Revealing the therapeutic potential of teriparatide: a review

Teriparatide is an FDA-approved medication for osteoporosis that presents promising results in treating various musculoskeletal conditions. It helps in improving the bone mineral density and preventing fractures in individuals with osteoporosis. Its effectiveness in treating non-union and delayed union fractures, atypical femoral fractures, and spinal fusion procedures makes it valuable in improving bone healing and reducing complications. Teriparatide also improves bone density and strength in individuals with osteogenesis imperfecta, helps prevent and treat hypocalcaemia post-thyroidectomy, and helps in the management of hypoparathyroidism. In MRONJ, teriparatide improves lesion resolution and reduces bony defects. Furthermore, it potentially prevents bone metastasis in cancer patients without stimulating tumour growth. Nevertheless, teriparatide may cause short-term side effects like nausea and long-term concerns pertaining to the risk of osteosarcoma. Recent European alliance of associations for rheumatology guidelines have highlighted teriparatide's superior effectiveness in achieving bone mineral density thresholds and reducing fracture risks. Further clinical trials are necessary to determine optimal dosages and treatment durations of teriparatide. The off-label use of teriparatide should be considered only under the guidance of a healthcare professional when standard options are unavailable or inadequate

Ossification of yellow ligament-lesser known common cause of thoracic myelopathy in Indian subcontinent treated surgically

Background: To undertake a study which outlines the clinical and radiological features of ossification of yellow ligament (OYL) causing thoracic myelopathy (TM) in Indian subcontinent, to assess the outcomes of surgical resection of yellow ligament and compare different preoperative factors that contribute to be a risk factor in the overall post-surgical recovery rates (RR). Methods: A retrospective analysis of prospectively collected data from a cohort of 45 patients who visited our spine OPD from January 2012 to December 2019 who underwent surgical decompression for TM due to OYL was studied. The surgical outcomes and RR were calculated, compared and pre operative risk factors which could possibly be involved in giving poorer RR were analysed. Results: Our study included 45 patients who underwent surgical resection of OYL for TM. On comparison of post operative improvement in myelopathic symptoms, pre-operative mJOA score of 4.56 had increased significantly to 7.83 at 2 years follow up. While the majority (80%) of patients had an excellent and good recovery rate while 16% of patients had a fair recovery rate and 4% had no change at all in comparison to pre-operative mJOA scores. Preoperative risk factors for poor outcomes were also analysed. Conclusions: Early and timely before the onset or progression of any neurologic involvement. The pre operative risk factors which could give guarded prognosis and lower RR are, the presence of intramedullary signal changes (myelomalacia), >6-10 months of progressive pre operative symptoms and an mJOA<5

Tubular Discectomy Versus Conventional Microdiscectomy for the Treatment of Lumbar Disc Herniation: A Comparative Study

Objective The study aims to compare the outcomes of micro-lumbar discectomy (MLD) with tubular micro-endoscopic discectomy (MED). Methods A retrospective analysis of 414 patients who underwent single-level lumbar discectomy either by tubular MED or MLD between 2008-2016 was performed. Demographics, surgical duration, intraoperative blood loss, total hospital stay, visual analogue scale (VAS) pain score, Oswestry disability index (ODI) score before and after the surgery and complications were evaluated between the groups. Results Out of the 414 patients, 217 patients were treated with MLD and 197 by tubular MED. The mean age in MLD and tubular MED group was 44.7 and 42.4 years. There was a significant improvement in VAS and ODI scores at 2 weeks in both the groups, without any significant difference. Average surgical time was shorter and the average blood loss was higher in MLD as compared to the MED group. Average hospital stay in MED (1.03 days) was significantly less than MLD group (1.91 days). There were similar incidences of dural tear in both the groups, however, more patients had wound infection in the MLD group. Conclusion Lumbar discectomy either by tubular MED or MLD are very safe and effective means of treating disc herniation related sciatic pain. Patients who underwent minimally invasive tubular micro-endoscopic discectomy were found to have similar outcomes as those of who underwent micro-lumbar discectomy. However, given the learning curve associated with minimally invasive approaches to clinical practice, these modest clinical benefits probably do not warrant the transition from a standard microsurgical approach to a minimally invasive approach

Awake spinal fusion: a retrospective analysis of minimal invasive single level transforaminal lumbar interbody fusion done under spinal anaesthesia in 150 cases

Background: Spinal anaesthesia carries the advantage of having rapid onset, lesser blood loss, early recovery and hospital stay as compared to general anaesthesia. The present study evaluated outcomes of awake spinal fusion i.e., minimal invasive single level transforaminal lumbar interbody fusion (MIS-TLIF) under spinal anaesthesia. Current study is a retrospective analysis of prospectively collected data carried to assess patient related outcome benefits for a single level transforaminal lumbar interbody fusion done under spinal anaesthesia.Methods: Patients who fit deemed criteria not responding to 6 weeks of conservative treatment to lumbar degenerative pathologies underwent MIS-TLIF. The demographic data, visual analogue pain scale (VAS), Oswestry disability index (ODI), blood loss, time from entering operation theatre to time of incision, time of bandaging to exit from operation theatre, time of stay in post anaesthesia care unit (PACU), duration of surgery, nausea/vomiting, urinary retention, requirement of analgesics, duration of stay in hospital, peri-operative complications, fusion rate and satisfaction score were compiled and assessed.Results: 150 patients were operated with MISTLIF under spinal anaesthesia. VAS and ODI score improved significantly at final follow up (p<0.05). The mean duration of surgery was 148±18.24 minutes and blood loss were 109.64±110.45 ml. The average time from entering OT to incision and bandaging to exit was respectively 27.32±8.44 and 6.43±3.28 minutes. Mean PACU time was 36.74±6.32 minutes while duration of stay averaged 1.58±0.67 days. Post operative analgesia requirement was in 10.6% patients and radiographic fusion was observed in 96.6% patients. 90.6% patients were fully satisfied with spinal anaesthesia.Conclusions: Awake spinal fusion should be considered as a novel surgical approach with newer minimal invasive surgical techniques and regional anaesthesia to improve patient satisfaction and overall surgical outcome

Peri-operative Management and the Role of Minimally Invasive Spine Surgery in a Case of Hemophilia B

Hemophilia A and B are rare X-chromosome-linked recessive bleeding disorders caused by mutations in the genes causing abnormalities of blood clotting factors VIII and IX, respectively. Surgery in these patients will require additional planning and interaction among the surgeon, anesthetist, and a hematologist because they inevitably result in bleeding, excessive blood loss, and other life-threatening complications. The authors present a case 62-year-old male with haemophilia B and progressive neurological claudication. On plain radiographs and MRI the patient had grade 1 spondylolisthesis with lumbar canal stenosis at L4-L5 with a VAS score of 8 and ODI score of 45 and was operated with MIS-TLIF with 22 mm diameter tubular retractor (METRx, Medtronics) and an operating microscope. Pre-operatively, the hematologist opinion was taken and the patient was optimised by maintaining the plasma factor peak level activity according to the WFH guidelines. The patient had uneventful peri-operative period. The total hospital stay is 16 days and a VAS score of 3 and ODI score of 12 after one-year follow-up and without any notable complications. Minimally invasive surgical techniques are a better option in hemophilia patients as these techniques provide the surgeon with an excellent magnification of the operative field, which enables the use of a smaller incision, better hemostasis, and facilitates less traumatic procedures

Surgical Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Fusion in Elderly

Objective The purpose of this study was to compare the clinical-radiological outcome and incidence of perioperative complications of MIS-TLIF at lower lumbar levels for elderly (Age >65 years) and younger patients (Age65 years and group B<65 years). Perioperative clinical (co-morbidities, surgical time, blood loss, hospital stay, fusion level, VAS, ODI), radiological parameters (fusion, cage subsidence, implant failure), postoperative complications and satisfactory outcomes in the form of Wang’s criteria were evaluated in both the groups. A statistical analysis between two matched groups was done with logistic regression analysis, chi-square and student t-test. Results There was no statistical difference in blood loss, surgical time, mobilization and hospital stay between two groups however elderly patients took longer time to become pain free (p=0.001). Both groups showed significant improvement in ODI, VAS and Wang’s outcome score however, no statistically significant difference noted in outcome between two groups at final follow up. General complications not affecting outcome were common in elderly group but no statistically significant difference noted among neurological events between both groups. Conclusion MISS-TLIF surgery in elderly can produce successful clinical outcome and satisfaction after surgery in judiciously selected patients with proper preoperative risk assessment and optimization of medical co-morbidities. Elder age does not prove deterrent to outcome and should not be a contraindication to perform MISS-TLIF in lumbar degenerative diseases

Efficiency of Spinal Anesthesia versus General Anesthesia for Minimal Invasive Single Level Transforaminal Lumbar Interbody Fusion: A Retrospective Analysis of 178 Patients

Objective To evaluate the efficacy of spinal anesthesia in patients undergoing minimal invasive single level transforaminal lumbar interbody fusion surgery (MIS TLIF) and to compare the results with that of general anesthesia. Method 178 patients were included in the study, 86 were in general anesthesia and 92 were in spinal anesthesia. Patients aged between 20 to 70 years who had undergone MIS-TLIF not responding to 6 weeks of conservative treatment were included. The routine steps of anesthesia for both general and spinal anesthesia were adhered. The VAS, blood loss, duration of surgery, time from entering operation theatre to time of incision, time of bandaging to exit from operation theatre, time of stay in Post Anesthesia Care Unit (PACU), nausea/vomiting, urinary retention, duration of stay in hospital, peri-operative complications were compiled and assessed. Appropriate statistical analysis was applied. Results The mean time for entering the operation theatre to the incision; mean time from bandaging to the exit; mean PACU time and the mean hospital stay were significantly lower in the spinal anesthesia group (p<0.05). The other parameters are comparable except, urinary retention which was significantly higher in spinal anesthesia group (p<0.05). Conclusion Spinal anesthesia offers efficient operating room functioning with decreasing overall operation theatre time. It is very efficient alternative technique to general anesthesia which can be considered for elective lumbar surgeries with a lower late of adverse events especially at lower lumbar levels

Learning Curve of Minimally Invasive C1-C2 Trans-articular Screw Fixation (MIS-TAS): Over A Period of Five Years

Objective To evaluate the learning curve associated with minimally invasive surgery (MIS) in posterior C1-C2 trans-articular (TAS) screw fixation based on surgical and clinical parameters. Also, to report the challenges faced and measures to overcome them. Methods 84 patients who underwent C1-C2 MIS-TAS between 2009-2014 were included in the study and were divided into four quartiles (q) (21 patients each) based on the date of their surgery with each consecutive group serving as a control for prior. Pre- and post-operative clinical and perioperative parameters, technical issues and complications were evaluated. Results The mean age of the patients was 36.26±5.78 years (20-78 years) with male to female ratio of 48:36. A statistically significant difference was observed between the mean operative time and mean blood loss between second and third quartile. Inadvertent vertebral artery injury occurred in 3 cases without any post-operative sequelae. There were 6 instances of guide wire migration(q1=4, q2=2). At 2 instances (q1=2) there was guide wire breakage. Total 9 times (q1=5, q2=2, q3=1, q4=1) dorsal burst into C2 pars occurred. VAS, ODI and mJOA scores showed a significant improvement from their pre-operative values in the entire study population without any significant difference between the quartiles. Conclusion C1-C2 MIS-TAS is a very safe and effective means of treating reducible atlanto-axial instability. Pre-operative planning, detailed radiological evaluation, practice on cadavers/bone-saw models and by following the mentioned recommendations the learning curve of C1-C2 MIS-TAS can be reduced

Comparative Prospective Study Reporting Intraoperative Parameters, Pedicle Screw Perforation, and Radiation Exposure in Navigation-Guided versus Non-navigated Fluoroscopy-Assisted Minimal Invasive Transforaminal Lumbar Interbody Fusion

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

Minimally Invasive Microscope-Assisted Stand-Alone Transarticular Screw Fixation without Gallie Supplementation in the Management of Mobile Atlantoaxial Instability

Study Design Retrospective study. Purpose To evaluate the clinico-radiological efficacy of stand-alone minimally invasive transarticular screw (MIS-TAS) fixation without supplemental Gallie fixation in the management of mobile C1–C2 instability. Overview of Literature Data evaluating the efficacy and feasibility of MIS-TAS in the literature is scanty. Methods Patients with mobile atlantoaxial instability and >2 years follow-up were included and managed by stand-alone TAS fixation using the Magerl technique and morselized allograft without additional fixation. Patient demographics and intra-operative parameters were noted. Clinical parameters (Visual Analog Scale [VAS] and Oswestry Disability Index [ODI]), neurology (modified Japanese Orthopaedic Association [mJOA]), and radiological factors (anterior atlanto-dens interval and space available for cord) were evaluated pre and postoperatively. Computed tomography (CT) was performed in patients who did not show interspinous fusion on X-ray at 1 year, to verify intra-articular fusion. Statistical analysis was performed using IBM SPSS ver. 20.0 (IBM Corp., Armonk, NY, USA); the Student t-test and analysis of variance were used to assess statistical significance (p <0.05). Results A total of 82 consecutive cases (three males, one female; mean age, 36.26±5.78 years) were evaluated. In total, 163 TASs were placed. Significant improvement was noticed in clinical (mean preoperative VAS=7.2±2.19, postoperative VAS=3.3±1.12; mean preoperative ODI=78.3±4.83, postoperative ODI=34.05±3.26) and neurological features (mean preoperative mJOA=14.73±2.68, postoperative mJOA=17.5±2.21). Radiological evidence of fusion was noted in 97.5% cases at final follow-up. Seventeen patients were found to have no interspinous fusions upon X-rays, but CT revealed facet fusion in all patients except in two. Inadvertent vertebral artery injury was noted in three cases. Conclusions Stand-alone TAS fixation with morselized allograft provides excellent radiological and clinical outcomes. The addition of a supplementary tension band and structural graft are not essential. This provides the opportunity to avoid the complications associated with graft harvesting and wiring