Body Of L5 Research Articles

Paraplégie secondaire à une infiltration épidurale interlamaire lombaire, à propos d’un cas

We report the first case of paraplegia observed after epidural steroid injection in the upper spine. The patient was a 42-year-old male who underwent surgery two years earlier for stenosis of the lumbar spine from L2 to the sacrum leading to early manifestations of an equina cauda syndrome. This first operation provided satisfactory function with complete resolution of the objective neurological symptoms. The patient later developed bilateral radiculalgia involving the L3 and L4 territories and was treated by radio-guided epidural steroid injection (125 mg hydrocortancyl) delivered in the L1-L2 interlaminar space. The injection was achieved with no technical difficulty and there was no injury to the dural sac. Immediately after the injection, the patient developed complete motor and sensorial paraplegia from T12. CT and MRI performed 30 min and 4h, respectively, after the accident revealed a medium-sized discal herniation behind the L2 body. No other lesion was observed. Emergency surgery was performed for radicular release but to no avail. The patient's neurological status remained unchanged and four days later the T2 MRI sequence revealed a high-intensity intramedullar signal in the cone. The diagnosis of ischemia of the medullary cone was retained, hypothetically by injury to the dominant radiculomedullary artery via an undetermined mechanism. This complication has been previously described after upper foraminal steroid injections but not after intralaminar epidural steroid injection.

Multiple myeloma with central nervous system involvement in a cat

A 1.5-year-old spayed female domestic shorthair cat was admitted for hind limb locomotor difficulties and signs of pain along the lumbar portion of the vertebral column. At the time of referral, the cat was paraparetic with deficits in the spinal reflexes of the hind limbs. Neuroanatomic localization was at the L6-S2 spinal cord segments, corresponding approximately to the region of the L4-L6 vertebral bodies. Radiography revealed a mixed osteolytic-proliferative lesion within the body of L5 involving the cranial end plate, as well as punctate radiolucencies in the distal portion of the femur. Magnetic resonance imaging revealed an intramedullary spinal cord lesion along with extensive meningeal and nerve root lesions in the area of the L4-L6 vertebral bodies. Cytologic analysis of a bone marrow aspirate from the right trochanteric fossa revealed a substantial plasma cell infiltrate. Analysis of CSF revealed a high protein concentration and morphologically abnormal plasma cells. Urine, but not serum, protein electrophoresis revealed a sharp gamma-globulin peak consistent with a monoclonal band of Bence-Jones proteins. The diagnosis was multiple myeloma. The cat was treated with melphalan and prednisolone. A rapid clinical response was reported, and by week 3 after diagnosis, the cat's locomotion and behavior had normalized. However, by month 4, multifocal neurologic deficits were evident. The cat was euthanized at 9 months because of tetraparesis and substantial weight loss. To our knowledge, this is the first report of myeloma in a cat that had electrophoretically detectable light chain proteinuria but lacked a detectable serum monoclonal gammopathy.

Vertebral fractures in AIDS patients within 6 months from highly active antiretroviral therapy initiation: two case reports

Vertebral fractures in AIDS patients within 6 months from highly active antiretroviral therapy initiation: two case reports

Intradural cement leakage: a rare complication of percutaneous vertebroplasty

Percutaneous vertebroplasty (PV) is one of the alternative treatments for vertebral fractures. Reported significant complications include pain, radiculopathy, spinal cord compression, pulmonary embolism, infection and rib fractures. In this report, we highlight intradural cement leakage which is a rare complication of the procedure. A 49 year old man with a T12 compression fracture due to multiple myeloma was referred to the neurosurgery department from the orthopaedics and traumatology clinic after developing a right lower limb weakness following percutaneous vertebroplasty with polymethylmethacrylate. An urgent thoraco-lumbar magnetic resonance imaging was performed. The T1 and T2-weighted images demonstrated intradural extramedullary and epidural cement leakages which were hypointense on both sequences. Total laminectomy was performed at T12 and L1 and two epidural cement collections were excised on the right. Then, a dural incision from T12 to the body of L1 was done and cement material seen in front of the rootlets excised without any nerve injury. The patient was discharged after a week and referred to the haematology clinic for additional therapy of multiple myeloma. Although the cement leakage was extensive, the right leg weakness improved significantly and he began to walk with assistance 3 months later. Good quality image monitoring and clear visualisation of cement are essential requirements for PV using polymethylmethacrylate to prevent this complication from the treatment.

Magnetic Resonance Elastography for the Noninvasive Staging of Liver Fibrosis

The purpose of our study was to prospectively compare the success rate and diagnostic accuracy of magnetic resonance elastography, ultrasound elastography, and aspartate aminotransferase to platelets ratio index (APRI) measurements for the noninvasive staging of fibrosis in patients with chronic liver disease. We performed a prospective blind comparison of magnetic resonance elastography, ultrasound elastography, and APRI in a consecutive series of patients who underwent liver biopsy for chronic liver disease in a university-based hospital. Histopathologic staging of liver fibrosis according to the METAVIR scoring system served as the reference. A total of 141 patients were assessed. The technical success rate of magnetic resonance elastography was higher than that of ultrasound elastography (133/141 [94%] vs 118/141 [84%]; P = .016). Magnetic and ultrasound elastography, APRI measurements, and histopathologic analysis of liver biopsy specimens were technically successful in 96 patients. The areas under the receiver operating characteristic curves of magnetic resonance elasticity (0.994 for F >or= 2; 0.985 for F >or= 3; 0.998 for F = 4) were larger (P < .05) than those of ultrasound elasticity, APRI, and the combination of ultrasound elasticity and APRI (0.837, 0.709, and 0.849 for F >or= 2; 0.906, 0.816, and 0.936 for F >or= 3; 0.930, 0.820, and 0.944 for F = 4, respectively). Magnetic resonance elastography has a higher technical success rate than ultrasound elastography and a better diagnostic accuracy than ultrasound elastography and APRI for staging liver fibrosis.

Reliability of Tuffierʼs Line as an Anatomic Landmark

The level of Tuffier's line was assessed on 200 standing and 60 prone lumbar radiographs. Sex, height, weight, and body mass index (BMI) were correlated with the radiograph findings. To determine whether the level of Tuffier's line is associated with sex, height, weight, or BMI. Tuffier's line (intercristal line) is a commonly used landmark for identification of the L4-L5 interspace; however, multiple studies have identified that this landmark is unreliable. The level of Tuffier's line was assessed retrospectively on 200 standing anteroposterior lumbar radiographs and correlated with sex. Prospectively, the level of Tuffier's line was assessed on 60 prone posteroanterior lumbar radiographs and correlated with sex, height, weight, and BMI. In men, the intercristal line most often intersected the L4 body or inferior endplate. In women, the intercristal line most often intersected the L5 body or superior endplate. Weight and BMI had no correlation with Tuffier's line. Subjects with a Tuffier's line through L4 were taller than those with a Tuffier's line through L5. Tuffier's line demonstrated predictable sex-related differences: men had an intercristal line that most often intersected the L4 body or inferior endplate whereas the women's intercristal line most often intersected the L5 body or superior endplate. However, because the actual level of Tuffier's line may vary from the L4 body to the L5 body, the intercristal line is insufficient to use as the sole landmark for assessing spinal segmental level.

Does the Shape of the L5 Vertebral Body Depend on the Height of CT Slices in the Pedicle?

The shape of the L5 vertebral body was analyzed using a computerized tomography (CT) scan. The aim of this study is to determine if the vertebral L5 body shape varies depending on the height of the CT slices through the L5 pedicle. The morphometry of L5 has been studied to help the introduction of pedicular screws. The shape of the vertebral body has been seldom looked into, and the findings obtained show a triangular shape and hemispherical shape, supposedly owing to interpersonal variability. The hemisphere shape enables pedicular screws to be introduced nonconvergently, whereas the triangular shape enables pedicular screws to be introduced at a convergent angle but posing the risk of cortical perforation unless these guidelines are followed. Abdominal CT multicut with 64 crowns was performed in 101 consecutive patients with diverse indications. Width of CT slices was with a 1-mm reconstruction increase. We selected one axial slice that passed through the upper part of the pedicle and another one that passed through the lower part of the pedicle and compared next parameters in both cuts: pedicular cortical width, pedicular endostal width, pedicular angle, vertebral body length, vertebral body width, vertebral perimeter angles, and visual appearance of vertebral body shape. We found statistical differences between all values except the anterior vertebral perimeter angle on comparing values of upper part with values of lower part and visual vertebral body shape was different in 93% of vertebrae. In the upper part the vertebral body is hemispherical whereas in the lower part it is triangular. In most cases, the vertebral body shape is hemispherical in the upper part of the pedicle and triangular in the lower part of the pedicle. It means that in the lower part pedicular screws must be introduced at a more convergent angle than in the upper part if we do not want to break any cortical of the vertebral body.

Cystothecostomy: a new technique to treat long segment spinal extradural arachnoid cyst

Pathogenesis and treatment of the spinal arachnoid cyst has not been well established. A novel method of treatment of a long segment spinal arachnoid cyst is being presented in a 9-year-old boy. He presented to us with a slowly progressive spastic paraparesis. MRI revealed dorsal epidural arachnoid cyst extending from T7 vertebral body to L1 body producing marked cord compression. In order to save the child from a long segment laminectomy or laminoplasty, a new minimally invasive technique was devised. In this technique L1 laminectomy was performed under local anaesthesia, and the cyst was communicated to thecal sac by making an interconnecting stoma. We named this procedure as cystothecostomy. There was gradual neurological recovery after the procedure.

A reply

We would like to thank Drs Hull and Rucklidge for their interest in our article. Our study found that the ‘pop’ was not always felt when using a 27G spinal needle in the term pregnant woman. The study did not compare the safety of a continuous push technique with that of incremental advancement of the spinal needle and so we cannot conclude that the incremental technique is safer. Given the result of our study, we can, however, suggest that a technique that could minimise the extent of needle penetration into the intrathecal space would, logically, lead to a reduced risk of impingement upon neurological tissue. As the incidence of neurological damage from spinal anaesthesia is fortunately very low, it would not be feasible to perform a study that could prove this. We would point out that it was Professor Reynolds' case series that recently highlighted the risks of causing severe neurological damage with a spinal needle and so we do have evidence that damage is caused using current techniques of spinal needle insertion [1]. Both cadaveric and radiological studies have found that Tuffier's line crosses the body of L4 or the L4/5 disc space in 78.6% of people [2, 3]. One space above Tuffier's line should be L3/4, one below L4/5 and two above, L2/3. In our study the first position attempted was one space above Tuffier's line, which should be L3/4 and the second position for spinal needle insertion was one space below Tuffier's line, which should be L4/5. Any space below this, in our experience, is often unsuccessful, as this would be L5/S1. This is especially true in the hands of cautious trainees who are often lower than they think. As for two spaces above Tuffier's line being out of bounds – one of the main points of our article is that you cannot reliably predict which intervertebral space you are using and that you will frequently be at the cord level, so an incremental advancement technique may be the safer option. L2/3 is an option if levels below have been unsuccessful. We feel that is better to insert a spinal needle using as safe a technique as possible at a higher level, rather than persisting at lower levels, failing, and needing to subject a woman to a general anaesthetic with its attendant risk. The gauge of the spinal needle is a compromise between the incidence of postdural puncture headache (PDPH) and failure to locate the subarachnoid space. In the study quoted by Drs Hull and Rucklidge, use of 25G Whitacre needles caused one severe PDPH necessitating blood patch and three mild cases [4]. There were none in the 27G group. Whilst we accept that the 27G has a higher failure rate, PDPH can be devastating for an otherwise well lady who has to care for a newborn infant. The 27G needle is the standard needle in our unit. In our study of elective patients, adequate spinal anaesthesia was provided within 20 min. The incremental technique added, at most, 1–2 min. No undue discomfort was felt by the women. Whilst we cannot extrapolate our data to the emergency situation, we cannot see any reason for our technique to cause undue delay and concern in terms of time to provide adequate anaesthesia. Again, as in all things medical, an assessment of the balance of risk must be made. For most, if not all, emergency category 2 Caesarean sections, an extra minute would be of no consequence. For a category 1 emergency Caesarean section it is always possible to revert to a continuous push technique, possibly utilising a 25G needle, if a spinal anaesthetic is deemed appropriate for that situation.

Bone Scintigraphy in Acute Intraosseous Disc Herniation

A 57-year-old woman initially presented with the acute onset of low back pain after gardening. Plain film at that time was reported as showing Scheurmann's disease of the lumbar spine. The pain resolved slowly, but recurred acutely after minimal trauma 5 months later. Bone scintigraphy revealed increased uptake in L4 and L5 around the disc space, thought to be suspicious for discitis. Other blood tests revealed a high alkaline phosphatase level with an elevated bone component. The erythrocyte sedimentation rate and leukocyte count were not elevated. Magnetic resonance imaging (MRI) showed an acute disc herniation of the L4/L5 disc into the lower body of L4 with considerable bone marrow edema. Follow-up imaging showed substantial resolution of marrow edema 18 months later. Acute disc herniation has rarely been reported in the scintigraphic literature and should be kept in mind in such circumstances, particularly in older patients.

Penetrating spinal injury by a projectile diamond bead in a limestone quarry

While operating a jackhammer, a 39-year-old manstood approximately 100 m behind a diamond wiresaw, a stone cutting device commonly used in thestone quarry industry. The diamond wire (Fig. 1)snapped resulting in high-speed projection of itscomponents including the diamond beads (Fig. 2).One such bead impacted with the patient’s lowerback.On presentation to the National Spinal InjuriesUnit a 1 cm circular puncture wound was noted inthe right paravertebral region at the level of thethirdlumbarvertebra(L3).Neurologicalassessmentrevealed reduced power in the left lower limb, withMedicalResearchCouncil(MRC)gradesoffouroutoffive in knee extension and ankle dorsiflexion andthree out of five in extensor hallicus longus (EHL)and ankle plantar flexion recorded. Voluntary analcontraction was absent.Radiographs of the lumbar spine confirmed thepresence of the diamond bead posterior to the bodyof L3 (Fig. 3). Computed tomography (CT) of thelumbar spine demonstrated a metallic foreign bodywithin the spinal canal at L3. Fragmentation of theright lamina with bony particles within the spinalcanal at this level was also noted (Fig. 4).Pre-operatively tetanus toxoid was administeredin addition to intravenous cefuroxime and gentami-cin. Under general anaesthetic, the patient wasplaced in the prone position. A midline incision,incorporating the puncture wound, was made. Aright paravertebral tract extending through thelamina at L3 was noted. Right L3 laminectomyrevealed a 12 mm dural tear. The diamond beadwas identified within the spinal canal and removed.The nerve roots at this level were intact. The duraltear was repaired using a combination of dural graftmatrix and fibrin glue.A supine position was maintained for 48 h post-operatively and intravenous antibiotics were con-tinued for 7 days. During this time motor function in

Prenatal diagnosis of segmental spinal dysgenesis

CASE REPORTA 20-year-old woman (gravida 1, para 0) was referred at22 weeks and 3 days of gestation with bilateral talipesand a suspected spinal abnormality. The nuchal translu-cency assessed at 12 weeks and 3 days was 2.3 mmwith a CRL (crown–rump length) of 59.8 mm givingan adjusted risk for Down syndrome of 1:825. Thepatient had an uneventful medical history, and no his-tory of abdominal trauma was elicited. We performeda detailed 2D–3D ultrasound examination of the fetalanatomy. This confirmed the finding of bilateral talipes,and reduced movements across the knee joint on bothsides were observed. In addition, complete disjunction ofthe thoracic and lumbar spine at the L1 and L2 level wasseen (Figure 1(a)). There was no spina bifida or hemiver-tebra nor any evidence of Arnold Chiari malformationor further associated structural abnormalities.In view of the findings suggestive of neurologicaldamage below the level of the spinal lesion, the par-ents opted for a termination of pregnancy. Cytogeneticanalysis of cells obtained from the fetal blood at thetime of the fetocide showed normal 46,XX karyotype.Postmortem fetal X-ray and (magnetic resonance imag-ing (MRI) scan were performed prior to pathologicalexamination, in order to better define the spinal abnor-mality and to inform of the risk of recurrence of theabnormality in future pregnancies. X-ray showed a com-plete disjunction of thoracic and lumbar spines withsevere kyphosis and gibbus apex marking the level ofthe lesion (Figure 1(b)). The L1 and L2 spinous processwere hypoplastic and a vestigial L1 body was fused toT12, while the L2 body was agenetic. The lower threelumbar and the sacrococcygeal vertebrae were present.Postmortem MRI confirmed the configuration of thespine as shown on the plain films (Figure 1(c)). Fur-thermore, it showed overlap of the unossified spinalsegments and an abnormally thin spinal cord at the levelof the lesion, while there was evidence of a thickened

A Primary Leiomyoma in the Neural Foramen of the Lumbar Spine: A Case Report

A primary leiomyoma in the neural foramen of the lumbar spine is a very rare condition. We examined a 23-year-old female presented with back and right flank pain. A plain radiography showed a well-defined, osteolytic lesion in the L3 body. In addition, MR images showed a mass lesion with intense enhancement, after intravenous injection with contrast material, in the right neural foramen at the L2/3 level. A histopathologic examination of the resected specimen revealed a benign leiomyoma.

Posteriorly ruptured abdominal aortic aneurism causing vertebral erosions

A 52-year-old black woman presented to the emergency department with a complaint of worsening lumbar pain during the last month. A report of untreated severe arterial hypertension was provided. She had been suffering from chronic lumbar pain for the previous 2 years. During the investigation of lumbar pain she had been diagnosed as having an abdominal aortic aneurism, but she declined treatment and follow-up. At presentation she was hemodynamically stable and had no signs of peritoneal irritation on physical examination. An abdominal computed tomography was performed and revealed a ruptured posteriorly blocked aortic aneurism, which caused severe erosions on the anterior vertebral bodies of L3 and L4. The patient was operated on the next day after admission, and an aneurysmal repair was performed. She was admitted to the ICU and evolved with shock, acute renal failure, mesenteric ischemia and multiple organ dysfunction. She died on the third day after hospital admission. Figure 1

Lumbar Wedge Resection Osteotomy for Congenital Scoliosis due to a Sacral Malformation - A Case Report -

Congenital scoliosis due to a sacral malformation is quite rare. To the best of our knowledge, most wedge resection osteotomies have been performed to correct a kyphotic deformity in ankylosing spondylitis. However, there is no report of a trapezoidal lumbar wedge resection osteotomy of the vertebral body in the surgical treatment of congenital scoliosis due to a sacral malformation. This paper reports a 41-year-old female with a 25-year history of lower back and buttock pain combined with radiating pain to the lower extremities. The coronal imbalance was 3.8 cm and the scoliosis angle using the Cobb method was 22˚. A trapezoidal wedge resection osteotomy of the L5 body was performed, and the scoliosis was corrected. We detail this modification of a vertebral osteotomy technique and show that a fixed coronal deformity could be corrected effectively using this technique.

An extensive vertebral hydatidosis revealed by a lumbosciatica

The vertebral hydatidosis is uncommon. It causes problems in diagnosis and in management. A case of an extensive vertebral hydatidosis with few symptoms is reported. A 21-year-old man has consulted for recurrent lumbosciatica that has been evolving for 1 year. Clinical exam was normal. Plain radiographic films disclosed a lytic lesion throughout the bodies of L4 and L5 and calcifications thrown on the liver area. The computed tomography (CT) and the magnetic resonance (MR) images revealed multicystic bony lesions involving the lumbar spine with extension into the spinal canal. Abdominal ultrasound showed also cyst lesions in the right kidney and in the liver. The diagnosis of vertebral and abdominal (liver and kidney) hydatidosis was retained. Four sets of 4-week albendazole cures were given with a 2-week interval in between. Our case of extended vertebral hydatidosis with few symptoms confirms the clinical latency and diagnosis difficulties usually encountered in this disease. This often leads to a late diagnosis of the stage of spinal cord compression. Radiological diagnosis and determination of extension of the hydatid cyst are usually provided by CT and MRI. Vertebral hydatidosis should be evoked in lumbosciatica especially in endemic regions.

THE CLASSIC: Pyogenic Vertebral Osteomyelitis

THE CLASSIC: Pyogenic Vertebral Osteomyelitis

Variation in position of the L4/5 disc inter-space from the anatomical landmark: review of 450 radiographs and clinical applications

The L4/5 disc inter-space is commonly believed to be represented by a line drawn between the two highest points of the iliac crests. This line is frequently used as a pre-operative guide for incision placement, in patients undergoing spinal surgery. We reviewed the antero-posterior and lateral lumbar spine films of 450 patients, ranging in age from 20 to 90 years, measuring the distance from the supracristal plane to the midpoint of the L4/5 disc interspace. The plane intersected the spine at the L4/5 interspace in only 31.9% of cases and was found to lie at the lower half of the body of L4 or above in 49.5% of cases. There was significant variation in the position of the supracristal plane between the different patient age groups studied (P≤0.05). The use of additional imaging, along with plain radiography is advised when attempting identification of this spinal level, as reliance on palpation of the iliac crests alone to identify this landmark may lead to unintentional cranial placement of a surgical incision during spinal procedures, or cannulation at a level above the intended interspace, during epidural and spinal anaesthesia.

Imaging in Acute Pyogenic Spondylitis

A 51-year-old woman who was receiving 7.5 mg prednisone daily for sarcoidosis presented with low backache on the right side, fever, and chills 2 weeks after dental surgery. Examination revealed lower lumbar tenderness andrestricted movement. Blood cultures grew Streptococcus viridans but echocardiography failed repeatedly to demonstrate any evidence of infective endocarditis. Skeletal scintigraphy, including a pinhole image, revealed abnormal uptake in L5. Computed tomography (CT) showed a lytic lesion in the body of L5 and Tc-99m ciprofloxacin (Infecton) imaging demonstrated increased uptake in the lower lumbar region on the right. After several weeks of antibiotic therapy, the patient became afebrile and pain-free.

Surgical treatment of achondroplasia with thoracolumbar kyphosis and spinal stenosis—a case report

A 13-year-old boy suffered from low back weak-ness and bilateral lower extremity numbness for many years. In June 2003, intermittent claudica-tion appeared, the boy could only walk for 5 min, and he was seen at our clinic. Physical examina-tion revealed a short stature of only 126 cm, promi-nent frontal bossing, nose-bridge depression, short limbs with long trunk, and thoracolumbar kypho-sis (Figure 1). No neurological deficit was noted. Radiographs revealed scoliosis and reduced inter-pediclar distance of the lumbar spine (Figure 2). An anterior wedged deformity of the L1 body with prominent thoracolumbar kyphosis was observed with a T12-L2 kyphosis angle of 55° (Figure 3). MRI of the thoracolumbar spine identified a spinal canal stenosis (diameter 10 mm) below the T11 level (Figure 4). One stage anterior L1 corpectomy with interbody fusion was performed, followed by posterior decompression with pedicle screw