Bony Spur Research Articles

Duropathy as a rare motor neuron disease mimic: from bibrachial amyotrophy to infratentorial superficial siderosis

BackgroundBibrachial amyotrophy associated with an extradural CSF collection and infratentorial superficial siderosis (SS) are rare conditions that may occasionally mimic ALS. Both disorders are assumed to be due to dural tears.Case presentationA 53-year-old man presented with a 7-year history of slowly progressive asymmetric bibrachial amyotrophy. Initially, a diagnosis of atypical motor neuron disease (MND) was made. At re-evaluation 11 years later, upper limb wasting and weakness had further progressed and were accompanied by sensorineural hearing loss. MRI of the brain and spine demonstrated extensive supra- and infratentorial SS (including the surface of the whole spinal cord) as well as a ventral longitudinal intraspinal fluid collection (VLISFC) extending along almost the entire thoracic spine. Osteodegenerative changes were observed at C5-C7 level, with osteophytes protruding posteriorly. The bony spurs at C6-C7 level were hypothesized to have lesioned the dura, causing a CSF leak and thus a VLISFC. Review of the MRI acquired at first evaluation showed that the VLISFC was already present at that time (actually beginning at C7 level), whereas the SS was not. 19 years after the onset of upper limb weakness, the patient additionally developed parkinsonism. Response to levodopa, brain scintigraphy with 123I-ioflupane and brain MRI with nigrosome 1 evaluation were consistent with idiopathic Parkinson’s disease (PD). On the latest follow-up 21 years after symptom onset, the VLISFC was unchanged, as were upper arm weakness and wasting.ConclusionsBased on the long-term follow-up, we could establish that, while the evidence of the VLISFC was concomitant with the clinical presentation of upper limb amyotrophy and weakness, the radiological signs of SS appeared later. This suggests that SS was not per se the cause of the ALS-like clinical picture, but rather a long-term sequela of a dural leak. The latter was instead the causative lesion, giving rise to a VLISFC which compressed the cervical motor roots. Dural tears can actually cause several symptoms, and further studies are needed to elucidate the pathophysiological correlates of “duropathies”. Finally, as iron metabolism has been implicated in PD, the co-occurrence of PD with SS deserves further investigation.

Use of Perpendicular Plate of Ethmoid Split Technique in Rhinoplasty and Septoplasty.

In recent years, the perpendicular plate of ethmoid (PPE) has become a prominent choice for bone-grafting materials. This study introduces the PPE split technique for efficient removal of the bony septum or the harvesting of partial PPE for septal batten grafts in rhinoplasty and septoplasty, particularly suited for cases with thick PPE. Herein, this technique was employed to minimize septal defects and prevent complications while achieving harvested bony grafts of the desired effective thickness. In this retrospective study, 36 patients underwent surgery using the PPE split technique (22 septoplasties and 14 rhinoplasties). The procedure involved detaching the PPE from the septal cartilage and performing a vertical plane osteotomy with a number 10 scalpel blade to remove bony spurs or prepare batten grafts. Paranasal sinus CT revealed that the average anteroinferior PPE thickness was 3.46 mm. This technique was used for both bony batten graft harvesting (26 cases) and bony spur removal, and septum reshaping (10 cases). Successful PPE harvesting was achieved in all cases except for three, which experienced graft breakage. This study demonstrates the viability and effectiveness of the PPE split technique as a supplementary maneuver in septoplasty and rhinoplasty procedures. Its diverse applications include reshaping, correcting deviated septum, harvesting bony batten grafts, and providing support for an aesthetically pleasing nasal profile.

Most elite athletes return to preinjury competitive activity after surgical treatment for medial malleolus stress fractures.

To provide return-to-performanceoutcomes after surgical treatment for medial malleolus stress fractures in the elite athlete. Additionally, to describe an individualised surgical approach in the management of medial malleolus stress fractures. Five athletes (six ankles) underwent surgical treatment for a medial malleolus stress fracture. The surgical technique was based on the extent of the fracture line in steps with first arthroscopic debridement of bony spurs, microfracturing of the fracture line and screw fixation. Return-to-performance data includedtime to return to sport-specific training, normal training, first competitive activity, performanceand the return-to-performance rate. Patients returned to sport-specific training at a median of 10 weeks. They started normal training at 16 weeks postoperativelyand returned to their first competitive activity after 19 weeks. All patients had bony spurs on the distal tibia which were arthroscopically debrided. One patient received arthroscopic debridement of bony spurs alone. Four patients received additional microfracturing of the fracture line and three patients received screw fixation. All patients achieved clinical and radiographic union on follow-up computed tomography scan at 3 months postsurgery. At latest follow-up, no refractures nor hardware complications, nor any other complications were observed. Arthroscopic debridement of bony spurs, debridement and microfracturing of the fracture lineand screw fixation are all viable surgical tools in the management of medial malleolus stress fractures in elite athletes. The surgical approach containing these options should be tailored to the individual athlete based on the fracture line in the sagittal plane. While most athletes return to full competitive activity in 3-4 months, time to self-reported return to full performance is often much longer. Level IV.

Quality of Life of Children Treated for Split Cord Malformation

PurposeSplit cord malformation (SCM), associated with neurological deficits, necessitates surgical intervention for spinal cord de-tethering. Limited evidence exists regarding its impact on children's quality of life. Our study aims to evaluate the postoperative quality of life in children treated for split cord malformation. MethodsThis retrospective cohort study examined records of patients with split cord malformation operated on between July 1, 2012, and July 31, 2022, at a single center. Data, including Health Utility Index-3 (HUI-3) scores provided by guardians, was collected to assess quality of life. Clinical and neurological outcomes were also analyzed. ResultsTwenty-five patients, predominantly females (68%), with a median age of 7 years, were included. Most presented with normal motor function (76%). The most common anatomic level of split cord malformation was lumbar (12 48%) followed by lumbosacral (5, 20%). A bony spur from the lamina was the most common cause of splitting the cord (64%). Over a median follow-up of 3.3 years, 64% showed neurological stability, 16% showed neurological improvement, and 4% experienced deterioration. The mean HUI-3 score for 21 children was 0.93 ± 0.24. ConclusionSurgical management of split cord malformation demonstrated favorable neurological outcomes and a positive long-term quality of life, as evidenced by HUI-3 scores. Our findings emphasize the efficacy of surgical intervention in improving the lives of children with this condition.

Preliminary Results of The Treatment for Failed Back Surgery Syndrome by Full Endoscopic Approach at Saint Paul General Hospital, in Hanoi, Vietnam

Objective: Patients with radiculopathy after failed spine surgery due to restenosis, regenerated bony spurs, or inadequate decompression face high risks for morbidity or disability following massive revision operations. Therefore, fully endoscopic spine surgery could be less invasive, safer, and more effective because of accurate exposure, precise decompression, and avoidance of neural tissue injury. Our report aimed to describe the clinical result of selected patients with failed back surgery syndrome (FBSS) treated with fully endoscopic spine surgery at Saint Paul General Hospital in Vietnam.Methods: We retrospectively reviewed 24 patients with FBSS who were treated with uniportal fully endoscopic surgery at Saint Paul General Hospital with an average follow-up period of 16 months.Results: The patients’ average age was 61 years (range, 24–83 years), and the difference between preoperative and postoperative leg pain at the last follow-up was statistically significant (preoperative leg pain visual analogue scale [VAS]=7.1; last follow-up leg pain VAS=0.8; p<0.01). The difference in Oswestry Disability Index scores between the preoperative assessment and the final examination was statistically significant (preoperative, 57.8; last follow-up, 21.2; p<0.01). According to improvements in the MacNab score, the percentage of patients who achieved good or excellent postoperative results was 75%.Conclusion: Major open surgery as a revisional procedure in patients with FBSS syndrome has many potential risks during and after surgery. Fully endoscopic spine surgery can be a safe and effective option for selected cases with lower risk.

Automated surgery planning for an obstructed nose by combining computational fluid dynamics with reinforcement learning

Septoplasty and turbinectomy are among the most common interventions in the field of rhinology. Their constantly debated success rates and the lack of quantitative flow data of the entire nasal airway for planning the surgery necessitate methodological improvement. Thus, physics-based surgery planning is highly desirable. In this work, a novel and accurate method is developed to enhance surgery planning by physical aspects of respiration, i.e., to plan anti-obstructive surgery, for the first time a reinforcement learning algorithm is combined with large-scale computational fluid dynamics simulations. The method is integrated into an automated pipeline based on computed tomography imaging. The proposed surgical intervention is compared to a surgeon’s initial plan, or the maximum possible intervention, which allows the quantitative evaluation of the intended surgery. Two criteria are considered: (i) the capability to supply the nasal airway with air expressed by the pressure loss and (ii) the capability to heat incoming air represented by the temperature increase. For a test patient suffering from a deviated septum near the nostrils and a bony spur further downstream, the method recommends surgical interventions exactly at these locations. For equal weights on the two criteria (i) and (ii), the algorithm proposes a slightly weaker correction of the deviated septum at the first location, compared to the surgeon’s plan. At the second location, the algorithm proposes to keep the bony spur. For a larger weight on criterion (i), the algorithm tends to widen the nasal passage by removing the bony spur. For a larger weight on criterion (ii), the algorithm’s suggestion approaches the pre-surgical state with narrowed channels that favor heat transfer. A second patient is investigated that suffers from enlarged turbinates in the left nasal passage. For equal weights on the two criteria (i) and (ii), the algorithm proposes a nearly complete removal of the inferior turbinate, and a moderate reduction of the middle turbinate. An increased weight on criterion (i) leads to an additional reduction of the middle turbinate, and a larger weight on criterion (ii) yields a solution with only slight reductions of both turbinates, i.e., focusing on a sufficient heat exchange between incoming air and the air-nose interface. The proposed method has the potential to improve the success rates of the aforementioned surgeries and can be extended to further biomedical flows.

Arthroscopic Posteromedial Corner Reconstruction: A Novel Technique and Case Series.

This study aimed to introduce a novel arthroscopic treatment for medial and posteromedial instability of the knee and present the primary and follow-up results. All patients who underwent the arthroscopic approach to treat medial and posteromedial corner instability from 2007 to 2017 were included in this report. Overall, 45 patients were included, among which 75.6% were male. The mean age of patients was 32.2 ± 8.4 years. Overall, 44.4% and 15.6% of patients had associated meniscal injuries and chondral lesions, respectively. The mean follow-up duration of patients was 84.2 ± 25.3 months. Overall, 37 patients developed a full range of motion (82.2%), and most patients (95.6%) showed excellent quadriceps strength (grades 4 and 5). All patients had a normal or 1+ posterior drawer test, Pivot shift test, and Lachman test on physical examination. Moreover, 60% had an associated isolated anterior cruciate ligament injury, 17.8% had an isolated posterior collateral ligament injury, and 17.6% had a combination of more than one ligament injury. One patient developed septic arthritis. Two patients experienced pain, and one pain patient developed pain with a bony spur formation in the medial epicondyle. Three patients showed a 2+ medial collateral ligament (MCL) test (moderate instability) at the final follow-up, all of whom had multi-ligament injuries. All patients, except the three patients who had a failed MCL reconstruction, returned to their previous activities. This study described a novel arthroscopic treatment of MCL injury, and the results showed acceptable postoperative and clinical outcomes. As the use of minimally invasive surgery may minimize multiple complications associated with open surgery, it is suggested that further studies be conducted regarding this approach when faced with patients who have MCL injuries requiring surgery.

Ayurvedic management of acute calcaneal spur with Viddhakarma and Siravedha: A case report

The feet are a highly dependent yet most neglected part of the body. The negligence may result in various levels of discomforts and associated heel pain. Abnormal pressure over foot muscles and ligaments may lead to chronic plantar heel pain and further development of calcaneal spur, which are the most encountered orthopedic problems. Various modern treatment options are available for the management of calcaneal spur, but either they involve longer duration or are expensive. Hence, there is a need to opt treatment approaches that may provide satisfactory results with minimum adversities. Viddhakarma (~therapeutic needle-piercing) and Siravedha (~therapeutic bloodletting) are the therapies of Ayurveda origin, with proven efficacy in pain management and can be used in conditions such as calcaneal spur. A 42-year-old female patient presented to the outdoor patient department in the hospital on August 17, 2022, complaining of sharp pricking pain with heat sensation in the right heel, morning stiffness in bilateral heels, and difficulty in walking for four days. On assessment, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Visual Analog Scale (VAS), and Foot Function Index Scale for the right foot of the patient were scored 47, 9 and 127, respectively. The X-ray of the bilateral foot (anterio-posterior and lateral view) showed an inferior bony spur projecting forward from calcaneal tuberosity more on the right side than on the left. The patient was treated with Viddhakarma, Siravedha of the right foot, along with oral Ayurvedic medicines. On completion of the treatment, the WOMAC and VAS scores were reduced significantly to 37 and 6, respectively. Further, there was a significant reduction in the Foot Function Index scale score to 96 within ten days of the treatment. Based on the clinical observations, it may be inferred that a combination of Viddhakarma, Siravedha, and oral Ayurvedic medicines can be safe, convenient, and effective in managing patients suffering from calcaneal spur. Both of these procedures can be performed by trained health-care professionals on an outpatient basis, thus convenient to the sufferers too.

Cuboid Cobbles Hinder Elite Youth Football Player.

We describe an elite youth football player who developed lateral foot pain of previously unknown origin. A thorough patient history and physical examination as well as an in-depth presentation of radiographic findings on Computed tomography (CT) and Magnetic Resonance Imaging (MRI) scan were described. Through this combination, the puzzle was resolved and a rare peroneus longus tendinopathy due to bony spurs in the cuboid groove was diagnosed. A peroneus longus exploration, release and reduction of the cuboidal bone spurs was performed and intensive rehabilitation phase followed. The patient successfully returned to performance and set a career in professional football.

Multilevel Spinal Canal Stenosis with Ossification of the Ligamentum Flavum in an Achondroplastic Patient : A Case Report

Achondroplasia is the most common form of dwarfism in humans. There are abnormalities of intracartilaginous ossification caused by mutation of FGFR 3 gene resulting in a narrow spinal canal accompanied by neurological impairements in some patients. The neurological impairements could be caused by ossification of ligamentum flavum, disc degeneration, kyphosis of lumbar spine, bony spurs, thickened laminae and facet joints. We reported a case of 23-year-old Indonesian male with achondroplasia, spinal canal stenosis accompanied by ossification of ligamentum flavum presented with progressive myelopathy and neurogenic claudication. Spinal canal stenosis with OLF was observed at L2-L5 level of lumbar spine. Laminectomy with decompression and removal of the OLF was performed at L2-L5. There was an improvement on patient's neurological symptoms and function after the surgery. In this report, we describe a rare case of achondroplasia with OLF presenting with neurological symptoms from multiple level of spinal canal stenosis. We perfromed decompressive wide laminectomy and resection of adherent OLF followed by fusion with instrumentation resulted in the improvement of patient's neurological symptoms and function.

Imaging features and clinical significance of atypical pleural plaques mimicking bone tumors: a retrospective case series.

This study aimed to examine the imaging characteristics and clinical implications of atypical pleural lesions that mimic bone tumors and form along the inner margins of consecutive ribs. This retrospective analysis included 45 atypical pleural lesions arising from 13 patients who underwent chest computed tomography (CT) between April 2021 and March 2023. The clinical features, CT findings, and radiologic diagnoses prior to pathologic identification were examined. Pathological findings were reviewed in the surgically resected case. Subgroup analysis was performed based on the presence of concurrent typical pleural plaques. The mean age of the patients was 69.3±8.4 years with a predominance of males (76.9%). The lesions primarily exhibited unilateral involvement (84.6%), being most frequently located in the right mid-level posterior region. Calcification was present in 75.6% of cases, typically seen continuously along the ribs (82.4%). Adjacent rib changes were observed in 28.9% of cases. These lesions were frequently misdiagnosed as osteochondromas or bony spurs (55.6%) by thoracic radiologists. No significant growth was observed during follow-up (n=11, 47±41 months), and the pathological findings were consistent with pleural plaques. Patients with concurrent typical pleural plaques had more atypical pleural lesions without statistical significance (P=0.071) and showed a more even distribution (P=0.039). In conclusion, atypical pleural lesions resembling bone tumors along consecutive ribs represent a distinct subset of pleural plaques. Their unique distribution and morphology should be recognized by radiologists to avoid misinterpretation and unnecessary interventions.

Management of extensor tendon injuries concerning distal radius fractures

IntroductionRupture of the extensor tendons secondary to fractures involving the distal radius is a well-recognized rare complication. In patients with implants particularly, there exists a tendency for attributing the implant as a cause for the tendon rupture. We retrospectively studied the patients with extensor tendon injuries related to distal radius fractures, analyzed the factors leading to the rupture, suggest few preventive measures and describe the management strategy of these ruptures. Materials and methods21 patients who were treated for extensor tendon rupture following distal radius fractures in the period of 2014–2022 were retrospectively analyzed. 19 patients had been managed with surgery and two patients conservatively for the distal radius fracture. The time interval between the fracture fixation and tendon rupture, the time interval between tendon rupture and presentation, the extensor tendons injured and the position of the impinging screws or bony spur in relation to the extensor compartments, necessity for implant removal and modality of tendon reconstruction were studied in these patients. ResultsExtensor pollicis longus was found to be ruptured in all the patients except one patient with Extensor indicis proprius rupture alone. The time interval between the fracture fixation and tendon rupture averaged at 32.5 months. End to end repair of the ruptured tendons was never possible even in patients who presented earlier. 10 patients underwent intertendinous bridge grafting and 11 patients underwent tendon transfer. All the patients achieved full extension of thumb with no donor deficit. ConclusionDistal radius fracture related extensor tendon injuries pose a technical challenge to the surgeon and concern to the patient in the form of recurring surgeries. However, with immediate presentation to the surgeon and their use of appropriately designed management algorithm, these patients could be immensely satisfied with the outcome.

The Ageing Foot.

Feet suffer significant stress throughout a lifetime and undergo ageing-associated problems due to gradual tissue degeneration affecting the skin, connective tissue, and nerves. Oxygen supply to the tissues may be diminished. The skin gets dry and calluses, ulcers and fungal infections of the skin and nails are not uncommon. Ligaments and tendons degenerate and, without proper prevention, deformities including claw toes, hammer toes, tendonitis, and bursitis may occur. Skeletal toe deformities such as bunions, bony spurs, and hallux valgus may increase discomfort, while stress fractures may have an adverse impact on the patients' quality of life. The ageing foot pathology may add up to common age-related problems, such as crystal deposition arthropathies, diabetes mellitus, peripheral circulatory disorders, and peripheral edema, increasing morbidity. This review summarizes ageing-related feet problems, focusing on prevention and treatment. Foot health has a paramount role in overall wellbeing, therefore prevention, proper foot care, and prompt diagnosis and management of ageing-related changes are vital for maintaining a healthy, active status.

Dorsal bony spur in pediatric split cord malformations: eight-year experience from a tertiary care hospital.

Dorsal spurs in Type I split cord malformations (SCM-I) are infrequent findings. The pathogenesis of the same is debatable. The objective of this study is to analyze our experience with SCM-I patients having dorsal bony spurs. Retrospective analysis of SCM patients operated from 2010 to 2017 was performed. Their demographic profile, clinic-radiological features, operative findings, and outcome following surgery were recorded. Twenty-four cases of Type I SCM harboring dorsal bony spurs were identified with mean age of 4.96years. The commonest split site was lumbar, documented in 62.5%. Scoliosis was observed in 58.3%. Pre-operative neurological deficits were seen in 66.6% cases with asymmetric weakness of limbs seen in 16.6%. There was no new neurological deficit observed post-operatively. This is the largest series of dorsal spurs occurring in SCM, reported in literature so far. Meticulous pre-operative evaluation and imaging are important to identify dorsal spurs for appropriate management and good clinical outcome. Differentiating dorsal spur from ventral spur is important as it has a bearing on surgical approach.

Unravelling the pathogenesis of foramen magnum stenosis in patients with severe achondroplasia: a CT-based comparison with age-matched controls and FGFR3 craniosynostosis syndromes.

Foramen magnum(FM) stenosis can be responsible for acute and chronic damage to the cervicomedullary junction in children with achondroplasia. The bony anatomy and patterns of suture fusion of the FM in this context are incompletely understood, yet becoming increasingly important in the light of novel medical therapies for achondroplasia. The objective of this study was to describe and quantify bony anatomy and fusion patterns of FM stenosis in patients with achondroplasia using CT scans, comparing them to age-matched controls and other FGFR3 craniosynostosis patients. Patients with achondroplasia and severe FM stenosis, classified as achondroplasia foramen magnum score(AFMS) grades 3 and 4, were identified from a departmental operative database. All had pre-operative CT scans of the craniocervical junction. Measurements obtained comprised sagittal diameter (SD), transverse diameter (TD), foramen magnum area, and opisthion thickness. Anterior and posterior interoccipital synchondroses (AIOS and PIOS) were graded by the extent of fusion. These measurements were then compared with CT scans from 3 age-matched groups: the normal control group, children with Muenke syndrome, and children with Crouzon syndrome with acanthosis nigricans (CSAN). CT scans were reviewed in 23 cases of patients with achondroplasia, 23 normal controls, 20 Muenke, and 15 CSAN. Children with achondroplasia had significantly smaller sagittal diameter (mean 16.2 ± 2.4mm) compared to other groups (control 31.7 ± 2.4mm, p < 0.0001; Muenke 31.7 ± 3.5mm, p < 0.0001; and CSAN 23.1 ± 3.4mm, p < 0.0001) and transverse diameters (mean 14.3 ± 1.8mm) compared with other groups (control 26.5 ± 3.2mm, p < 0.0001; Muenke 24.1 ± 2.6mm, p < 0.0001; CSAN 19.1 ± 2.6mm, p < 0.0001). This translated into a surface area which was 3.4 times smaller in the achondroplasia group compared with the control group. The median grade of the AIOS fusion achondroplasia group was 3.0 (IQR 3.0-5.0), which was significantly higher compared with the control group (1.0, IQR 1.0-1.0, p < 0.0001), Muenke group (1.0, IQR 1.0-1.0, p < 0.0001), and CSAN (2.0, IQR 1.0-2.0, p < 0.0002). Median PIOS fusion grade was also highest in the achondroplasia group (5.0, IQR 4.0-5.0) compared with control (1.0, IQR 1.0-1.0, p < 0.0001), Muenke (2.5, IQR 1.3-3.0, p < 0.0001), and CSAN (4.0, IQR 4.0-4.0, p = 0.2). Distinct bony opisthion spurs projecting into the foramen magnum were seen in achondroplasia patients but not others, resulting in characteristic crescent and cloverleaf shapes. Patients with AFMS stages 3 and 4 have significantly reduced FM diameters, with surface area 3.4 times smaller than age-matched controls. This is associated with premature fusion of the AIOS and PIOS in comparison with controls and other FGFR3-related conditions. The presence of thickened opisthion bony spurs contributes to stenosis in achondroplasia. Understanding and quantifying bony changes at the FM of patients with achondroplasia will be important in the future quantitative evaluation of emerging medical therapies.

Cubitus varus after pediatric lateral condylar fracture: true or pseudo?

PurposeCommon complications of lateral condylar fractures are lateral condylar overgrowth, lateral bony spur and cubitus varus. Lateral condylar overgrowth or lateral bony spur may appear as cubitus varus on gross examination. Such gross cubitus varus without actual angulation is pseudo-cubitus varus, while a difference of more than 5° in varus angulation on X-ray is true cubitus varus. This study aimed to compare true and pseudo-cubitus varus.MethodsOne hundred ninety-two children treated for unilateral lateral condylar fracture with a follow-up period of over six months were included. The Baumann angle, humerus-elbow-wrist angle and interepicondylar width of both side were compared. More than 5° in varus angulation on X-ray was considered cubitus varus. Increase in interepicondylar width was considered lateral condylar overgrowth or a lateral bony spur. The risk factors that could predict the development of a true cubitus varus were analyzed.ResultsTrue cubitus varus was 32.8%, measured by Baumann angle and 29.2%, measured by humerus-elbow-wrist angle. A total of 94.8% of patients showed an increased interepicondylar width. The predicted cut-off value for 5° varus angulation on the Baumann angle was a 3.675 mm increase in interepicondylar width by ROC curve analysis. The risk of cubitus varus in stage 3, 4, and 5 fractures according to Song’s classification was 2.88 times higher than that in stage 1 and 2 fractures on multivariable logistic regression analysis.ConclusionPseudo-cubitus varus is more prevalent than true cubitus varus. A 3.7 mm increase in interepicondylar width could simply predict true cubitus varus. The risk of cubitus varus increased in Song’s classification stages 3, 4, and 5.

Morphological Measurements of Innominate Foramina and Bony Spurs along the Base of Sphenoid as a Potential Risk Factor for Neurovascular Entrapment, Radiological Interpretation and Surgical Access.

Restricted access and compression of neurovascular structures at various anatomic variations at the skull base poses a challenge to surgeons, neurologists and anesthetists. The present study was performed with the objective of providing morphometric analysis of innominate foramina, and anomalous bony bars and spurs along the infratemporal surface of the greater wing of the sphenoid and reviewing the practical significance of dealing with this region. A total of 100 dry-aged human adult skulls from the archives of the osteology library of the Department of Anatomy were studied. A detailed morphometric analysis of such innominate foramina and anomalous osseous structures along the base of the sphenoid was performed using a sliding digital vernier caliper. Anomalous bony bar was found in 22 skulls (25.28%). A complete bar was observed at eight (9.1%). An innominate foramen was located inferomedial to foramen ovale (5 unilateral and 3 bilateral) with a mean anteroposterior diameter of 3.44 mm and a mean transverse diameter of 3.16 mm. Neurovascular structures may be compressed by abnormal bony outgrowths or while traversing through such unnamed bony foramina. The latter may also be overlooked and mistaken during radiological interpretation leading to delayed diagnosis. Such unnamed foramina and bony outgrowths need to be documented in the literature due to their surgical, and radiological implications and limited citations.

Biomechanical impact of elbow motion in elbow stiffness.

A mechanical block in the elbow due to osteophytes in the olecranon fossa is a common clinical symptom for elbow stiffness. This study aims to understand the biomechanical characteristics or changes in the stiff elbow in the resting (or neutral) and swing position of the arm using a cadaveric model. The hypotheses included the following: (1) a difference exists in the articular contact pressure of the elbow by comparing the non-stiff and stiff models in in vivo studies; (2) the degree of stiffness would affect the increase of the joint loading of the elbow. Controlled laboratory study, cadaveric study. Eight fresh-frozen specimens from individuals of both sexes were included in the biomechanical study. The specimen was mounted on a custom-designed jig system with gravity-assisted muscle contracture to mimic the elbow in a standing position. The elbow was tested in two conditions (the resting and passive swing). Contact pressure was recorded for three seconds in the resting position, which was the neutral position of the humerus. By dropping the forearm from 90° of the elbow flexion, the passive swing was performed. The specimens were tested sequentially in three stages of stiffness (stage 0, no stiffness; stage 1, 30° of extension limitation; and stage 2, 60° of extension limitation). After data collection was completed in stage 0, a stiff model was sequentially created for each stage. The stiff model of the elbow was created by blocking the olecranon by inserting a 2.0K-wire into the olecranon fossa horizontally with the intercondylar axis. The mean contact pressures were 279 ± 23, 302 ± 6, and 349 ± 23kPa in stages 0, 1, and 2, respectively. The increases in the mean contact pressure in stages 2 versus 0 were significant (P < 0.0001). The mean contact pressures were 297 ± 19, 310 ± 14, and 326 ± 13kPa in stages 0, 1, and 2, respectively. The peak contact pressures were 420 ± 54, 448 ± 84, and 500 ± 67kPa in stages 0, 1, and 2, respectively. The increases in mean contact pressure in stage 2 versus 0 were significant (P = 0.039). The increases in peak contact pressure in stages 0 versus 2 were significant (P = 0.007). The elbow bears the load created by gravity and muscle contracture in the resting and swing motion. Moreover, extension limitation of stiff elbow increases the load bearing in the resting position and swing motion. Careful surgical management should be considered for meticulous clearance of bony spur around olecranon fossa to resolve the extension limitation of the elbow.

Abstract Number ‐ 76: Bow hunter’s syndrome‐ a rare case of hearing loss associated with co‐dominant vertebral artery compression

Introduction Bow hunter’s syndrome (BHS), also known as rotational vertebral artery syndrome, refers to symptomatic vertebrobasilar insufficiency (VBI) caused by mechanical compression and severe stenosis or occlusion of the vertebral artery (VA) during neck and head rotation. Etiologies include bony spurs and osteophytes, or hypertrophic muscles and ligaments compressing typically on the dominant vertebral artery. Upon turning their head, patients experience posterior circulation symptoms such as vertigo, dizziness, syncope, nausea, tinnitus, or headache. These patients are at risk of stroke due to repetitive mechanical damage to the vessel and thromboembolism. [1] We present a rare case of BHS associated with hearing loss that was caused by bony spurs compressing on a left co‐dominant vertebral artery seen on turning head to both sides. Methods A woman in her 50s presented with sporadic progressive episodes of dizziness which started about 4 years. In addition, she reported experiencing episodic tinnitus in her left ear, frequent headaches, neck pain, and syncopal episodes. She was diagnosed with severe left ear sensorineural hearing loss (SNHL). Vestibular therapy and multiple neuropathic medications (nortriptyline, gabapentin) only provided her with minimal relief. Results Examination showed left SNHL and neck tenderness. X‐ray of cervical spine showed bony hypertrophy adjacent to the dens and inferior to the anterior arch of C1, suggestive of large osteoarthritic bony spurs. CT angiogram showed narrowing of the left vertebral artery at C1 due to severe hypertrophic arthropathy of the lateral mass articulation. It also showed impingement of the left VA in the left transverse foramen. The intradural portion of the VA (V4) appeared to be co‐dominant with normal size. Dynamic cerebral angiogram revealed near occlusion of the left VA at the level of C1‐C2 with head to the right. Left VA remained patent in neutral position, and experienced reduction in flow with head rotation to the left. The dynamic stenosis of VA caused by mechanical compression upon head turn leading to VBI, and reversal of stenosis when rotating head to neutral position was consistent with diagnosis of Bow hunters syndrome. Conclusions This case report highlights a rare presentation of VBI caused by dynamic stenosis of VA as a sequela of mechanical compression of a co‐dominant VA upon head turn to both sides. Only about 2% of the BHS patients experience symptoms during head turn to both sides [2], which was the finding in our patient. Furthermore, this case illustrates an association between BHS and SNHL. Hearing loss is previously described in vertebral artery atresia [3]; however, we present a novel association between acquired BHS and SNHL. Although we could not prove the causality, the coexistence of the two conditions in this patient may help to elicit further clinical consideration and evaluation in patients with SNHL of unknown etiology.

Multiple Split Cord Malformation with Dysplasia of the Hip Joints: A Rare Association or Part of a Sydromic Presentation

Abstract Background: Multiple level split cord malformations (SCMs) with associated skeletal abnormality are rare. Here we discuss a 3-year-old male child with double-level SCM type 1 and developmental dysplasia of the hip joints. Case: A 3-year-old male child presented with chronic constipation since birth with urinary incontinence. There was gait abnormality and he could not able stand without support. Radiology showed SCM type 1 at the level of D9-11 and L4. X-ray showed left dysplastic hip joints. Surgically both the bony spurs were resected and dural sac was repaired along with detethering of the low-lying filum. Orthopedic intervention was done after 3 months. At 18-month follow-up the child has improved bowel and bladder symptoms and could able to walk independently. Conclusion: Though rare, skeletal abnormalities like dysplastic hip joints may be associated with SCM. Early diagnosis and management of both conditions have better outcomes.