Comma Sign Research Articles

Meniscal Comma Sign Responds to Partial Meniscectomy Despite Increased Levels of Arthritis

PurposeTo compare the outcomes of patients undergoing partial meniscectomy preoperatively identified with the “meniscal comma sign” with those undergoing meniscectomy with other tear patterns. MethodsPatients with meniscal “comma sign,” as indicated by a query of MRI reports, were screened using the search terms “meniscotibial recess,” “meniscus perched over the medial tibial margin,” or other search terms by radiologists between January 2008 and November 2019. Patients were matched and chart review was done for demographics, revision surgery, and progression to total knee arthroplasty. Radiographs were used for osteoarthritis grading using the Kellgren-Lawrence (KL) scoring system. Preoperative and postoperative International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Lysholm, and Short Form 12-item Survey (SF-12) scores were collected. Results406 patients met inclusion (comma sign =197; control group n=209). The control group had an increased duration of symptoms at the initial visit (P=0.001). More meniscal comma sign patients received corticosteroid knee injections before surgery (P=0.011). Comma sign patients also had greater mean KL scores (P=0.001) as well as higher KL categorical scores (P=0.002), indicating more advanced levels or arthritis. There were no differences in those receiving physical therapy (PT) before surgery (P=0.966) or those receiving injections or PT after surgery (P=0.631, P=0.37, respectively). IKDC, KOOS, Lysholm, and SF-12 Physical scores improved preoperatively to postoperatively in both groups (P<0.05), and there was no difference between the case and control group (P>0.05). No significant difference was found in revisions or progression to total knee arthroplasty between cohorts. (P=0.676 and P=0.424). ConclusionPatients presenting with preoperative findings of meniscal comma sign fare similarly to those that do not. Patients with this meniscal injury tend to have more advanced grading of osteoarthritic changes in the knee upon presentation and seek care earlier than those without. Arthroscopic meniscectomy is a good treatment option for patients with a meniscal fragment in the meniscotibial recess and shows outcomes comparable to those with other tear patterns. Level of EvidenceLevel III, retrospective cohort

Prevalence, diagnosis, and impact on clinical outcomes of dural ossification in the thoracic ossification of the ligamentum flavum: a systematic review.

Systematic review. Thoracic ossification of the ligamentum flavum (TOLF) has become the principal cause of thoracic spinal stenosis. Dural ossification (DO) was a common clinical feature accompanying with TOLF. However, on account of the rarity, we know little about the DO in TOLF so far. This study was conducted to elucidate the prevalence, diagnostic measures, and impact on the clinical outcomes of DO in TOLF by integrating the existing evidence. PubMed, Embase, and Cochrane Database were comprehensively searched for studies relevant to the prevalence, diagnostic measures, or impact on the clinical outcomes of DO in TOLF. All retrieved studies meeting the inclusion and criterion were included into this systematic review. The prevalence of DO in TOLF treated surgically was 27% (281/1046), ranging from 11 to 67%. Eight diagnostic measures have been put forward to predict the DO in TOLF using the CT or MRI modalities, including "tram track sign", "comma sign", "bridge sign", "banner cloud sign", "T2 ring sign", TOLF-DO grading system, CSAOR grading system, and CCAR grading system. DO did not affect the neurological recovery of TOLF patients treated with the laminectomy. The rate of dural tear or CSF leakage in TOLF patients with DO was approximately 83% (149/180). The prevalence of DO in TOLF treated surgically was 27%. Eight diagnostic measures have been put forward to predict the DO in TOLF. DO did not affect the neurological recovery of TOLF treated with laminectomy but was associated with high risk of complications.

Repair Technique for Displaced Meniscal Flap Tears Indicated by MRI Comma Sign

The meniscus comma sign has been described for displaced flap tears of the meniscus. These meniscus tears are displaced into the tibia or femoral recesses and can be often difficult to diagnose intraoperatively. We describe the technique of diagnosis and treatment of a large displaced lateral meniscus flap tear, presenting as a meniscus comma sign. The identification of the meniscus comma sign on consecutive magnetic resonance imaging (MRI) cuts suggest a flap tear of a significant size that indicates reparability. The technique would be to lift the meniscus flap from the meniscotibial recess, reduce it and then repair it with an all-inside meniscus repair or by hybrid meniscus repair techniques.

Arthroscopic Suture-Bridge Repair of the Subscapularis Tendon—“Inside and Outside the Box” With Preservation of the Comma Sign

The subscapularis muscle and its tendon are of major importance in the kinematics of the glenohumeral joint. Therefore, a diligent repair of subscapularis tears is essential. We describe our reliable standardized arthroscopic suture bridge technique to repair subscapularis tears under intra- and extraarticular visualization and with preservation of the “comma sign.” This technique provides excellent exposure of the subscapularis tendon, allows its complete release in the subcoracoid space and ensures a safe and stable repair.

A “Comma Sign”–Directed Subscapularis Repair in Anterosuperior Rotator Cuff Tears Yields Biomechanical Advantages in a Cadaveric Model

Background: Additional stabilization of the “comma sign” in anterosuperior rotator cuff repair has been proposed to provide biomechanical benefits regarding stability of the repair. Purpose: This in vitro investigation aimed to investigate the influence of a comma sign–directed reconstruction technique for anterosuperior rotator cuff tears on the primary stability of the subscapularis tendon repair. Study Design: Controlled laboratory study. Methods: A total of 18 fresh-frozen cadaveric shoulders were used in this study. Anterosuperior rotator cuff tears (complete full-thickness tear of the supraspinatus and subscapularis tendons) were created, and supraspinatus repair was performed with a standard suture bridge technique. The subscapularis was repaired with either a (1) single-row or (2) comma sign technique. A high-resolution 3D camera system was used to analyze 3-mm and 5-mm gap formation at the subscapularis tendon-bone interface upon incremental cyclic loading. Moreover, the ultimate failure load of the repair was recorded. A Mann-Whitney test was used to assess significant differences between the 2 groups. Results: The comma sign repair withstood significantly more loading cycles than the single-row repair until 3-mm and 5-mm gap formation occurred (P≤ .047). The ultimate failure load did not reveal any significant differences when the 2 techniques were compared (P = .596). Conclusion: The results of this study show that additional stabilization of the comma sign enhanced the primary stability of subscapularis tendon repair in anterosuperior rotator cuff tears. Although this stabilization did not seem to influence the ultimate failure load, it effectively decreased the micromotion at the tendon-bone interface during cyclic loading. Clinical Relevance: The proposed technique for stabilization of the comma sign has shown superior biomechanical properties in comparison with a single-row repair and might thus improve tendon healing. Further clinical research will be necessary to determine its influence on the functional outcome.

The Use of the Comma Sign and Tissue for Recognition, Reduction, and Stability During Arthroscopic Repair of Combined Anterosuperior Cuff Tears

Background: The comma sign is a useful marker for combined retracted supraspinatus and subscapularis tears. It was first described by the group of Burkhart as a “composite ligamentous structure” of the rotator interval attached to the retracted subscapularis. However, Neyton and coworkers suggested that the ruptured superior part of subscapularis is pulled upward by supraspinatus retraction. This video illustrates the value of “comma” recognition for reduction and repair stability. We feel that the comma tissue can be a composition of rotator interval ligaments with or without superior subscapularis contribution depending on an associated cleavage tear. Indications: Patients with retracted anterosuperior tears, unless muscle quality is poor (Goutallier classification ≥3). Understanding of the comma tissue is difficult but of crucial importance to assess complex anterosuperior cuff tears for reduction and repair with stability by maintaining and integrating this comma link into the repair construct. Technique Description: Arthroscopic setup includes beach chair position, armholder, cerebral saturation monitoring (target mean arterial blood pressure of about 70 mm Hg). Previously described circumferential portals were used for a repair with a double row construct (4 medial anchors: 2.5 for subscapularis; 1.5 for supraspinatus) and 2 lateral anchors. The superior boarder of subscapularis as well as the retracted capsular layer of supraspinatus was reduced and fixed using a lasso loop technique. Key stages are (1) tendon manipulation with 2 traction sutures; (2) tendon release; (3) comma reduction; (4) footprint preparation (burr, microfracture); (5) retrograde suture passing; (6) knot tying, knotless lateral row; and (7) a close surgeon to physiotherapist rehabilitation link (6 weeks passive to 90°, no resistance training for 3-6 months). Results: Senior author’s (S.B.) series: 32 anterosuperior tears over 4 years (mean age: 62 years, 48-73 years), minimum follow-up 1 year showed good results (mean SSV: 85% [preop. 35%], range: 40%-95%; mean Constant: 82 [preop. 30], range: 40-90). One major complication (cutibacterium infection; brick layer; workers compensation; invalidity demand; Constant/Subjective Shoulder Value both 40) and minor temporary stiffness at 3 months (8 patients; 22%). Conclusion: Adequate reduction and comma integration into a solid repair construct, as well as responsible rehabilitation surveillance, deliver successful results after technically intricate anterosuperior repairs.

Preoperative Magnetic Resonance Imaging Accurately Detects the Arthroscopic Comma Sign in Subscapularis Tears

To assess the accuracy and reliability of routine preoperative magnetic resonance imaging (MRI) in the detection of the comma sign compared with the gold standard of arthroscopic findings. Preoperative MRI exams in consecutive patients undergoing arthroscopic subscapularis tendon repair, over a 5-year time frame, were retrospectively reviewed for full-thickness tears of the subscapularis and supraspinatus tendons, fatty atrophy of the subscapularis and supraspinatus muscles, and status of the long head of the biceps tendon. Each case was also evaluated for presence or absence of a comma sign on MRI. Surgical findings served as the diagnostic standard of reference in determination of a comma sign. The study cohort included 45 male and 10 female patients (mean age, 56; range, 32-80 years). A comma sign was present at arthroscopy in 19 patients (34.5%). Interclass and intrarater correlation showed 100% agreement in preoperative assessment of a comma sign on MRI. MRI showed an overall accuracy of 83.6% in diagnosis of a comma sign (sensitivity, 63.2%; specificity, 94.4%; positive predictive value, 85.7%; negative predictive value, 82.9%; positive likelihood ratio, 11.37; negative likelihood ratio, 0.39). No statistically significant association was observed betweenan arthroscopic comma sign and patient demographics or MRI findings of full-thickness rotator cufftears, muscle fatty atrophy, or long head of the biceps tendon pathology. MR imaging illustrates excellent reliability and good specificity and accuracy in detection of the arthroscopic comma sign in the setting of subscapularis tendon tearing. Detection of a comma sign on MRI may be important preoperative planning information in the arthroscopic management of patients with subscapularis tendon tears. Level IV, retrospective diagnostic study.

Elasticity evaluation of the fiber bundle forming the comma sign with ultrasound microscopy

The comma sign is a well-known marker of the torn edge of the subscapularis tendon (SSC). The purpose of this study was to evaluate the elasticity of the supraspinatus tendon (SSP), the fiber bundle forming the comma sign (FBCS), and the SSC in intact and cuff-torn shoulders using ultrasound microscopy to examine the reason why the FBCS is maintained even in cuff-torn shoulders.

A histoanatomical study of the fiber bundle forming the ‘Comma Sign,’ a critical marker of the torn edge of the subscapularis tendon

The "Comma sign" is a well-known indicator of the subscapularis torn edge of the shoulder. We undertook a histoanatomical study of the fiber bundle forming Comma sign (FBCS) to determine why FBCS is maintained even in cuff tear cases. Part 1: five tissue blocks including the supraspinatus tendon (SSP), rotator interval (RI), and subscapularis tendon (SSC) out of 5 cuff-intact cadavers were histologically observed in serial sections. Part 2: another tissue blocks of 6 cuff-intact cadavers were serially sectioned along the estimated FBCS direction based on the Part 1 findings. Additionally, 5 tissue blocks of cuff-torn cadavers including the three components, SSP, FBCS, and SSC, were serially sectioned along the apparent FBCS. In one slice clearly demonstrating FBCS fibers out of each section series, the components were measured of the sound speed and visualized through a scanning acoustic microscope (SAM). At the lateral portion, RI tissue with the joint capsule became thick and tightly surrounded SSP. Similarly, thicker RI tissue adhered to SSC from the superior and bursal side. More laterally, the borders of SSP/FBCS and FBCS/SSC were unclear with intermingled fibers. At the lateral most portion, RI tissue formed a fiber bundle, FBCS, extending from SSP to the bursal side of SSC. The sound speeds of SSP and SSC were significantly faster than FBCS in both cuff-intact and cuff-torn slices. In SAM images of cuff-torn specimens the FBCS borders were all unclear. As FBCS extends from the capsule beneath SSP and to the bursal surface of SSC, the FBCS connection to SSP and SSC is hardly lost, even though SSP or SSC detaches from the greater or lesser tubercle, respectively. Additionally, as degeneration make the elasticity difference gradual, the stress concentration at the borders may be diminished, leading to less breakage of FBCS.

Subcapularis tendon tear: A structure-based arthroscopic description

IntroductionSubscapularis (SSC) tendons differ from supraspinatus tendons, although both have similar histologic structure comprising two layers with distinct collagen fiber organization. HypothesisThe partial/full-thickness tear classification for the supraspinatus based on tendon structure can be applied to the subscapularis tendon on objective criteria. Material and methodsThe present study used 100 films of arthroscopic rotator cuff repair involving SSC lesion. Lesions were reported on 3 objective criteria: horizontal superior tendon edge visibility, lesser tuberosity bone exposure, and lateral tendon edge visibility. Combining the three distinguishes deep, superficial or interstitial partial tear versus full-thickness tear. Degree of retraction was also noted. ResultsForty-six of the 73 partial lesions involved the deep articular layer, which was often retracted, but conserving the horizontal superior tendon edge and thus misleadingly suggesting SSC integrity; 23 were interstitial, without detachment from the lesser tuberosity; 4 involved only the superficial layer. Full-thickness tears were always retracted, with loss of horizontal superior tendon edge, visibility of the lateral tendon edge and presence of comma sign. Inter- and intra-observer reproducibility was satisfactory. Discussion – conclusionLike in superior cuff tear, a structure-based classification can be made of SSC lesions on objective criteria. Level of evidenceIV.

The diagnostic accuracy of CT-based "Banner cloud sign" for dural ossification in patients with thoracic ossification of the ligamentum flavum: a prospective, blinded, diagnostic accuracy study protocol.

BackgroundOssification of the ligamentum flavum (OLF) is the most common cause of thoracic spinal stenosis, which responds poorly to conservative treatment. Thus, surgery is the only effective treatment for OLF. The existence of dural ossification (DO) makes surgery challenging and increases the risk of intra-/post-operative complications. To date, several methods have been proposed to identify DO, but either the diagnostic accuracy is low or the feasibility is poor. Therefore, the aim of this study was to propose a new imaging sign (Banner cloud sign, BCs), evaluate the accuracy of BCs in the diagnosis of DO, and provide reliable evidence-based data for its application in clinical practice.MethodsA prospective, blinded, diagnostic accuracy study will be conducted to assess and compare the accuracy of BCs in the diagnosis of DO with other radiological signs [Tram track sign (TTs) and Comma sign (Cs)]. A total of 120 patients diagnosed with OLF who underwent decompression at the Peking University Third Hospital between January 2018 and June 2019 will be enrolled. Patients’ medical records and imaging data will be retrieved from the hospital database server. An observational group consisting of six spine surgeons (with different seniority levels) and two epidemiological researchers will read the patients’ images to identify typical imaging signs and determine the presence of DO. Surgical records will be reviewed to confirm the presence of DO, and the results will serve as the reference standard for estimating accuracy. The primary outcome of the study is to determine the accuracy of BCs for DO diagnosis, and the secondary outcome is to compare the sensitivity, specificity, area under the receiver operating characteristic (ROC) curve and inter-observer reliability of each imaging sign. The time taken and level of confidence in DO diagnosis of each observer will also be compared.DiscussionThis study represents the first large-scale investigation of the diagnostic value of BCs, TTs and Cs in the diagnosis of DO, and will provide convincing evidence about their clinical application.Trial registrationRegistered on 29 February 2020. Trial number is ChiCTR2000030380.

Budd-Chiari Syndrome: The “inferior vena cava reverse-flow” sign and “jet-blood” sign on CT and MRI

ObjectiveTo investigate the CT and MR features of “inferior vena cava(IVC) reverse-flow” sign and “jet-blood” sign in Budd-Chiari Syndrome (BCS). MethodsThe liver CT and/or MRI plain scan and dynamic enhancement of 107 cases of BCS diagnosed by DSA and/or clinic were collected, including 17 patients with hepatic vein obstruction type, 79 patients with IVC obstruction type, and 11 patients with mixed type. The manifestations of IVC reverse-flow sign and jet-blood sign in the latter two type BCS (90cases) imaging were analyzed. Results1) The incidence of IVC reverse-flow sign in the IVC obstruction type and mixed type was 93.3 %(83/90), which was manifested as: The contrast agent was shown below the level of renal veins in the hepatic arterial phase enhancement, while no contrast agent was shown above it at the same time. 2) The incidence of jet-blood sign in membrane-perforated subtype was 100 %(15/15) or 16.7 %(15/90), which was manifested as: The low density/signal dots appeared within full of contrast agent at the superior liver segment IVC on axial slices in arterial phase of CT/MRI enhancement, or the low signal line within agent presented above the IVC membrane on coronal image in equilibrium phase of MR enhancement. 3) Other imaging findings: 75 cases of membrane, 18 cases of membrane calcification, 27 cases of abnormal hepatic vein, 76 cases of abnormal structure of IVC, 18 cases of thrombus/cancer embolus in hepatic vein and/or IVC. There were 65 cases of abnormal liver appearance; 71 cases of abnormal liver enhancement; 21 cases of hepatic vein unsynchronous enhancement. Anastomotic branches among the hepatic veins open with comma sign in 54 cases; dilatation of intraspinal and paravertebral veins, azygos and hemiazygos veins in 90 cases(100 %, 90/90) or 96 cases(89.7 %, 96/107). ConclusionsThe “IVC reverse-flow” sign is a specific CT and MR sign of IVC type and mixed type BCS, and the “jet-blood” sign is a characteristic CT and MR sign of membrane-perforated subtype BCS.

Comma sign of subscapularis tear: diagnostic performance and magnetic resonance imaging appearance

The main aim of this study was to evaluate the performance of magnetic resonance imaging (MRI) and interobserver agreement in the identification of the comma sign. The second objective was to look for a correlation between the comma signand the detachment of the superficial fascia of the subscapularis. Two radiologists, blinded to the arthroscopic findings, retrospectively assessed the magnetic resonance images of 110 shoulders and were asked to assess the presence of the comma sign and the intact subscapularis fascia. The inter-reader agreement and the MRI performance values for detection of the comma sign were calculated. In addition, the association between the intact superficial subscapularis fascia and the comma sign was evaluated. The agreement between the 2 radiologists was perfect. The following values were obtained: sensitivity, 90.9%; specificity, 98.8%; positive predictive value, 95.2%; negative predictive value, 97.7%; and accuracy, 97.2%. No association between the comma sign and subscapularis fascia lesions was found. MRI appears to be a reliable method for preoperative assessment of the comma sign. The comma sign appears not to be formed by the detached subscapularis fascia.

Analysis of Spelling Error In Dissertation Based on the General Guideline for Indonesian Spelling (Pedoman Umum Ejaan Bahasa Indonesia)

This study aims at describing and classifying forms of misspelling in dissertations based on General Guideline for Indonesian Spelling (Pedoman Umum Ejaan Bahasa Indonesia [PUEBI]). It is a descriptive qualitative study. The type of data obtained in this study is document text, consisting of primary data sourced from dissertation and secondary data sourced from related documents. Data collection is carried out by using text analysis, documentation, and recording techniques. The result of this research shows that spelling errors in dissertation include 10 errors of writing capital letter, 9 errors of writing italic, 14 errors of forming word, 5 errors of using full stop mark, 5 errors of using comma sign, 1 error of using colon sign, and 6 errors of using quotation mark. Maximum errors are in the use of punctuation and the word formation. Based on the result, it can be concluded that there are still many spelling errors in writing dissertation. Therefore, it needs more effort to understand the rules of writing, such as the use of standard words, PUEBI, capital letter, punctuation, and word formation to make a good writing, especially in writing dissertation.

The Meniscal Grammar Signs: Comma and Apostrophe Signs for Characterization of a Displaced Fragment in the Meniscal Recess

Vertical flap tears, or parrot beak flap tears, are oblique tears of the meniscus thought to originate as a central radial tear and propagate longitudinally towards the periphery, generating a partially detached unstable fragment that can subsequently displace into the meniscal recess. Although magnetic resonance imaging (MRI) is frequently used to diagnose and characterize meniscus pathology, imaging findings for displaced flap tears are not well described in the literature. The recently published meniscal comma sign describes inferior displacement of a meniscus flap tear into the meniscotibial recess that, when seen on MRI, resembles a comma. In the present article, we define the meniscal apostrophe sign, characterized by superior displacement of a meniscus flap tear into the meniscofemoral recess found on MRI. Displaced fragments in the meniscal recess are crucial to identify, as they often result in significant pain and mechanical symptoms related to tenting of the deep medial collateral ligament, which responds poorly to nonoperative treatment. Misdiagnosis of these unstable flap tears as degenerative meniscus extrusion or isolated progression of osteoarthritis can lead to a delay in treatment.

SPATIAL ANALYSIS OF DISTRIBUTION PATTERNS OF DENGUE HEMORRHAGIC FEVER IN ENDEMIC VILLAGES IN TEMANGGUNG REGENCY INDONESIA

Background: Dengue Hemorrhagic Fever (DHF) infection is the most important arboviral disease in humans based on the geographical distribution, morbidity and mortality. It is transmitted by person to person by Aedes sp . In Indonesia the trend of Incidence Rate (IR) What is IR? Is it incidence rate? Please clarify. in DHF in 2015 to 2016 increased from 50.75 to 78.85 For the number, dot is usually used instead of comma sign (50.75 and 78.85). per 100.000 residents, and decreased in 2017 to 26.10 per 100.000 residents. One of the regencies with high IR of DHF in Central Java Province is Temanggung regency. In 2017, Temanggung regency was in the third position among the highest in Central Java. With the existence of cases each year, it revealed that there were endemic villages of DHF. Until June 2018, there were 56 endemic villages scattered in 19 endemic sub-districts in Temanggung Regency so that it was necessary to analyse the distribution patterns in order to predict and analyse DHF and be able to plan to prevent it. Materials and Methods: This research applied descriptive research with spatial analysis. It used secondary data taken from the Public Health Office in Temanggung regency. The data were processed spatially using the ArcGis application by overlaying an administrative map with a map of the highway and height of the region. Result: There were 35 endemic villages (62,5%) from 56 endemic villages were scattered along the main road and other roads. This could be related to population density and mobility. Based on height, WHO stated the ability of mosquitoes to survive and breed below 1000 meter above sea level (masl) What is masl? This should have been written as meter above sea level . As many as 54 (96.4%) endemic villages were at height below 1000 masl, while 2 (3.6%) villages were above 1000 masl. Conclusion: The distribution characteristics of the endemic villages in Temanggung regency follow the pattern of major highways and other roads and height below 1000 masl. Keywords: DHF, Endemic Villages, Highway Patterns, Height, Risk Factors

Thoracic myelopathy secondary to ossified ligamentum flavum and dural ossification – A series of 19 cases and review of literature

Objective: Thoracic myelopathy has gradually risen to be a prominent diagnosis in patients with persistent upper back pain, bladder symptoms and spastic paraparesis. Often encountered, these conditions pose a serious dilemma to neurosurgeons with respect to surgical planning, timing of surgery, prognosis and possible complications and outcome assessment. In view of these queries and to clarify the indications of when to intervene the following study has been undertaken. To analyze the clinical presentation, radiological features, clinical implications and surgical nuances and outcomes in patients with single and multiple level dorsal canal ossified ligamentum flavum (D-OLF) and associated dural ossification (DO). Patients and methods: Nineteen patients with the diagnosis of thoracic myelopathy (TM) were identified between January 2012 and March 2017. All patients were treated surgically, with decompressive laminectomies, in a single tertiary care center in Southern India. mJOA was calculated preoperatively and assessed postoperatively and a mean mJOA was calculated to assess the significance in neurological improvement. The data was collected from the medical records department and various factors were analyzed, using SPSS software, for correlation.Results: Mean age of our group was 50.84 years with a range of 29 to 71 years. It comprised of 11 males and 8 females. All patients had features of myelopathy. Surgery did have a positive effect on neurological improvement (p = 0.001) in all patients except one. Dural ossification had correlation with pre op and post op urinary disturbances with p value of 0.02. (Mann Whitney Test for 2 independent variables used). A total of ten patients had urinary symptoms pre operatively, out of which six patients showed postoperative improvement at the end of one year. Four of these patients continued to have symptoms, two patients were on Clean Intermittent Catheterisation (CIC), and one patient had features of hesitancy and frequency. Preoperative bladder dysfunction was a strong predictor for continued bladder dysfunction at the end of 1 year (p < 0.004). Conclusions: All patients with D-OLF and or DO presented with myelopathic features. MRI with concurrent CT spine helps to delineate dural ossification from D-OLF and helped to rule out other differentials. The classical “tram track” and “comma sign” is well noted in CT spine and helps to plan surgical approach and anticipate probable complications. Patients with concurrent D-OLF and DO and long segment pathology had increased risk of intraoperative dural tears and postoperative CSF leaks. These subset of patients had a peaked incidence of bladder involvement or non-improvement of existing bladder dysfunction, postoperatively. Patients with D-OLF and DO seemed to do better after surgical decompression. Surgery should be offered once diagnosis is confirmed on imaging, as all patients in out study, except one, showed postoperative neurological improvement.Our study concluded that patients with prolonged preoperative symptoms persisted to have them even after surgery. Patients with concurrent D-OLF and DO showed more significant improvement, postoperatively, in terms of mJOA – postop with a p = 0.002 as compared to patients with D-OLF alone.We recommend that each case be treated individually and treatment should be planned appropriately, based on the radiology and levels involved, keeping in mind the preoperative symptoms and their duration.

The Meniscal Comma Sign: Characterization and Treatment of a Displaced Fragment in the Meniscotibial Recess.

Displaced parrot beak flap tears in the meniscotibial recess are complex tears of the meniscus that begin as central radial tears and progressively extend toward the periphery, creating a detached fragment. These tears have not been described in the literature, but the authors have described them as the "meniscal comma sign" based on their appearance on magnetic resonance imaging. Displaced fragments are clinically significant because of the pain and mechanical symptoms they can cause as a result of tenting of the deep medial collateral ligament. Failure to distinguish these tears from meniscal extrusion and superimposed osteoarthritis on magnetic resonance imaging can cause them to be misinterpreted or missed, leading to a delay in treatment. [Orthopedics. 2018; 41(3):e442-e444.].

Dural ossification associated with ossification of ligamentum flavum in the thoracic spine: a retrospective analysis

ObjectivesTo investigate the incidence, distribution and radiological characteristics of dural ossification (DO) associated with ossification of ligamentum flavum (OLF) in the thoracic spine.DesignA retrospective radiographical analysis.SettingThis study was conducted at...

The “CT Comma Sign” in concurrent extradural and hyperacute subdural hematomas is revisited

The “CT Comma Sign” in concurrent extradural and hyperacute subdural hematomas is revisited