Background: Junctional kyphosis (JK) is usually observed in long-level instrumented fusion surgeries. Various contributing factors are proposed, the pre-existing and postoperative spinal imbalance is considered as the single most important factor for the development of JK in adult spinal deformity surgeries. Distal JK (DJK) is seldom reported compared to proximal JK (PJK), and scarce literature exists.Methods: We report 2 unique cases of distal junctional failure (DJF) with worsening of neurology, secondary to nontraumatic fracture of a lower instrumented vertebra operated for thoracic canal stenosis without deformity. The first case had acute worsening of the Neurology during follow up and on evaluation, the supine CT and MRI scan revealed well decompressed spinal canal, no implant migration to the canal, no screw loosening, or rod failure. Supine sitting radiographs demonstrated DJK with Fracture and the patient underwent extension of fusion till the pelvis with 3-rod construct and interbody fusion, because of the instability at the L1 level. The second case remained neurologically stable for a month and then had an acute onset of back pain, sensory deficit, and urine incontinence. The supine-sitting dynamic radiograph done demonstrated L1 fracture with DJK at D12-L1 levels. The patient was counseled for extension of fusion, which was deferred by the patient.Results: Patients in our series, had an acute worsening of neurological deficit within a month of posterior spinal fixation. Their supine imaging was almost normal, and the diagnosis of DJK with L1 fracture instability was possible only on a supine-sitting dynamic radiograph. Various factors like obesity, TL kyphosis, osteoporosis, etc. can be the attributing factors for the development of DJK Conclusion: A high index of suspicion is required for diagnosing nontraumatic fracture in long-level fusion patients with acute neurological worsening. The supine-sitting dynamic radiograph is an important diagnostic tool for DJF in patients having difficulty standing erect.Level of Evidence: 4. Clinical Relevance: Application of sitting and supine dynamic radiographs to diagnose instability in patients unable to stand for flexion and extension radiographs.

Paraspinal tumors are uncommon tumors involving the soft-tissue around the vertebrae. The lesion could originate from nerve roots, soft tissue, or blood vessels. The diversity of the lesions poses diagnostic dilemma, warranting robust histopathological diagnosis. We report such a case presenting with radicular pain due to paraspinal extramedullary hematopoiesis (EMH) masquerading as nerve sheath tumor. EMH is presence of hematopoietic tissue outside the bone marrow. EMH is usually seen as a compensatory mechanism associated with underlying hematological disorder. Our case presented primarily as paraspinal mass without underlying hematological disorder on evaluation. Thus, recognizing that EMH can present as paraspinal mass even without a diagnosis of pre-existing hematological disorder is crucial.

Introduction: Osteoporosis is a common disease in elderly associated with high morbidity and economic burden. Low bone mass is the strongest predictor of low and moderate energy fracture risk. As there are accurate as well as safe diagnostic tests available and treatment is effective, early diagnosis and quantification of bone loss and fracture risk have become more important so that it can slow or even reverse the progression of osteoporosis. Material and Methods: This is a prospective study, conducted on patients with intertrochantric and neck of femur fractures in the age group of 50 to 75 years. The period of study is 6 months from May 2017 to October 2017. 96 Patients (34 neck of femur and 62 intertrochantric fractures) were selected into the study from those presenting to Victoria hospital and Bowring hospital, Bangalore medical college and research institute, Bangalore. The calcaneal X ray of the uninjured limb was taken along with the X ray of pelvis with both hip joint. The films were then scored based on the trabecular pattern by 2 different observers and recorded in separate charts. After a minimum of 2 weeks, the same observers scored the radiographs again for assessment of intra-observer reproducibility. Calcaneal index score and Singhs index scores were compared. Results: As the age progressed there is a linear relationship in the bone density and the calcaneal index scored. However there is some discrepancy in the score of Singhs index and Calcaneal index. But this difference is not a statistically significant. Conclusion: Calcaneal index can be used as a screening tool for diagnosing osteoporosis, it is cost effective, requires less radiation dose exposure and the radiation directed away from the gonads, even though it does not predict the exact bone density.

BACKGROUNDClavicle is the bony structure that links shoulder girdle to thorax and is 'S' shaped bone. Clavicle fracture is a common traumatic injury around shoulder girdle due to their subcutaneous position. It has been managed non-operatively in many cases. This study was undertaken to study the outcome of surgical management in displaced or comminuted clavicular fractures with precontoured Locking Compression Plates. MATERIALS AND METHODSTwenty adult patients with clavicular fractures treated surgically between November 2011 and October 2013 were included for this study and treated surgically with precontoured Locking Compression Plates. RESULTSAmong 20 patients with middle third clavicle fracture treated with precontoured locking plate, 18 fractures united at an average of 9.3 weeks; 2 patients had delayed union, 2 patients had plate loosening and 3 patients had plate prominence. The functional outcome according to Constant and Murley score after fracture union were excellent in 16 patients, good in 3 patients and fair in 1 patient. CONCLUSIONThis study shows rigid fixation with precontoured Locking Compression Plates for fresh displaced or comminuted middle third clavicle fracture, we can archive immediate pain relief and avoid the complications like shoulder stiffness and non-union.

Background Data: Adult spinal deformity (ASD) needing surgical treatment is often seen in the aging population. Radiological goals for ASD surgery have been standardized to achieve a good functional outcome. Lesser complication rates and blood loss have made MIS surgeries more popular in the current day. Trans-psoas / Pre-psoas Lateral Lumbar Interbody Fusion (LIF) has been the cornerstone of MIS surgeries for ASD. The corrective potential of conventional MIS surgeries was limited, owing to which various modifications have been described. Despite the demonstration of good clinical outcomes by various studies employing different surgical techniques, cumulative analysis of the radiological outcome of the various modifications of LIF is poorly discussed in the literature. A recommendation of an ideal MIS technique based on the type and magnitude of ASD is also lacking. Purpose: We aim to perform a qualitative systematic review of the radiological outcomes of various modifications of LIF surgeries for ASD and to decipher a treatment algorithm based on the type and severity of ASD with existing literature. Study design: Systematic review. Patients and Methods: A systematic search of two electronic databases (PubMed & Google Scholar) from its inception till December 2020 was done independently by 3 different authors. Relevant keywords and MeSH terms were used to identify articles and further filtered by applying appropriate selection criteria. Results: A total of 171 articles were selected for abstract screening, followed by full-text screening. After applying the selection criteria, 28 articles were selected for the systematic review. The methodology and radiological parameters of each study were analyzed qualitatively, and the inferences in regards to the radiological outcomes were validated. Conclusion: Circumferential MIS (cMIS) seems to be adequate in milder forms of ASD, while hybrid surgeries may be needed in higher magnitude deformities. Addressing the L5-S1 junction using LIF and anterior column realignment (ACR) are useful tools to correct more severe deformities. (2020ESJ223)