spine MRI to measure canal dimensions and to grade cord compression. The choice of surgical strategy — simultaneous (one-stage) decompression of both regions versus staged procedures addressing the dominant lesion first — was individualized according to symptom predominance, radiological severity, patient fitness for prolonged anesthesia and surgeon judgement. Surgical procedures included posterior decompression (laminoplasty or laminectomy), anterior cervical decompression and fusion, and lumbar decompression with or without instrumented fusion when instability or deformity required fixation.
Perioperative data included operative time, blood loss, hospital stay, and complications such as transient neurological deterioration, dural tears, wound infection, or need for reoperation. Patients were followed at routine intervals with clinical and functional scoring at early (6 weeks), intermediate (6–12 months) and longer-term (≥ 24 months when available) time points. Outcomes were compared between groups (simultaneous vs staged; cervical-first vs lumbar-first) with descriptive statistics and where feasible simple comparative tests. Ethical approval and institutional clearances were obtained for retrospective analysis as per the attached thesis document.
Results
The study reviewed 23 patients with tandem spinal stenosis: 21 men and 2 women, aged between 35 and 77 years (mean 67.8 years). Eight patients were 60 or younger, while 15 were older than 60. Eighteen patients had both cervical and lumbar decompression in a single operation and five were treated with staged procedures. Follow-up extended up to twelve months.
Medical problems were common — hypertension affected ten patients and diabetes three — while single cases had prior stroke, ischemic heart disease, rheumatoid arthritis or hypothyroidism; twelve patients reported no major illnesses. Function and neurological status were tracked with JOA (cervical and lumbar), the European myelopathy score and SF-36 at baseline and at several postoperative time points.
Overall, patients improved after surgery. Measures of pain, function and general health rose steadily from the immediate postoperative period through the 6- and 12-month checks. Improvements in lumbar-related scores were more rapid, while cervical scores tended to climb more gradually. When comparing those who had simultaneous surgery with the staged group, no clear statistical difference appeared in the principal outcome measures within this sample. Younger patients (≤60 years) showed stronger gains in SF-36 domains and overall function at one year. Major Perioperative complications were uncommon, and no new permanent major neurological deficits were observed during follow-up.
Discussion
Tandem spinal stenosis often produces a complex clinical picture because two separate levels can contribute to a patient’s symptoms. In practice this means patients commonly present with mixed complaints — walking difficulty or leg pain from lumbar stenosis together with hand numbness, weakness or balance problems from cervical involvement — and teasing apart which level is driving disability can be difficult. That is why whole-spine imaging paired with a careful neurological exam is essential: it helps identify all relevant lesions and prevents treating only part of the problem.
In this series both single-stage and staged surgical strategies delivered meaningful clinical benefit when used for appropriately selected patients. Across the cohort pain, function and quality-of-life scores improved and these gains were generally maintained at one year. The absence of a marked difference between staged and simultaneous approaches in our data suggests that the surgical plan should be guided more by patient factors — physiological reserve, comorbidities and the clinically dominant lesion — than by a rigid preference for one technique. For fit patients with clear multi-level symptoms, a combined procedure can be efficient and spare a second operation; for older or medically complex individuals, staging the surgery reduces immediate physiological stress and remains a sensible option.
Age appeared to influence recovery: patients aged 60 or under tended to regain function and report better quality-of-life scores by one year, likely reflecting greater baseline fitness and fewer competing health problems. Our low observed complication rate is encouraging and likely reflects careful patient selection, thorough preoperative optimization and attentive postoperative care, but surgeons must remain vigilant for issues reported elsewhere, such as transient neurological change, CSF leak or wound complications, and manage them promptly when they occur.
Key limitations of this work include the small cohort size, the imbalance between groups (18 simultaneous vs 5 staged), variable follow-up duration and the mixed retrospective–prospective design. These factors limit statistical power and the ability to generalize the findings widely. Despite these constraints, the consistent trend toward clinical improvement supports the practice of tailoring the operation to the individual patient. Larger, prospective studies with balanced groups and longer follow-up are needed to define more precisely when one strategy is preferable to the other.
Conclusion
In this single-centre cohort, surgical decompression for tandem cervical and lumbar stenosis produced meaningful improvements in neurological function and quality of life. There was no clear superiority of staged versus simultaneous decompression in our sample; instead, outcomes correlated more strongly with patient factors such as age and comorbidity. Younger patients tended to regain better function at one year. Given the small, heterogeneous sample, surgical plans should be individualized: use single-stage combined decompression for physiologically fit patients with concordant symptoms, and prefer staged procedures for older or medically fragile patients who may not tolerate prolonged combined surgery. Thorough whole-spine evaluation and careful perioperative management are essential to achieve good outcomes while minimising risk.
References
1. Kikuike K, Miyamoto K, Hosoe H, Shimizu K. One-staged combined cervical and lumbar decompression for patients with tandem spinal stenosis on cervical and lumbar spine: analyses of clinical outcomes with minimum 3 years follow-up. J Spinal Disord Tech. 2009; 22(8):593–601.
2. Eskander MS, Aubin ME, Drew JM, Eskander JP, Balsis SM, Eck J, Lapinsky AS, Connolly PJ. Simultaneous versus staged decompression for combined cervical and lumbar spinal stenosis: clinical comparison. J Spinal Disord Tech. 2011; 24(6):409–413.
3. Lee MJ, Garcia R, Cassinelli EH, Furey C, Riew KD. Tandem stenosis: a cadaveric study in osseous morphology. Spine J. 2008; 8(6):1003–1006.
4. Dagi TF, Tarkington MA, Leech JJ. Tandem lumbar and cervical spinal stenosis: natural history, prognostic indices, and results after surgical decompression. J Neurosurg. 1987; 66(6):842–849.
5. Lee SH, Kim KT, Suk KS, Lee JH, Shin JH, So DH, Kwack YH. Asymptomatic cervical cord compression in lumbar spinal stenosis patients: a whole-spine magnetic resonance imaging study. Spine (Phila Pa 1976). 2010; 35(23):2057–2063.
6. Park JY, Chin DK, Kim KS, Cho YE. Thoracic ligament ossification in patients with cervical ossification of the posterior longitudinal ligaments: tandem ossification in the cervical and thoracic spine. Spine (Phila Pa 1976). 2008; 33(13):E407–E410.
7. Ahn N, et al. (abstract). Is congenital stenosis of the cervical spine associated with congenital lumbar stenosis? Spine J. 2011; 11:164S. (conference abstract as cited in thesis)
8. Krishnan A, Dave BR, Kambar AK, Ram H. Coexisting lumbar and cervical stenosis (tandem spinal stenosis): retrospective analysis of single-stage simultaneous surgery (53 cases). Eur Spine J. 2014; 23(1):64–73.
9. Nagata K, Yoshimura N, Hashizume H, et al. The prevalence of tandem spinal stenosis and its characteristics in a population-based MRI study: The Wakayama Spine Study. Eur Spine J. 2017; 26(10):2529–2535.
10. Overley SC, Kim JS, Gogel BA, Merrill RK, Hecht AC. Tandem spinal stenosis: a systematic review. JBJS Rev. 2017; 5(9):e2.
11. Farahbakhsh F, Khosravi S, Baigi V, et al. The prevalence of asymptomatic cervical spinal cord compression in individuals presenting with symptomatic lumbar spinal stenosis: a meta-analysis. Global Spine J. 2024; 14(3):1052–1060.
12. Molinari RW, Flanigan R, Yaseen Z. Tandem spinal stenosis (TSS): literature review and report of patients treated with simultaneous decompression. Curr Orthop Pract. 2012; 23(4):356–363.
13. Chen Y, Chen DY, Wang XW, Lu XH, Yang HS, Miao JH. Single-stage combined decompression for patients with tandem ossification in the cervical and thoracic spine. Arch Orthop Trauma Surg. 2012; 132(9):1219–1226.
14. Hu PP, Yu M, Liu XG, Liu ZJ, and Jiang L. Surgeries for patients with tandem spinal stenosis in cervical and thoracic spine: combined or staged surgeries? World Neurosurg. 2017; 107:115–123. doi:10.1016/j.wneu.2017.07.129.
| How to Cite this Article: Joshi A, Hadgaonkar S, Kothari A, Aiyer S, Bhilare P, Sonawane D, Shyam A, Sancheti P. Comparative Outcomes of Simultaneous Versus Staged Decompression in Tandem Spinal Stenosis: A Retrospective–Prospective Analysis. Journal of Medical Thesis. January-June 2023; 9(1):1-4. |
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2017
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