Ganga Medical Centre & Hospitals Pvt Ltd

Coimbatore, India.

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Ongoing and Future Research Project

Ongoing and Future Research Project

Project 1: Application of diffusion tensor imaging for quantifying severity of spinal cord compression in cervical myelopathy and nerve fibre integrity in cervical spinal cord injuries

The difficulty in assessing the extent of irreversible nerve damage in patients with acute or chronic cord injury has many implications. The prognosis of such patients with cervical spondylotic myelopathy or traumatic cord injury has not been accurately corelated to the extent of compression, cord oedema or myelomalacia. Though MRI has played a huge role in the diagnosis, accurate surgical planning and management, its prognostic usefulness is questionable. Diffusion Tensor Imaging (DTI) is a different dimension of MRI with ability to detect alterations in microstructural water diffusion.

 Application of diffusion tensor imaging for quantifying severity of spinal cord compression

  • Figure A: Saggital T2 MRI of the calf spinal cord.
  • Figure B: DTI Tractography image showing well organised fiber tracts of the calf spinal cord.
  • Figure C: Saggital T2 MRI of calf spinal cord shows hemisection site as a thin hyper intense signal (yellow arrow).
  • Figure D: DTI Tractography image shows abrupt cessation of fiber tracking at the hemisection site whereas the uninterrupted fibers are tracked down.
  • Figure E: Saggital T2 MRI of calf spinal cord shows mild (red arrow) and severe (yellow arrow) compressions as smooth indentations of the spinal cord.
  • Figure F: DTI Tractography image shows irregularity and attenuation of fiber tracts at the site of mild compression and completely thinned out fibers at the site of severe compression.

With several studies proving its capacity to identify interruption in myelin sheath integrity, it can be useful in predicting prognosis in spinal cord damage. The ability to foresee prognosis and extent of recovery would then allow both the diagnostician and the patient to not only plan surgery but also avoid surgery where its benefit is doubtful. The application of diffusion tensor imaging in cervical spinal cord injuries is a relatively new and emerging area in spine diagnostics.


 Normal interhemispheric connections in corpus callosum

Orthogonal directions are seen as the following colors: blue, superior–inferior; green, anterior–posterior; red, medial–lateral. Head on view demonstrating no crossing over of major fibers at the level of the pons in a patient with HGPPS

  • (A) seen enlarged in (B) with normal decussation in the control subject (C and D). Normal interhemispheric connections in corpus callosum (A and B).

Our study is aimed at evaluating the sensitivity and specificity of diffusion tensor imaging MRI as an investigatory tool in assessing the extent of nerve fibre damage in acute and chronic spinal cord injuries. We have developed a standardized protocol for image acquisition through serial DTI in calf spine models. In the clinical part of the study, we have planned to do DTI in 20 normal healthy human volunteers, which will help us to develop a normative database. Similarly 20 patients with acute and chronic spinal cord injuries will undergo index DTI and postoperative follow-up DTI at three, six and twelve months. Patients' clinical status will be compared with changes in DTI parameters. Values taken from healthy people will be taken as a standard with which those of spinal cord injury patients will be compared

Project 2: An Innovative Technique to Identify Risk of Fracture by Texture Analysis in Comparison with Quantitative Computed Tomography

Osteoporosis is characterized by bone mineral density (BMD) and trabecular bone microarchitecture. Trabecular bone is approximately eight times more metabolically active than cortical bone. Quantitative computed tomography (QCT) measures trabecular bone and cortical bone separately, and may be ideal to assess the changes in skeletal density. However, the high cost and more radiation are the major limiting factors. In contrast, fractal analysis, a computerized method of textural analysis permits the measurement of changes in trabecular bone using plain x-rays. Although QCT assesses trabecular BMD, it fails to discriminate patients with risk of fracture from controls. We aimed to evaluate changes in trabecular texture using fractal analysis on the x-ray images of distal radius and calcaneus in the assessment of the risk of osteoporotic fracture.

Trabecular Microarchitectural

Trabecular microarchitectural image taken by µ-Quantitative Computed Tomography, most of the trabecular bones are absent in the case of osteoporosis

Color coded plain radiographs

Color coded plain radiographs showing the trabecular microarchitectural in the proximal femur

Project 3: Functional MRI study on patients with chronic non-specific low back pain (NS LBP) – Assessing the patterns of pain perception and the role of psyche in the perpetuation of chronic back pain

Functional MRI study on patients

A healthy volunteer undergoing functional MRI assessment. The image shows as active spot in the brain when his right hand thumb was under action.

Chronic pain as defined by International Association for the Study of Pain (IASP) is, "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage". Functional imaging techniques have revolutionized the field of neuroscience research. Functional magnetic resonance imaging (fMRI) is a non-invasive technique that assesses cortical activation by measuring changes in the local concentration of

paramagnetic deoxyhemoglobin. This method has been referred to as blood oxygen level dependent (BOLD) imaging. In a BOLD experiment, regional neuronal activation is associated with changes in blood flow and blood volume, generally leading to a washout of deoxyhemoglobin, which results in an increase in local signal intensity. Functional MRI defines dynamic changes in blood flow with relatively high spatial resolution, and is a powerful tool that can be used to investigate neuronal networks involved in cognitive processing and the effects of disease states on brain functioning. Because it is non-invasive, fMRI can be used repeatedly in children, therefore allowing longitudinal studies of the development of neural networks during childhood and adolescence, evolution of disease processes and treatment effects. Our hypothesis is to investigate patients with lower back pain that cannot be linked to a physical cause may have abnormal pain processing pathways in their brains. There would seem to be some pathologic process making these patients more sensitive.

Project 4: Prevalence and pattern analysis of disc degeneration – a retrospective study on whole-spine MRI of non-randomised patients

Previous studies have studied the prevalence of MRI changes in the spine and correlated these changes to clinical findings. Most of these studies have the drawbacks and have focused on a single or few changes and are restricted to the lumbar spine. Vertebral endplate signal changes (Modic changes) are associated with low back pain. The prevalence of ''Modic changes'' and its association with low back pain however varies greatly between studies. Also Modic changes are assumed to be associated with disc degeneration while others have suggested that endplate damage is the critical factor determining disc degeneration. Studying the association of MRI changes with disc degeneration will help in determining the factor most influencing disc degeneration.

Prevalence Pattern

Cluster analysis based on pattern of disc degeneration

Our objectives are

  1. to examine the pattern and prevalence of MRI changes in the spine and correlate the changes to age, pain symptoms and occupation.

  2. to examine the association of various MRI findings to one another within each spinal level

  3. to determine patterns of distribution of disc degeneration in the spine this, may provide insights into the aetio-pathogenesis of DDD.

Project 5: Patient Oriented Evidence That Matters (POEM) - Does educating the patient regarding the radiological findings affect the functional outcome of back pain treatment - A prospective study

Patients with low back ache form a major group in the day today orthopaedic practice. Among these more than 50% fall under the category of non-specific low back ache patients. These patients typically have symptoms lasting more than 6 weeks, do not have radicular symptoms and their radiological findings are largely insignificant. Many practitioners give undue importance to certain radiological findings of the spine, which either are insignificant or have been not proved as consistent pain generators. The aim of the study is to find out whether the educating the patient about such 'non-specific' radiological findings makes the patient prone to have persistent symptoms with poor functional outcomes. This study is also propelled by the observation from many studies that a strong psycho-social element is attached to the etio-pathogenesis of non-specific low back pain.

Patients with insignificant MRI findings and non-specific back pain without neurological deficitor adicular features will form the major study group. Patients coming to the out patient department with specific inclusion criteria are selected and randomized into two groups. Those patients with spondylolysis / listhesis, neurological deficits ( radiculopathy or myelopathy), viserogenic causes, trauma, neoplasm, deformity, infection, inflammatory disorders will be excluded from the study.

The group A patients are further divided into educated and uneducated and are explained with the artificial spine model regarding the normal anatomy and the area where the patient is having problem in the MRI. They are also explained that their problem does not require any specific treatment except for some analgesics and back exercises. The group B patients are not explained about the radiological findings and standard treatment for non-specific low back pain is initiated. They were evaluated using the SF – 36 V2 score on day 1, 1 month, 6 months.

Project 6: Identifying the Vertebral End Plate as the Weak Link in Lumbar Disc Herniation – Prospective Non-randomised Evaluation by Computerised Tomographic Analysis, Diffusion Studies and Histopathologic Examination of Prolapsed Lumbar Discs

It is widely believed that lumbar disc herniation is a result of annular tear that permits the nucleus pulposus to escape from its natural confines and compress on the neurological structures. This study aims to establish the exact patho-anatomy of lumbar disc herniation with special emphasis on the role of end plate as the point of failure in lumbar disc herniation. Our hypothesis is that the anulus-endplate junction is the weak link and is responsible for mechanical failure in a large proportion of LDH.

So far we have collected clinical,radiological and histopathological data from 71 patients and preliminary analysis indicate that our hypothesis is tenable. If established, the results can have wide ranging implications on the diagnosis and management of backpain and LDH which is the leading cause of loss of working hours globally.

Identifying the Vertebral end Plate 1

Identifying the Vertebral end Plate 2

Project 7: Evaluation of the Efficacy, Functional and Radiological Outcome of Bone Bank Allografts for Achieving Spinal Fusion in Scoliosis Surgeries

Spinal instrumentation and bone grafting have an established role in the treatment of both idiopathic and degenerative scoliosis. The long term successful outcomes in deformity correction surgeries depend on good initial correction, sound fixation of the implant and maintenance of surgical correction by achieving solid fusion. Although autograft bone has traditionally been considered as the ideal in spinal fusion, it is not without its complications. The use of allograft bone provides a reasonable alternative to meet the growing need for primary or supplementary graft material. Our hospital has an in house bone bank where freeze dried bone grafts are stored for future usage. The bone banks improve the safety and availability of allografts.The problems of transfer of infection and antigenicity have been widely studied and represent a minimal risk to the patient. The guidelines for the collection of allografts, its suitability as a graft material, and its storage are now established and followed in our institute.

Evaluation of the Efficacy Evaluation of the Efficacy

Antero-posterior radiographs of a patient treated with instrumentation and allografts

All patients undergoing posterior corrective instrumentation and fusion for scoliosis (both idiopathic and degenerative) form the study group. Femoral heads, proximal tibial and distal femoral metaphysis harvested from patients during joint replacement surgeries, are processed and stored in the hospital bone bank. During scoliosis surgeries, once the implants are inserted and deformity corrected, the processed allograft will be morcelised, mixed with locally harvested bone grafts and packed in the graft bed. Fusion will be assessed by radiographs taken at 3, 6 and 12 months post-operatively and graded based on Fusion component of Massachusetts General Hospital Anatomic, Economic and Functional (AEF) rating system criteria. The functional outcome will be assessed by Scoliosis Research Society Outcome Questionnaire.

The use of allograft bone provides the only real alternative to autogenous graft in the quest for suitable material to secure predictable fusion in scoliosis surgery. The use of allografts in spine fusion surgeries has recently been receiving more attention and with the regular performance of total hip and knee arthroplasties, femoral heads and tibial slices are readily available in large quantities and can very well be used in spine surgeries.