Intervertebral Foramen Research Articles

SAT563 Follicular Thyroid Cancer Masquerading as Chest Wall Mass With an Aggressive Course

Abstract Disclosure: I. Goyal: None. E. Punni: None. L. Adhikari: None. Introduction:Follicular thyroid cancers (FTC) are more aggressive than papillary thyroid cancer and usually have more advanced tumor stage at the time of presentation. Musculoskeletal metastases are rare though, but when present can cause various complications like pathological fractures and nerve compression. Clinical case:A 75-year-old female was seen in orthopedics clinic for a left infraclavicular chest wall mass. MRI chest showed a large destructive mass invading the manubrium. Biopsy showed follicular cells consistent with ectopic thyroid tissue. CT neck/chest showed 2x1.8 cm right thyroid lobe nodule and left sternoclavicular joint metastasis. She underwent total thyroidectomy and resection of portions of manubrium, left clavicle and left 1st and 2nd rib. Pathology showed FTC in right thyroid lobe, measuring 2.6 cm in greatest dimension with angioinvasion, and FTC of manubrium, adjacent connective tissue and sternoclavicular joint and ribs, measuring 6.3 cm in greatest dimension. Pathological TNM staging was pT2N0M1. Her 6-week post-op thyroglobulin (Tg) level was 28.7 ng/mL (Beckman Coulter Immunometric Assay, reference value <0.1 athyrotic). She was started on levothyroxine supplementation to achieve a TSH <0.01 uIu/mL. She was subsequently treated with 200 mCi of radio-active iodine (RAI) as adjuvant therapy. Post-therapy whole body scan showed increased activity in the right strap muscle and iodine-avid osseous metastasis in right hemisacrum. She further received radiation therapy to neck and sternal regions, and the right sacroiliac joint. Following this, patient was monitored with serial Tg panel and neck ultrasound (US). Her initial post-op US neck showed a soft tissue fullness in right thyroidectomy bed, concerning for residual disease but this was no longer seen after 3 months. Her Tg level downtrended from 28.7 ng/mL to 12.6 ng/mL and further to 1.8 ng/mL at 1-year follow-up. However, her course was complicated by development of several oral ulcers resulting from high-dose RAI therapy which were treated symptomatically with hydration, topical analgesics and Listerine mouth washes. The patient reported ongoing bowel incontinence since her initial cancer diagnosis. MRI pelvis showed rim-enhancing 4.5cm lesion centered at right sacral ala and extending into adjacent S1/S2 neural foramina. She was re-referred for palliative radiation therapy.Conclusion:This case of FTC is unique due to its uncommon initial presentation. Skeletal metastases to sacrum resulted in bowel incontinence in our patient. When present, skeletal metastases need treatment with high-dose (200 mCi) RAI. RAI therapy can cause xerostomia, hypogeusia and sialadenitis due to reductions in salivary flow. Clinicians should be aware of the early and late-onset complications of RAI therapy, discuss these with the patient before therapy and manage the complications adequately if these occur. Presentation Date: Saturday, June 17, 2023

THU230 Consumptive Hypothyroidism Secondary To Hemangioma

Abstract Disclosure: R. Thirunagari: None. D. Taha: None. Background: Peripheral Hypothyroidism also known as consumptive hypothyroidism has been rarely described in association with vascular tumors such as hemangiomas. It is due to excessive production of type 3 iodothyronine deiodinase (D3) enzyme by the hemangioma leading to increased rate of deiodination of T4 and T3 to inactive forms. Clinical case: We report a 4-year-old girl who was diagnosed with consumptive hypothyroidism at the age of 2 months. She was born at full term via scheduled C-section. Mother has hypothyroidism. She was admitted to NICU for respiratory distress and needed oxygen supplementation. She had a large hemangioma covering most of her back on exam. An ultrasound of the head/neck soft tissue showed an ill-defined lobular heterogeneous mass measuring 3.4 x 1.2 x 4.5 cm, markedly hypervascular with both arterial and venous flow likely consistent with hemangioma. At follow up plastic surgery clinic she had respiratory distress which necessitated readmission to the NICU for further workup and possible initiation of Propranolol. An abdominal ultrasound showed enlargement of the right adrenal and on further dedicated ultrasound a right suprarenal lobulated mass as well as intrathoracic soft tissue mass were found. MRI of the abdomen and thorax, revealed multiple large bilateral paraspinal masses throughout the thoracic and lower cervical spine(largest measuring 3.3 x 7 x 15 cm AP) invading the neural foramen at multiple levels, and causing mass effect on the spinal cord which is displaced to the left. There was mass effect on adjacent vascular structures without significant vascular compromise. Biopsy was consistent with hemangioma. Thyroid Newborn screening result was normal. Thyroid evaluation done at 3 months age revealed, free T4 level of 1.04 ng/dL and TSH level of 11.3 µIU/mL. She was started on Levothyroxine 50 mcg daily. Reverse T3 was elevated at 139.2 ng/dl (reference range 13-107 ng/dl) 2 weeks after treatment initiation. She was initiated on propranolol and was followed up by plastic surgery and oncology. She had a very good response to Propranolol. Follow up MRI at 4 years shows almost complete resolution of the mass. She continues to be on Levothyroxine but is requiring smaller dose. Conclusion: Infantile hemangiomas can express high levels of type 3 iodothyronine deiodinase (D3), an enzyme that catalyzes the inner-ring deiodination of T4 to reverse T3 (rT3) and of T3 to 3,3'-diiiodothyronine (T2), both of which are biologically inactive. The hypothyroidism is a result of degeneration of thyroid hormones at rates that exceed the synthetic capacity of the infant's thyroid gland. Our case illustrates the importance of closely monitoring thyroid function tests in infants with large hemangiomas even if newborn thyroid screening result is normal. Some infants may require higher Levothyroxine doses than usual. Hypothyroidism usually resolves after resolution of the mass. Presentation: Thursday, June 15, 2023

Role of Panchakarma in the Management of Spinal Canal Stenosis - A Case Study

Spinal canal stenosis is a painful, degenerative condition, and is localized to facets, joints, and ligamentum flavum of the vertebra which is often referred to for surgical correction. The main cause of stenosis is herniated vertebral disc. If there is no compression, the spinal canal can be referred to as narrow, but not stenotic. Certain studies have defined lumbar spinal stenosis as the narrowing of the osteo-ligamentous vertebral canal or the intervertebral foramina, which causes compression of the thecal sac or the caudal nerve roots. The narrowing may impact the entire canal or just a portion of it, but it occurs at a single vertebral level. In this condition, it may, drastically affect the quality of life due to severe pain in doing daily routine activities. In contemporary science, there is no treatment except surgical intervention which is having a high chance of complication and the chances of recurrence. Surgery is necessary when there are clinically significant motor deficiencies or symptoms of cauda equina syndrome. Based on the manifestation of clinical signs and symptoms it can be correlated with Gridhrasi, according to Ayurveda. Gridhrasi can be treated successfully by the intervention of Panchakarma procedures along with Shamana Chikitsa. Here is a case study of a patient suffering from low back pain radiating to bilateral lower limbs, stiffness, numbness, burning sensation in the bilateral sole region, and unable to walk without support, who was previously diagnosed as a case of Spinal Canal Stenosis. He was treated with a Panchakarma procedure, Shamana Chikitsa along with Physiotherapy Exercises. The patient showed marked improvement and could do daily routine activities properly.

Ultrasound Imaging of the Sciatic Nerve.

The sciatic nerve (SN) is the biggest nerve in the human body and innervates a large skin surface of the lower limb and several muscles of the thigh, leg, and foot. It originates from the ventral rami of spinal nerves L4 through S3 and contains fibers from both the posterior and anterior divisions of the lumbosacral plexus. After leaving the neural foramina, the nerve roots merge with each other forming a single peripheral nerve that travels within the pelvis and thigh. Non-discogenic pathologies of the SN are largely underdiagnosed entities due to nonspecific clinical tests and poorly described imaging findings. Likewise, to the best of our knowledge, a step-by-step ultrasound protocol to assess the SN is lacking in the pertinent literature. In this sense, the aim of the present manuscript is to describe the normal sono-anatomy of the SN from the greater sciatic foramen to the proximal thigh proposing a standardized and simple sonographic protocol. Then, based on the clinical experience of the authors, a few tips and tricks have been reported to avoid misinterpretation of confounding sonographic findings. Last but not least, we report some common pathological conditions encountered in daily practice with the main purpose of making physicians more confident regarding the sonographic "navigation" of a complex anatomical site and optimizing the diagnosis and management of non-discogenic neuropathies of the SN.

Clinical Effectiveness of Artificial Disc Replacement in Comparison With Anterior Cervical Discectomy and Fusion in the Patients With Cervical Myelopathy: Systematic Review and Meta-analysis.

Cervical myelopathy (CM) describes the compressive cervical spinal cord state, often accompanied by serious clinical condition, by herniated disc or hypertrophied spurs or ligament. Anterior cervical discectomy and fusion (ACDF) has been frequently employed as conventional surgical solution for this CM despite its inherent biomechanical handicap. Alternatively, an artificial disc replacement (ADR) preserves cervical motion while still decompressing the spinal canal and neural foramen. This analysis elaborated to clarify the potential benefits of ADR application to CM over ACDF from the conglomerated results of the past references. A literature search was performed using MEDLINE, Embase, Cochrane review, and KMbase databases from the studies published until March 2023. Six studies (3 randomized controlled study [RCTs] and 3 non-RCTs) were included in a qualitative and quantitative synthesis. Data were extracted and analyzed using a random effects model to obtain effect size and its statistical significance. Quality assessment and evidence level were established in accordance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. Among 6 studies, 2 studies showed that ADR group achieved significantly better clinical improvement than the ACDF group, while the rest 4 studies revealed no significant difference. A meta-analysis showed better clinical outcomes with or without statistical significance. The level of evidence was low because of inconsistency and imprecision. ADR was superior or at least, not inferior to ACDF in terms of functional recovery. However, its application to the CM patients is merely empowered with weak strength due to low level of evidence.

Pre-operative magnetic resonance imaging as a predictor of success in lumbar disc herniation patients undergoing laminectomy

Introduction. Lumbar disc herniation is a condition in which annulus fibrosus in the lumbar area is herniated with numerous etiologies, such as degenerative. One of the mainstay treatment for lumbar disc herniation is decompressive laminectomy. Magnetic Resonance Imaging (MRI) with the diagnostic accuracy of 97% also has an excellent resolution for soft tissue. The aim of this study is whether pre-operative MRI may be a predictor of successful clinical outcome in lumbar disc herniation patients undergoing laminectomy surgery. Methods. In this cross-sectional study, we consecutively collected all patients in Radiology Department “Prof. Dr. IGNG Ngoerah” Hospital, Denpasar Bali between January 2021 to December 2022. We enrolled patients with older than 18 years old who had undergone pre-operative lumbosacral MRI and had laminectomy surgery within the sampling time period. The following variables were recorded from each patient: age, gender, Body mass index (BMI), history of diabetes mellitus, hypertension, number of herniated discs, herniation grade, spinal canal stenosis grade, neural foramen stenosis grade, lateral recess stenosis grade, annular tear, disc degeneration, facet disc degeneration, thickening of ligamentum flavum, modic changes, cerebrospinal liquor obstruction, and clinical outcome. Outcomes. We collected 30 patients who underwent laminectomy surgery and had their pre-operative MRI. Patients’ mean age ± SD was 57.7±10.9 years old with 20 male (66.7%) and 10 female (33.3%). There was no significant association between gender, hypertension, diabetes mellitus, body mass index, number of disc herniation, spinal canal stenosis, lateral recess stenosis, neural foramen stenosis, disc degeneration, facet joint degeneration, ligamentum flavum hypertrophy, Modic changes and cerebrospinal liquor obstruction with clinical outcome post laminectomy patients. Conclusion. Pre-operative MRI can reliably diagnose lumbar disc herniation but are not a predictive tool in assessing the clinical outcome of post-laminectomy patients. Laminectomy has an excellent management value for lumbar disc herniation patients especially in reducing the pain, and for them to have better quality of life.

Advantage of Adding Non-Coplanar Arcs for Scalp-Avoidance Whole-Brain Irradiation with Volumetric-Modulated Arc Radiotherapy to Reduce Scalp Dose in Pediatric Patients with Medulloblastomas

With increasing long-term survival, permanent alopecia has received much attention as a crucial late adverse effect in pediatric patients with medulloblastoma. Therefore, we performed scalp-avoidance whole-brain irradiation with volumetric-modulated arc therapy (SAWB-VMAT) as a component of craniospinal irradiation. We have previously reported that SAWB-VMAT significantly reduced the scalp equivalent doses in 2 Gy per fraction (assuming α/β = 2) to 50% of the areas (EQD50%) compared to conventional WBRT, and the estimated cut-off EQD50% was 19.9 Gy for severe permanent alopecia. In SAWB-VMAT with two coplanar arcs, there were cases with the high-risk disease in which radiation oncologists and medical physicists had difficulty in reducing the scalp dose below the cut-off EQD50%. Therefore, to investigate the utility of adding non-coplanar arcs to reduce the scalp dose, we conducted a planning study to compare the scalp EQD50% and the dose to the organ at risk (OAR) in VMAT with two coplanar arcs (Co2arcVMAT), VMAT with three coplanar arcs (Co3arcVMAT), and VMAT with two coplanar and two non-coplanar arcs (NcVMAT). Co2arcVMAT, Co3arcVMAT, and NcVMAT plans were created for 10 pediatric patients with medulloblastoma. The planned target volume (PTV) for SAWB-VMAT included regions of the whole brain, cervical spinal cord, cerebrospinal fluid space, and intervertebral foramen. The prescribed dose for the PTV was 35.2 Gy in 22 fractions, and all plans were normalized to ensure that V90 = 99%. The scalp EQD 50% was evaluated separately for four areas (top, back, left, and right) according to anatomical structures in each case. In addition, we also calculated normalized scalp EQD50% values (NV_EQD50%scalp), and Co2arcVMAT was set to unity. The eye, lens, hypopharynx, cochlea, thyroid, oral cavity, and parotid gland were defined as other OARs. The median EQD50% of the top area of the scalp was 21.8 Gy, 22.0 Gy, and 18.2 Gy for Co2arcVMAT, Co3arcVMAT, and NcVMAT, respectively. The scalp EQD50% of the top area in NcVMAT was significantly reduced than in Co2arcVMAT and Co3arcVMAT (P-value < 0.05). The median EQD50% of the top area of the scalp for NcVMAT was < 19.9 Gy, which was the cut-off dose for severe permanent alopecia. The NV_EQD50%scalp index of the back area was reduced in a similar manner with statistical significance (Co2arcVMAT, 1.0; Co3arcVMAT, 1.0; and NcVMAT, 0.94) (P-value < 0.001). When considering the dose of indices of other OARs and coverage of PTV, there were no significant differences between the three techniques. SAWB-VMAT with non-coplanar arcs can reduce the scalp EQD50% of the top area below the cut-off dose of 19.9 Gy.

Prospective Feasibility Trial of Vertebral Body Sparing Pencil Beam Scanning Proton Craniospinal Irradiation in Growing Children

Advanced proton therapy techniques now allow for delivery of craniospinal irradiation (CSI) to the entire brain and thecal sac while sparing many of the anterior vertebral bodies from doses expected to inhibit growth, though this technique has not been prospectively studied. The purpose of this trial is to test the feasibility and robustness of vertebral body sparing (VBS) CSI in children with standard image guidance, to assess the dosimetric and toxicity benefits of this approach, and to report early clinical outcomes. Children 3-18 years old requiring CSI treatment were eligible for this IRB approved prospective clinical trial. The CSI clinical target volume (CTV) included the brain, entire thecal sac and neural foramina with no expansion. Select anterior vertebral bodies (AVB) could be included at the physician's discretion. The spinal portion of the CTV was treated with PA beam(s) with robust optimization (+/-3.5% range, 5mm positional uncertainty). Daily image guidance included kV/kV imaging. Cone beam CT (CBCT) was acquired weekly after final positioning and a virtual CT (vCT) was created for quality assurance (QA) analysis. Acute toxicity was prospectively assessed weekly during treatment and 1 month after per CTCAE v5.0. Ten children with a median patient age and CSI dose of 9 years (range 3-16) and 36 Gy (RBE) (range 15-36 Gy (RBE)) were enrolled. Common diagnoses were medulloblastoma (n = 4) and non-germinomatous germ cell tumor (n = 3). Seven patients received prior chemotherapy; 2 patients were treated with palliative intent. Dose statistics for the anterior vertebral body varied according to age, CSI dose and portion of the spine, with the greatest sparing in the lower thoracic and lumbar vertebrae for all patients. Nine patients completed all QA CTs; one patient required a replan due to weight gain. For all remaining patients the treatment was highly robust: CTV V95 reduction at the C-spine, T-spine, and L-spine was 0.0±0.1%, 0.6±1.3%, and 0.8±1.1%, respectively. The highest grade non-hematologic acute toxicity was grade 2 alopecia (n = 9) and grade 2 nausea/vomiting (n = 5). One patient reported transient grade 1 esophagitis during treatment. Hematologic toxicity included >/ = grade 3 lymphopenia in 7 patients, >/ = grade 3 leukopenia in 1 patient, >/ = grade 2 anemia in 6 patients, and >/ = grade 1 thrombocytopenia in 3 patients. Median follow-up is 16.6 months (range 10-36 months). Three patients experience intracranial disease progression: 2 local and 1 distant intracranial failure. There were no failures within the spine. Proton vertebral body sparing CSI targeting the thecal sac only is a highly robust treatment technique and is well tolerated. Weekly CBCT to assess changes in soft tissue posterior to the spine is recommended. Further follow-up is required to assess long-term growth outcomes.

Using Longitudinal MRI to Manage Proton Range Uncertainty for Pediatric Proton Craniospinal Irradiation

Clinical evidence has shown that proton therapy can effectively reduce side effects for pediatric patients undergoing vertebral body-sparing craniospinal irradiation (VBS CSI), compared to conventional photon treatment modalities. However, radiation-induced growth impairment remains challenging for VBS CSI due to proton range uncertainty, compromising vertebral body sparing for growing children. Previous studies have shown that fatty marrow replacement can be observed in vertebral bodies 4-48 weeks after treatment is complete. This study aims to detect and quantify the fatty marrow replacement in vertebral bodies using longitudinal magnetic resonance (MR) to manage proton range uncertainty. A prospective clinical trial of proton VBS CSI was designed, and ten pediatric patients were enrolled with prescribed doses of 15-36 Gy. The thecal sac and neural foramina were the clinical target volumes, and a Monte Carlo planning system was used to robustly optimize treatment plans with a 3.5% range margin. We analyzed patients' T1/T2 MR images acquired before, during, and after proton treatment to investigate the hematopoietic marrow transformation induced by irradiation. A metric was defined to calculate the ratio of fatty and hematopoietic marrow based on relative MR intensity histograms. We proposed a machine learning method via Gaussian fitting process (ML-GFP) to explore hidden correlations between marrow transition and radiation dose to 2 cm3 of the bone marrow (D2cc). We also leveraged this method to embed uncertainty to support potential proton range management for VBS enhancement. The results indicated that fatty marrow replacement could be observed during inter-fractional treatment. For instance, an individual patient showed that the fatty marrow generation ratios were 0.54, 0.74, and 0.45, corresponding to 11, 18, and 65 days after the treatment started. Using ML-GFP, the fatty marrow transition was found to be quadratically correlated to treatment fractions, and the maximum transformation ranged from 40 to 50 days. Then marrow regeneration was observed due to the decrease in fatty marrow ratios. The fatty marrow ratios were also positively correlated to the D2cc doses ranging from 10 Gy to 36 Gy. Limited by insufficient low-dose data, the ML-GFP model extrapolated the data to predict the marrow transformation below 10 Gy. We demonstrated the feasibility of using non-invasive longitudinal MR to quantify the fatty marrow transition from inter-fractional treatment. Based on this prospective study, the method can detect early fatty marrow generation in vertebrae caused by proton irradiation due to the conservative range margin used for robust optimization. The proposed method could be used to validate the actual proton range, allowing an accurate range margin to be defined to preserve bone marrow. Future investigation will likely focus on clinical implementation to improve life quality for pediatric CSI patients.

Supervised spectral feature learning for fine-grained classification in small data set

Fine-grained image classification is a challenging task due to the small inter-class variance, the large intra-class difference, and the small training data. Traditional methods typically rely on large-scale training samples with annotated part annotations, making them costly and severely limiting their application area. In this paper, we propose an effective and weakly supervised fine-grained classification framework. In this framework, a discriminative class-specific spectral feature is learned by intra-class spectral coupling and inter-class spectral decoupling under the weak supervision of image-level category labels, and then the new input images are classified based on the learned class-specific spectral feature. Different from existing strong supervised methods, the proposed technique creatively combines weak supervision of the image-level category labels with unsupervised spectral graph decomposition, not relying on large-scale training samples with dense part annotations, which are heavily labor-consuming. The performance of the proposed methods has been verified on four kinds of typical datasets: the JAFFE dataset, the Yale database, the UCI-CMU face database, and the neural foramina dataset. The satisfactory classification results have been achieved by the proposed method in expression recognition on the JAFFE dataset (with a mean accuracy of 95.31%), face recognition on the Yale database (with a mean accuracy of 98.79%), object recognition on the UCI-CMU face database (with a mean accuracy of 96.96%), and disease grading on the neural foramina dataset (with a mean accuracy of 92.09%). Compared with most state-of-the-art methods, the proposed method has superior classification performance in the small data set.

Clinical and radiographic outcomes of oblique lumbar interbody fusion with anterolateral screw and rod instrumentation in osteopenia patients: a retrospective study

PurposeThe purpose of this paper is to evaluate the clinical and radiographic outcomes of oblique lumbar interbody fusion (OLIF) to perform in L4/5 degenerative lumbar spondylolisthesis (DLS) patients who diagnosed with osteopenia.MethodsFrom December 2018 to 2021 March, 94 patients were diagnosed with degenerative spondylolisthesis underwent OLIF and divided into two groups with different bone mineral density. Anterolateral screw and rod instrumentation was applied in two groups. The primary outcomes were VAS, JOA and ODI. The secondary outcomes included disc height (DH), cross-sectional height of the intervertebral foramina (CSH), cross-sectional area of the dural sac (CSA), lumbar lordorsis (LL), pelvic titlt (PT), pelvic incidence (PI) and sacrum slop (SS).ResultsAll patients finished at least 1 years follow-up with 21.05 ± 4.42 months in the group A and 21.09 ± 4.28 months in the group B. The clinical symptoms were evaluated by VAS, JOA and ODI and 94 patients showed good outcomes at final follow-up (P < 0.05), with significant increases in DH, CSH and CSA. In group A, DH increased from 8.54 ± 2.48 to 11.11 ± 2.63 mm, while increased from 8.60 ± 2.29 to 11.23 ± 1.88 were recorded in group B. No statistical difference was found in DH between the two groups (P > 0.05). The cage subsidence was 1.14 ± 0.83 mm in group A and 0.87 ± 1.05 mm in group B (P > 0.05). There was no significant difference in the adjusted parameters of spino-pelvic between two groups (P > 0.05).ConclusionOblique lumbar interbody fusion with anterolateral screw and rod instrumentation is feasible to be performed in osteopenia patients who diagnosed with degenerative spondylolisthesis.

Thoracolumbar Retrolaminar Block: Anatomical and Radiological Study of Injectate Pattern Distribution in Canine Cadavers.

The retrolaminar block is a regional anaesthetic technique, first developed in humans, in which the local anaesthetic is deposited directly onto the dorsal aspect of the thoracic or lumbar vertebral lamina. This study aims to evaluate the distribution of landmark-guided thoracolumbar retrolaminar injections in greyhound cadavers. Thirteen injections of contrast-dye solution were performed in eight cadavers at the level of the twelfth thoracic vertebra (T12), with either 20 mL (n = 8, high volume, HV) or 10 mL (n = 5, low volume, LV) per site. The spread of the injectate was evaluated through computed tomography and transverse anatomical dissection. The groups were compared using the Mann-Whitney U test. The median (range) of the extent of the spread was 4 (2-5) and 3 (2-4) intervertebral foramina in the LV and HV groups, respectively. The median (range) of the spread along the retrolaminar space was 3 (2-3) retrolaminar segments in the LV and 3 (2-4) in the HV group. Epidural and retroperitoneal spread was identified in seven cadavers. Following landmark-guided retrolaminar injections, the injectate spread both in the retrolaminar and paravertebral spaces, without any obvious association between the volume of injectate and the extent of the spread. Further studies are warranted to determine the clinical efficacy of the technique.

Efficacy of OLIF combined with pedicle screw internal fixation for lumbar spinal stenosis on spinal canal changes before and after surgery

PurposeThe purpose of the study was to evaluate the efficacy of OLIF combined with pedicle screw internal fixation in the treatment of lumbar spinal stenosis by assessing the changes in spinal canal before and after surgery.MethodsIn this retrospective study, we included sixteen patients who underwent a combination of single-segment OLIF and pedicle screw internal fixation for the treatment of lumbar spinal stenosis at the Affiliated Hospital of Jiangxi University of Chinese Medicine between February 2018 and August 2022. The patients' pre- and post-operative data were compared. Intraoperative bleeding, duration of surgery, visual analogue score (VAS), Oswestry Disability Index (ODI), disc height (DH), cross-sectional area of vertebral canal (CSAVC), cross-sectional area of dural sac (CSADS), cross-sectional area of intervertebral foramen (CSAIF), spinal canal volume (SCV), spinal canal volume expansion rate, lumbar lordosis, and sagittal vertical axis were observed and recorded. The efficacy of OLIF combined with pedicle screw internal fixation for lumbar spinal stenosis on spinal canal changes before and after surgery was summarized.ResultsThe results showed that OLIF combined with pedicle screw internal fixation effectively restored disc height and increased the cross-sectional area of the spinal canal. It also had an indirect decompression effect. The intraoperative bleeding and duration of surgery were within acceptable ranges. The VAS and ODI scores significantly improved after surgery, indicating a reduction in pain and improvement in functional disability. The CSAVC, CSADS, CSAIF, SCV, and spinal canal volume expansion rate were all increased postoperatively. Additionally, there was improvement in lumbar lordosis and sagittal vertical axis. We conducted a follow-up of all patients at 1 year after the surgery. The results revealed that the parameter values at 1 year post-surgery showed varying degrees of decrease or increase compared to the immediate postoperative values. However, these values remained statistically significant when compared to the preoperative parameter values (P < 0.05).ConclusionsOLIF combined with pedicle screw internal fixation effectively restores disc height and increases the cross-sectional area of the vertebral canal in patients with LSS, reflecting the indirect decompression effect. Measuring parameters such as DH, CSAVC, CSADS, CSAIF, SCV, and SCV expansion rate before and after surgery provides valuable information for evaluating the efficacy and functional recovery of the lumbar spine in LSS patients treated with OLIF surgery.

Biomechanical evaluation of graded ventralfacetectomy simulating foraminoplasty of percutaneous endoscopic lumbar discectomy.

To explore the lumbar spine biomechanics of graded ventral facetectomy and determine the appropriate extent of resection for foraminoplasty. We retrospectively measured several radiological parameters of superior articular process (SAP) and bony intervertebral foramen in computed tomography scans of 170 lumbar vertebral discs. The intact finite element (FE) spine of L2-sacrum was modified to simulate foraminoplasty with two typical graded ventral facetectomy methods (Method Ⅰ: basal part resection of SAP; Method Ⅱ: apical part resection of SAP) to explore the biomechanical effects under different physiological motions. Examination of the radiological parameters of the bony intervertebral foramen indicated that they were generally narrower than the diameters of commercially available working cannulas. Some of these parameters showed gender differences. The biomechanical evaluation indicated that the range of motion increased gradually with the expansion of the resection extent, and the differences compared to the intact spine at the same level were greater in Method I than in Method Ⅱ. The appropriate ventral resection extent of the basal part of the SAP (Method I) was 4 mm, 3 mm, and 3 mm on the lateral view at L3-L4, L4-L5, and L5-S1, respectively. The appropriate ventral resection extent of the apical part of the SAP (Method II) were 10 mm, 6 mm and 6 mm on the lateral view at L3-L4, L4-L5, and L5-S1, respectively. Extensive resection of foraminoplasty may destabilize lumbar motion segments.

Heterogeneous porosity design triggered stress reorganization to avoid intervertebral cage subsidence and promote spinal fusion

The common phenomenon of cage subsidence after intervertebral fusion may lead to intervertebral foramen stenosis and implantation failure. In this study, a heterogeneous porous cage was designed to trigger the stress reorganization so as to avoid intervertebral cage subsidence and promote spinal fusion. Firstly, finite element analysis (FEA) was used to predict the heterogenous stress distribution on intervertebral discs. Then, a heterogeneous porous structure cage was inspired by the stress reorganization method. Parametrical modeling was employed to customize the porous structure of the cage. Heterogenous Ti6Al4V cage was successfully fabricated via selective laser melting 3D printing. The results from FEA simulation indicated that heterogenous cage with a dense periphery and a porous center may drive the load outward which mimicking the natural stress distribution of spine system. Finally, an animal model between the C3-C4 vertebras of goats was studied to prove the effectiveness of the cage fusion. The histologicaland micro-CT results indicated that the heterogeneous structure may accelerate bone tissue ingrowth so as to promote osteointegration and fusion. Compared with conventional cage, the heterogenous cage may avoid subsidence and this heterogenous structure provide a promising strategy for customized bio-fusion intervertebral cage.

Pain Management Interventions in Lumbar Spinal Stenosis: A Literature Review.

Lumbar spinal stenosis (LSS) occurs due to the narrowing of the space within the vertebral canal and or intervertebral foramina. This results in the compression of the spinal cord and possibly the roots of the spinal nerves.Lower back pain and neurogenic claudication (NC) are major symptoms of spinal stenosis. This is a literature review that summarizes the important findings pertaining to pain management of spinal stenosis. Twenty-four original articles were assessed. Pain can be treated through non-invasive or surgical methods. Conservative techniques include physical exercises, epidural corticosteroid injection, local anesthetic injection therapy, and oral analgesics. Surgical intervention deals with the decompression of the affected spinal region, with or without vertebral fusion surgery. Other novel surgical techniques include implantation of specific equipment, known as interspinous spacer devices and minimally invasive lumbar decompression (MILD). Most studies offering a comparative analysis have demonstrated that surgical intervention is more efficacious than non-surgical interventions to manage pain associated with spinal stenosis.

Comparison between OLIF and MISTLIF in degenerative lumbar stenosis: an age-, sex-, and segment-matched cohort study

To compare outcomes after oblique lateral interbody fusion (OLIF) versus minimally invasive transforaminal lumbar interbody fusion (MISTLIF) with bilateral decompression via unilateral approach for treating mild to moderate symptomatic degenerative lumbar spinal stenosis (DLSS). We retrospectively compared patients who underwent single-level (L4/5) OLIF with an age-, sex-, and segment-matched MISTLIF with bilateral decompression via unilateral approach cohort. Perioperative data were collected for the operative time, intraoperative blood loss, drainage in the first postoperative day, postoperative hospital stay, cost, intraoperative fluoroscopy, and complications. Lumbar radiographs were measured for changes in posterior intervertebral space height (PISH), intervertebral space foramen height (IFH), intervertebral foramen area (IFA), and area of the spinal canal (ASC). Clinical and psychological outcomes included the visual analog scale (VAS), Oswestry Disability Index (ODI), and hospital anxiety and depression scale (HADS). 35 OLIF patients were compared with 35 MISTLIF patients in L4/5 DLSS. The OLIF group had shorter bedtime, postoperative hospital stays, less intraoperative and postoperative blood loss (all P < 0.05), but had more times of intraoperative fluoroscopy, longer operative time, and higher cost (all P < 0.05). The complication rates were equivalent (OLIF vs MISTLIF: 22.86% vs 17.14%). PISH (11.94 ± 1.78 mm vs 9.42 ± 1.94 mm, P < 0.05), IFH (23.87 ± 3.05 mm vs 21.41 ± 2.95 mm, P < 0.05), and IFA (212.14 ± 51.82 mm2 vs 177.07 ± 51.73 mm2, P < 0.05) after surgery were significantly increased in the OLIF group. The ASC was increased significantly after the operation in both groups, but the ASC in the MISTLIF group was increased significantly more than that in the OLIF group (450.04 ± 66.66 mm2 vs 171.41 ± 58.55 mm2, P < 0.05). The lumbar VAS scores at 1 month (1.89 ± 0.87 vs 2.34 ± 0.84, P = 0.028) and 6 months (1.23 ± 0.97 vs 1.80 ± 0.99, P = 0.018) after operation in the OLIF group were significantly lower. There were no significant differences in lower extremity VAS and ODI scores between the two groups. Compared with MISTLIF group, HADS scores on postoperative day 3 (2.91 ± 1.46 vs 4.89 ± 1.78, P < 0.05) and prior to hospital discharge (PTD) (2.54 ± 1.38 vs 3.80 ± 1.78, P = 0.002) in the OLIF group were decreased significantly. OLIF showed more advantages of less surgical invasion, lower incidence of postoperative low back pain, faster postoperative recovery, and less anxiety compared with MISTLIF. Regardless of cost, OLIF seems to be a better option to treat mild to moderate symptomatic DLSS.

A retrospective cohort study on the significance of preoperative radiological evaluation of lumbar degenerative diseases for surgical reference.

Radiography has low radiation exposure and the ability to acquire information. Due to its cost-effectiveness and availability, preoperative radiographic imaging examination is considered to be a valuable method to evaluate the condition of patients with spinal disease. The aim of this cohort study is to analyze the impact of evaluating preoperative X-rays on the surgical management of lumbar degenerative diseases (LDD). We reviewed 49 patients with LDD underwent single-level posterior instrumented lumbar fusion (PILF) between November 2017 and October 2022 in this cohort study. The median iliac angle (MIA), iliac crest height, intervertebral facet joint degeneration, lumbosacral angle (LSA), L5/S1 intervertebral space angle (ISA), intervertebral foramen height (IFH) and intervertebral space height (ISH) were measured on preoperative radiographs. In addition, operative time, intraoperative blood loss and postoperative complications were used to evaluate the surgical management. Correlation analysis was used to determine the correlation between preoperative radiographic presentation and surgical managements. Multivariate linear regression analysis was used for determination of risk factors for surgical management. Correlation analysis showed that the median iliac angle, height of iliac crest, lumbosacral angle and intervertebral facet joint degeneration were significantly correlated with surgical managements (P<0.05). Height of iliac crest, intervertebral facet joint degeneration and lumbosacral angle were positively correlated with surgical management. Meanwhile, MIA was negatively correlated with surgical management. No significant difference was found between the IFH, ISA, ISH and surgical managements in posterior lumbar surgery (P>0.05). After multiple linear regression analysis, height of iliac crest, median iliac angle and intervertebral facet joint degeneration were independent influence factors for the single-level lumbar surgical managements. Some variables measured in radiograph shows that height of iliac crest, median iliac angle and intervertebral facet joint degeneration have a potential influence on surgical managements. The lumbosacral angle was positively associated with surgical management, but it was not statistically significant in multiple linear regression analysis (P>0.05). The above measurements in plain film can reflect the surgical procedure and have some guiding implications for the operation.

WITHDRAWN: A multilocular discal cyst extending from the spinal canal to the extraforaminal region: A case report

Lumbar discal cysts are intraspinal extradural cysts communicating with the intervertebral disc. The usual location and morphology are in the caudal ventrolateral epidural space of the spinal canal, without extension to the neural foramen or crossing the midline and described as a well-defined homogeneous oval or spherical cyst on low and high signal intensities observed in lumbar lesions on T1- and T2-weighted magnetic resonance imaging, respectively. We report an unusual lumbar discal cyst in terms of the lesion location and morphology. A 33-year-old-man presented with lower back and right anterior thigh pain. Magnetic resonance imaging revealed multilocular cystic lesions in the cranial ventrolateral epidural space at L2-L3 with low and high signal intensities on T1- and T2-weighted magnetic resonance imaging, respectively. We performed a full-endoscopic transforaminal cystectomy under general anesthesia. Lumbar discal cysts should be considered a differential diagnosis for multilocular intraspinal cystic lesion.

Transitional lumbosacral vertebrae

Transitional lumbosacral vertebrae in the form of SI lumbarization and LV sacralization are classified as spinal anomalies. In the domestic medical literature, there are few publications devoted to these pathological conditions. In the course of a study of the available literature on the problem of transitional lumbosacral vertebrae, it was found that the frequency of cases of transitional lumbosacral vertebrae diagnosis ranges from 4 to 30% of clinical cases. The share of patients with lumbar vertebrae accounts for an average of 40% of cases, the share of patients with sacralization of the vertebrae is 60% of clinical observations. Mutations in the Hox gene are considered to be the trigger for the development of pathology, and pain is usually the leading clinical symptom. Plain radiography, computed tomography and magnetic resonance imaging are used to diagnose the pathology. Radiation imaging of the entire spine is required to eliminate errors in vertebrae counting. The type of pathology is determined using various classifications. As conservative therapeutic agents, drug blockades applying anesthetics and hormonal drugs are used. The arsenal of surgical interventions includes resection of the enlarged transverse process of the supracacral vertebra, decompression of stenotic intervertebral foramina, impulsive radiofrequency ablation, and posterior fusion. Measures for the prevention of pathology are not currently developed.