Pedicle Involvement Research Articles

Development of a New Score Based on Image Defined Risk Factors to Standardize Surgical Risk in Neuroblastoma Resection - A SIOPEN Collaborative Study.

Image Defined Risk Factors (IDRFs) assess surgical risk in neuroblastoma (NB) and guide neoadjuvant therapy. Despite chemotherapy IDRFs may persist in 70% of cases. Several studies have suggested that not all IDRFs hold equal significance and that the presence of an IDRF does not inherently signify unresectability. This current study seeks to stratify and assign a score to each IDRF based on its impact on surgical risk. This collaborative study entailed retrospective collection of patient data from NB operations conducted between 2016 and 2020, together with the computation of a Surgical Complexity Index (SCI) for every patient. The SCI values obtained were correlated with preoperatively identified IDRFs. Mann-Whitney statistical test was employed to assign a relevance score to the association between individual IDRFs and SCI. 14 centers contributed 427 neuroblastoma index cases meeting study inclusion criteria. 303 patients had 1 or more IDRFs. The presence and number of IDRFs in all patients significantly correlated with the SCI value (p<0.0001). The most frequently encountered IDRF was renal pedicle involvement. There was a significant association observed between clusters of abdominal IDRFs and the occurrence of post-operative complications (p<0.05), while a weak association link was found with intra-operative complications. A relevance score for individual IDRFs allowed their stratification based on surgical risk. The most relevant IDRFs were extension within two anatomical body compartments, infiltration of the hepato-pancreatic block, encasement of the superior mesenteric artery and coeliac axis, and tumor compressing the trachea. This current study has facilitated the assignment of a relevance score to each IDRF, correlating it with surgical risks. Considering this stratification of surgical risk alongside oncologic risk as defined by the neuroblastoma treatment patient risk grouping should facilitate a more precise definition of surgical objectives and the optimal conditions favoring gross tumor resection. Clinical Research - Study of Diagnostic Test. III.

Intrahepatic Glisson Intrathecal Dissection via a Hepatic Parenchymal Transection-First Approach for Laparoscopic Anatomical Hemihepatectomy in Patients with Left/Right Glisson Pedicle Involvement.

Background: Because of lack of an appropriate surgical approach, laparoscopic surgery in patients with left/right Glisson pedicle involvement is still rarely conducted. This study aimed to discusses the methods of intrahepatic Glisson intrathecal dissection via a hepatic parenchymal transection-first approach for laparoscopic hemihepatectomy in patients with left/right Glisson pedicle involvement. Materials and Methods: We retrospectively analyzed the clinical data of 21 patients who underwent laparoscopic hepatectomy in the Second Affiliated Hospital, Third Military Medical University (Army Medical University) from March 2021 to May 2022. Results: The mean age of the patients was 53.1 ± 11.6 years; mean operation time, 191.9 ± 22.3 minutes; median intraoperative blood loss, 205 mL (160-300 mL); and median length of hospital stay, 8 days (7-9 days). None of the patients underwent conversion to open procedure. Thirteen patients had pathologically confirmed hepatocellular carcinoma (HCC) with portal tumor thrombi (PVTT), and 8 was confirmed hepatolithiasis. Intraoperative frozen pathology and final pathology showed tumor free surgical margins in HCC with PVTT patients. After conservative treatment, all the complications such as postoperative liver section effusion, pleural effusion, pneumonia, intra-abdomen bleeding, and bile leak were cured. During outpatient follow-up examination, no other abnormality was detected. All HCC with PVTT patients were treated with a tyrosine kinase inhibitor after the operation and survived tumor-free. Conclusions: Proposed here is a more safe and feasible method of laparoscopic hemihepatectomy in patients with left/right Glisson pedicle involvement, but many problems still needs further exploration.

Keyhole Fenestration for Cerebrospinal Fluid Leaks in the Thoracic Spine: Quantification of Bone Removal and Microsurgical Anatomy.

A safe working trajectory is mandatory for spinal pathologies, especially in the midline, anterior to the spinal cord. For thoracic cerebrospinal fluid (CSF) leaks, we developed a minimally invasive keyhole fenestration. This study investigates the necessary bone removal for sufficient exposure of different leak types particularly regarding weight-bearing structures. In this retrospective case series between January 2022 and June 2023, the volume of bone resection and the axial and sagittal diameter of hemilamina defects after closure through keyhole fenestration were quantified. The involvement of facet joints and pedicles was qualitatively rated. Demographic (age, sex, body mass index, leak type) and surgical data (blood loss, surgery time, discharge after surgery) and complications were analyzed. Thirty-three patients with 34 approaches were included. The volume of resected bone was 1.5 cm3, and the diameter of the hemilamina defect was 17.8 mm in the sagittal and 15.1 mm in the axial plane. Facet joints were uninvolved in 24% and partly resected in 74%, and one facet joint was resected completely. Pedicles remained intact in 71% and were minimally involved in 29%. The median surgery time was 93 minutes, blood loss was 45 mL, and discharge was 4 days after surgery. Three patients (9%) needed revision surgery. No relevant and persisting morbidity occurred. Within the median follow-up period of 10 months, no stabilizing surgery was necessary. No permanent neurological deficit occurred. The keyhole fenestration leaves weight-bearing structures like facet joints and pedicles intact in most cases. The limited, penny-sized bone resection is sufficient to reach and close thoracic CSF leaks Type 1, 2, and 3 from the anterior midline to the ganglion. For experienced centers, it is a universal minimally invasive approach for treating all CSF leaks.

Percutaneous CT-Guided Microwave Ablation Combined with Pedicle Screw Fixation Followed by Vertebroplasty (MASFVA): Initial Experience of a Minimally Invasive Treatment of Vertebral Metastases with Extension to the Vertebral Pedicle.

(1) Background: The aim of this study was to retrospectively evaluate the safety and efficacy of a combined CT-guided percutaneous microwave ablation (MWA) and pedicle screw fixation followed by vertebroplasty (MASFVA) for the treatment and stabilization of painful vertebral metastases with vertebral pedicle involvement. (2) Methods: from January 2013 to January 2017 11 patients with 16 vertebral metastatic lesions (7 men and 5 women; mean age, 65 ± 11 years) with vertebral metastases underwent CT-guided microwave ablation and screw fixation followed by vertebroplasty (MASFVA). Technical success, complication rate, pain evaluation using a visual analogue scale (VAS), Oswestry Disability Index (ODI) and local tumor control were examined. (3) Results: Technical success rate was 100%. No procedure-related major complications occurred. VAS score decreased from 6.8 ± 0.7 to 0.6 ± 0.6. ODI score decreased from 3.1 ± 0.7 to 1.2 ± 0.4. All patients could walk independently without neurological complication after one week from the procedure. No new bone fractures or local disease recurrence occurred during a median follow-up of 12 months. (4) Conclusions: Our results suggest that MWA and percutaneous pedicle screw fixation followed by vertebroplasty for the treatment of painful vertebral metastases is a safe and effective procedure for painful vertebral metastases with vertebral pedicle involvement, allowing pain relief and local tumor control.

Can the Unipedicular Approach Replace Bipedicular Percutaneous Balloon Kyphoplasty for the Management of Metastatic Vertebral Lesions?

To compare the clinical and radiographic results of bipedicular and unipedicular approaches(UPK and BPK) in the management of metastatic vertebral lesions MATERIALS AND METHODS: Eighty-two patients with 159 metastatic vertebral lesions who underwent UPK(25 cases, 69 lesions) or BPK(57 cases, 90 lesions) were retrospectively evaluated. Clinical results were assessed mainly depending on the Visual Analogue Scale(VAS) score, Oswestry Disability Index(ODI) and Quality of Life(QoL). Radiographic outcomes were evaluated primarily on the basis of bone cement distribution and changes in vertebral body height(VBH). Major and minor complications were systematically evaluated and compared to assess the safety of the 2 procedures. No statistically significant differences were observed in age, sex, types of lesions, location of lesions, posterior vertebral body and/or pedicle involvement, percentage of vertebra invasion between the groups(p=0.17-0.83). The radiographic parameter VBH was similarly improved in both groups(p=0.26-0.93). There was a significant improvement in the clinical parameters VAS score, ODI, and QoL at each follow-up examination compared with the preoperative results(p<0.001). Significant improvement was observed in the VBH at each follow-up point(p<0.05) compared to pre-procedure. UPK was superior to BPK in terms of the operative duration(p<0.001), cement volume(p=0.004), and surgical complications(p=0.04). Both UPK and BPK resulted in similar clinical and radiographic outcomes in patients with metastatic vertebral lesions. The UPK had advantages including a shorter operation and lower cement volume than the BPK, which may have played an important role in reducing the incidence of complications. UPK can replace BPK in the treatment of metastatic vertebral lesions.

The influence of diverse bone cement distribution patterns for metastatic vertebral lesions after bilateral percutaneous kyphoplasty

ObjectiveTo investigate the influence of diverse bone cement distribution patterns in patients with metastatic vertebral lesions after bilateral percutaneous kyphoplasty (PKP).MethodsFifty-nine patients with single-level metastatic vertebral lesions who received bilateral PKP were retrospectively reviewed. According to the different bone cement distribution patterns, patients were divided into confluent (n = 35, CF) and separated (n = 24, SP) groups. Indicators including visual analogue scale (VAS), Oswestry Disability Index (ODI), vertebral body height (VBH) variation, quality of life (QoL), and related complications were reviewed and compared between the two groups.ResultsNo statistically significant differences were observed between the two groups in age, sex, types of lesions, locations of lesions, posterior vertebral body and/or pedicle involvement, percentage of vertebral invasion, procedure duration or cement volume (p > 0.05). There was significant improvement in VAS, ODI, VBH and QoL at any follow-up examination (p < 0.05) compared with those preoperatively. The CF group exhibited better pain relief in VAS scores than did the SP group just at 3 days and 1 month after PKP (p < 0.05). There were no significant differences between the two groups in VAS scores at 3 months or 1 year after PKP (p > 0.05). No statistically significant differences were observed between the two groups in terms of ODI, VBH or QoL (p > 0.05). There was no statistically significant difference in the incidence of complications between the two groups (p > 0.05).ConclusionsMore rapid pain relief was achieved with confluent rather than separated bone cement distribution patterns in PKP for patients with metastatic vertebral lesions.

A retrospective study of the use of percutaneous vesselplasty for pathological vertebral compression fractures

To assess percutaneous vesselplasty's safety and efficacy in treating pathological vertebral compression fractures (VCFs). This retrospective review covered nine patients with an equal number of symptomatic pathological VCFs treated with vesselplasty. The study assessed the patients' pain scores, subjective conditions, imaging guidance, and incidence of procedure-related complications. The VCFs were at the T4 and L5 spine regions. The procedure success rate was 100%. In 88.89% (8/9) of the examined cases, there was a posterior vertebral body or pedicle involvement or both. Two patients with high thoracic VCFs underwent combined computed tomography and mobile C-arm fluoroscopy guidance. The other patients underwent digital subtraction angiography guidance. The average visual analog scale (VAS) score and the Oswestry Disability Index (ODI) before the treatment were 7.78 ± 0.67 standard deviation (SD) and 75.45 ± 7.55, respectively. The average VAS score and ODI 3 months after the treatment were 2.67 ± 0.50 (SD) and 32.45 ± 6.19 (P < 0.001), respectively. There were no recorded cases of symptomatic cement leakage or other operation-associated complications. Percutaneous vesselplasty appears to be a safe and effective minimally invasive local treatment for pathological VCFs. This approach may offer benefits in improving pain, mobility, and function and minimizing the bone cement leakage rate while providing a safe and effective alternative treatment for pathological VCFs.

Simultaneous Bipedicular Radiofrequency Ablation Combined with Vertebral Augmentation for Local Tumor Control of Spinal Metastases.

Percutaneous radiofrequency ablation combined with vertebral augmentation has emerged as a minimally invasive treatment for patients with vertebral metastases who do not respond to or have contraindications to radiation therapy. The prevalence of posterior vertebral body metastases presents access and treatment challenges in the unique anatomy of the spine. The purpose of this study was to evaluate the safety and efficacy of simultaneous bipedicular radiofrequency ablation using articulating bipolar electrodes combined with vertebral augmentation for local tumor control of spinal metastases. Imaging-guided simultaneous bipedicular radiofrequency ablation combined with vertebral augmentation was performed in 27 patients (33 tumors) with vertebral metastases selected following multidisciplinary consultations, to achieve local tumor control in this retrospective study. Tumor characteristics, procedural details, and complications were documented. Pre- and postprocedural cross-sectional imaging was evaluated to assess local tumor control rates. Thirty-three tumors were successfully ablated in 27 patients. Posterior vertebral body or pedicle involvement or both were present in 94% (31/33) of cases. Sixty-seven percent (22/33) of the tumors involved ≥75% of the vertebral body volume. Posttreatment imaging was available for 79% (26/33) of the treated tumors. Local tumor control was achieved in 96% (25/26) of tumors median imaging follow up of 16 weeks. No complications were reported, and no patients had clinical evidence of metastatic spinal cord compression at the treated levels. Simultaneous bipedicular radiofrequency ablation combined with vertebral augmentation is safe and effective for local tumor control of vertebral metastases. Articulating bipolar electrodes enable the placement and proximity necessary for optimal confluence of the ablation zones. Local tumor control may lead to more durable pain palliation, prevent disease progression, and reduce skeletal-related events of the spine.

Lymphadenectomy of the hepatic pedicle during hepato-pancreato-biliary surgery

Nodal involvement of the hepatic pedicle is variable and depends on the underlying hepato-bilio-pancreatic pathology. Although its value for ultimate prognosis has not been demonstrated, lymphadenectomy is usually performed to determine tumor stage and to inform the decision about eventual adjuvant treatment. Lymph node dissection of the hepatic pedicle requires a thorough understanding of the anatomy of hepatic lymphatic drainage as well as accurate analysis of pre-operative imaging in order to identify and locate abnormal lymph and to rule out anatomical variations that might complicate the surgical procedure.

Perioperative management of hypertensive neuroblastoma: A study from the Italian Group of Pediatric Surgical Oncologists (GICOP)

BackgroundHypertension (HT) is rarely reported in patients affected by Neuroblastoma (NB), and management guidelines are lacking. Clinical features and perioperative medical treatment in such patients were reviewed to 1) ascertain whether a shared treatment strategy exists among centers and 2) if possible, propose some recommendations for the perioperative management of HT in NB patients. MethodsA retrospective multicenter survey was conducted on patients affected by NB who presented HT symptoms. ResultsFrom 2006 to 2014, 1126 children were registered in the Italian Registry of Neuroblastoma (RINB). Of these, 21 with HT (1.8%) were included in our analysis. Pre- and intraoperative HT management was somewhat dissimilar among the participating centers, apart from a certain consistency in the intraoperative use of the alpha-1 blocker urapidil. Six of the 21 patients (28%) needed persistent antihypertensive treatment at a median follow-up of 36months (range 4–96months) despite tumor removal. Involvement of the renal pedicle was the only risk factor constantly associated to HT persistency following surgery. A correlation between the presence of HT and the secretion of specific catecholamines and/or compression of the renal vascular pedicle could not be demonstrated. ConclusionBased on this retrospective review of NB patients with HT, no definite therapeutic protocol can be recommended owing to heterogeneity of adopted treatments in different centers. A proposal of perioperative HT management in NB patients is however presented. Level of evidenceIV.

New imaging characteristics for predicting postoperative neurologic status in patients with metastatic epidural spinal cord compression. A retrospective analysis of 81 cases

Background ContextSeveral clinical features have been proposed for the prediction of postoperative functional outcome in patients with metastatic epidural spinal cord compression (MESCC). However, few articles address the relationship between preoperative imaging characteristics and the postoperative neurologic status. PurposeThis study aims to analyze the postoperative functional outcome and to identify new imaging parameters for predicting postoperative neurologic status in patients with MESCC. Study DesignThis study is a retrospective consecutive case series of patients with MESCC who were treated surgically. Patient SampleWe assessed 81 consecutive patients who were treated with decompressive surgery for MESCC between 2013 and 2015. Outcome MeasuresEight imaging characteristics were analyzed for postoperative motor status by logistic regression models. Neurologic function was assessed using the Frankel grade preoperatively and postoperatively. MethodsThe following imaging characteristics were assessed for postoperative motor status: location of lesions in the spine, lamina involvement, retropulsion of the posterior wall, number of vertebrae involved, pedicle involvement, fracture of any involved vertebrae, T2 signal of the spinal cord at the compression site, and circumferential angle of spinal cord compression (CASCC). ResultsThe postoperative neurologic outcome was better than the preoperative neurologic status (p<.01). In the entire group, 40.7% of the patients were non-ambulatory before the surgical procedure, whereas 77.8% of the patients could walk after surgery (p=.01). In the multivariate analysis, the location of the lesions (odds ratio [OR]: 3.89, 95% confidence interval [CI]: 1.19–12.77, p=.02) and CASCC (OR: 2.31, 95% CI: 1.44–3.71, p<.01) were significantly associated with postoperative neurologic outcome. A CASCC of more than 180° was associated with an increased OR that approached significance, and the larger the CASCC, the higher the risk of poor postoperative neurologic status. ConclusionsThe postoperative neurologic status was dependent on the location of spine lesions and the CASCC. Patients with upper thoracic or cervicothoracic junction spine metastases or CASCC over 180° were at higher risk of relatively poor postoperative neurologic outcome. Timely, adequate surgical decompression is urgently warranted in these patients.

Predictive value of pedicle involvement with MRI in spine metastases.

ObjectivesThe study aimed to retrospectively evaluate the accuracy and value of magnetic resonance imaging (MRI) in predicting pedicle involvement for patients with spine metastases.MethodsForty-five patients with a vertebral metastasis encroaching at least one pedicle were studied using MRI before surgery and regularly after surgery. Patients were categorized on the basis of their numbers of pedicle involvement (Group 1: one pedicle was involved, n = 23; Group 2: two pedicles were involved, n = 22). The diagnostic accuracy was calculated, and comparisons of intraoperative blood loss and recurrence rate between the two groups were performed.ResultsThe overall performance of MRI in predicting the pedicle involvement was as follows: accuracy, 94.4%; sensitivity, 95.5%; and specificity, 91.3%. Less intraoperative blood loss was observed for Group 1 compared with Group 2 (1,661 ± 672 ml and 2,173 ± 790 ml, respectively, P = 0.024). Tumor relapse occurred in 8.7% (2/23) of Group 1 and in 22.7% (5/22) of Group 2 with median recurrence free survival time 14 and 9 months, respectively.ConclusionsMRI is a reliable approach to assess pedicle involvement. It has potential for use in the evaluation of the clinical characteristics of patients with spine metastases.

Results of cement augmentation and curettage in aneurysmal bone cyst of spine.

Aneurysmal bone cyst (ABC) is a vascular tumor of the spine. Management of spinal ABC still remains controversial because of its location, vascular nature and incidence of recurrence. In this manuscript, we hereby describe two cases of ABC spine treated by curettage, vertebral cement augmentation for control of bleeding and internal stabilization with two years followup. To the best of our knowledge, this is the first case report in the literature describing the role of cement augmentation in spinal ABC in controlling vascular bleeding in curettage of ABC of spine. Case 1: A 22 year old male patient presented with chronic back pain. On radiological investigation, there were multiple, osteolytic septite lesions at L3 vertebral body without neural compression or instability. Percutaneous transpedicular biopsy of L3 from involved pedicle was done. This was followed by cement augmentation through the uninvolved pedicle. Next, transpedicular complete curettage was done through involved pedicle. Case 2: A 15-year-old female presented with nonradiating back pain and progressive myelopathy. On radiological investigation, there was an osteolytic lesion at D9. At surgery, decompression, pedicle screw-rod fixation and posterolateral fusion from D7 to D11 was done. At D9 level, through normal pedicle cement augmentation was added to provide anterior column support and to control the expected bleeding following curettage. Transpedicular complete curettage was done through the involved pedicle with controlled bleeding at the surgical field. Cement augmentation was providing controlled bleeding at surgical field during curettage, internal stabilization and control of pain. On 2 years followup, pain was relieved and there was a stable spinal segment with well filled cement without any sign of recurrence in computed tomography scan. In selected cases of spinal ABC with single vertebral, single pedicle involvement; cement augmentation of vertebra through normal pedicle has an important role in surgery aimed for curettage of vertebra.

Role of Percutaneous Image Guided Biopsy in Spinal Lesions: Adequacy and Correlation with MRI Findings

Although, MRI has increased our understanding of spinal pathologies, accurate diagnosis of spinal lesions need biopsy, so that early treatment can be initiated. To evaluate the accuracy of biopsy, safety and yield of percutaneously done image guided spinal biopsy using a large bore needle and correlate between MRI findings and biopsy as well as the importance of various MRI findings in establishing the diagnosis. All spinal lesions after clinical and MRI evaluation were subjected to Jamshidi Needle biopsy using 11 gauge needles. Biopsy material was sent for culture/sensitivity, AFB smear and histopathological examination. The outcome assessment included percentage of patients in whom diagnosis was changed after biopsy, yield in biopsy and complications of biopsy. MRI findings, biopsy findings and final diagnosis were correlated to know the sensitivity and specificity of MRI and biopsy diagnosis. Logistic regression analysis was used to study the importance of each of MRI findings in making a diagnosis. Forty five patients with spinal lesions underwent biopsy using an 11 gauge Jamshidi needle. Initial biopsy was inconclusive in 4 patients giving a positive yield in about 91.2% of cases and a repeat biopsy ensured conclusive report in all cases. Following biopsy there was a change in diagnosis in 8% cases. MRI showed sensitivity of 85.71% and specificity of 93.54% for the diagnosis of malignancy and sensitivity of 85.71% and specificity of 86.48% for the diagnosis of tuberculosis. In contrast, initial biopsy had sensitivity of 92.85% and specificity of 100% for the diagnosis of malignancy and sensitivity of 71.42% and specificity of 100 % for the diagnosis of infection. Logistic regression analysis showed good correlation between malignancy and posterior bugle in the vertebral body in the absence of a fracture (p = 0.007), involvement of pedicles and posterior elements (p = 0.001) and soft tissue extension (p = 0.002); there was good correlation between infection and epidural abscess (p<0.001) as well as paradiscal involvement (p<0.001). Image guided biopsy done with good technique helps in accuracy of diagnosis thus ensuring the correct treatment at the earliest and has minimal complications. This study also shows that presence of epidural abscess and paradiscal involvement in MRI are highly suggestive of infection, while pedicle involvement and posterior bulge of vertebral body before the onset of pathological fracture are suggestive of malignancy, but all spinal lesions should be biopsied to confirm the diagnosis.

Winking-owl Sign - An Uncommon Presentation of Spine Metastasis

Introduction: Spinal metastasis is the commonest form of secondary osseous involvement by variety of cancers usually presenting clinically in the form of backache. They may be osteolytic, osteoblastic or mixed types. Spinal radiograph is usually the first investigation used to define the future course of action. Case Presentation: A 50-year old female from a nearby village came to outpatient department of our hospital with an acute history of severe backache since few days. Clinical examination revealed focal tenderness in mid-lumbar region. Laboratory investigations were however, unremarkable. She was advised radiograph of dorsolumbar spine region in anteroposterior and lateral projections. Careful evaluation of radiographs revealed nonvisualisation of left-sided pedicle of L3 vertebra representing winking-owl sign, conspicuously noted on anteroposterior projection associated with surrounding vertebral lucency (Figures 1A and 1B). There was associated early lumbar spondylotic changes and diffuse osteopenia as well. Based on radiological findings, the diagnosis of solitary vertebral metastasis was kept as the first differential diagnosis and further work-up was advised to search for the primary tumour. A thorough clinical history and examination revealed invasive breast carcinoma with history of occasional blood stains on clothes and metastases to lungs on chest radiograph. Histopathological examination confirmed the primary malignancy and metastases. Patient was referred to higher center for further management. Discussion: All types of spinal metastases are usually multiple at the time of presentation, but occasionally they may be solitary at first presentation. Detecting solitary metastasis is important in a patient with known primary malignancy as it predicts progression of disease, poorer prognosis and requires further intervention in the form of chemotherapy or radiotherapy depending on the sensitivity of the primary tumour. At time, solitary metastasis may be the first presentation of cancer thus making aggressive search for primary tumour very imperative for deciding future course of action as seen in our index case. Pedicle destruction of a vertebra is an important radiographically detectable signs of osteolytic metastasis especially carcinoma. Though any part of the neural arch of vertebra may be involved by metastases yet the vertebral pedicle is the commonest site. Involvement of pedicle with adjacent part of posterior vertebral body results in loss of cortical margins that can be detected radiographically as nonvisualisation of vertebral pedicle on anteroposterior radiograph [1]. This is described as one-eyed pedicle or winkingowl sign. It is most commonly noted in the lower dorsal and lumbar vertebrae with solitary involvement being commoner than the multifocal involvement. Rarely both the pedicles may be involved by the above process leading to nonvisualisation of both vertebral pedicles on anteroposterior radiograph resulting in blind-vertebra [1,2]. Differential diagnosis includes congenital absence of pedicle which is usually associated with hypoplastic /agenetic ipsilateral and hyperplastic contralateral pedicles. There may be some degree of abnormal spinal curvature as well. Congenital disease usually presents in early childhood/adolescence. To summarise, it is important to recognise solitary spinal metastasis in form of winking-owl sign on spine radiograph as it affects the prognosis of the patient suffering from the cancers.

Computed Tomography and Magnetic Resonance Imaging in the Differentiation of Osteoporotic Fractures From Neoplastic Metastatic Fractures

Determining whether a low-intensity vertebral fracture in an older person, particularly one with a history of cancer, is due to osteoporosis (OP) or is the result of a metastasis, is a not infrequent clinical problem that has important prognostic and therapeutic implications. The 2 types of fracture are usually indistinguishable on plain radiographs and require higher order imaging for diagnosis. Magnetic resonance imaging is the modality of choice because of its unique ability to depict the bone marrow, which becomes transiently edematous in an acute OP fracture. Preservation of at least part of the normal marrow signal, the visualization of a fracture line parallel to the end plates, the presence of an intravertebral cleft, lack of pedicle involvement, and no extra-osseous mass all favor a benign OP fracture. Absence of the preceding signs, particularly if there is complete replacement of the normal bone marrow and a convex posterior contour of the vertebral body, favors a fracture of malignant origin. Non-routine magnetic resonance sequences using diffusion-weighted imaging and/or chemical shift imaging may be helpful in difficult cases.

Pattern of Tumour Spread of Common Primary Tumours as Seen on Magnetic Resonance Imaging.

Although some reports with computed tomography and bone scintigraphy are available in the literature, the distinct epidemiologic description of skeletal metastatic pattern of various tumors is still lacking. This study uses a novel approach to identify skeletal metastases from magnetic resonance imaging (MRI) data to describe metastatic pattern in common malignancies. A retrospective analysis of 130 cancer patients (42 lung, 56 breast, 11 prostate cancers; 21 multiple myeloma) with vertebral metastases and without disseminated disease, and whom underwent a whole body 3Tesla MRI investigation (Discovery MR750w), was carried out. Multiple myeloma had the most commonly disseminated metastatic disease (95%) compared to lung (28%), breast (44%) and prostate (71%) cancers. Lung cancer was related to more frequent pedicle involvement compared to breast or prostate cancer (29, 9 and 0%, p < 0.05). Pathologic fracture was mainly associated with multiple myeloma (43%). The prevalence of lung cancer metastases was more frequent in the lumbal spine (81%), as well as particular in C7, D7, D8, D9 and L1, compared to breast cancers. Most differences among tumors were detected in the extravertebral osseous metastatic pattern (p < 0.05). The highest frequency of extravertebral skeletal metastases was present in multiple myeloma (28 to 76%). Brain metastasis was more frequent in lung cancer compared to breast cancers (35% vs. 17%, p < 0.05). Significant differences in the skeletal metastatic pattern among common malignancies were demonstrated with MRI.

Osteoporotic or malignant vertebral fracture? This is the question. What can we do about it?

ReviewThe differentiation between benign and malignant vertebral compression fractures is a daily encountered problem particularly in elderly patients. It is important to differentiate between malignant and osteoporotic compression fractures. Aim of the workTo study the different MRI signs allowing to differentiate between benign and malignant vertebral fractures. MethodsA total number of 150 collapsed vertebrae (120 patients) were collected during a period of 40months. All were subjected to MRI evaluation. For half of patients diffusion weighted imaging was performed. Biopsy was taken from 45 vertebrae. ResultsAverage age of patients was 65±2.3years. The ratio of men to women was 1:1. Metastases were seen in 70 and osteoporosis in 80 vertebrae.Signs that showed statistically significant value were Water line sign and sharp wedging in favor of osteoporotic fractures and pedicle involvement, non signal drop in out of phase sequence, homogenous T1 hypointensity and restriction in DWI favoring malignancy. ConclusionsSeveral signs are found to favor osteoporotic or malignant vertebral fractures. Chemical shift and DWI are strong allies to morphological signs in differentiating between both entities. Depending on a group of signs rather than one sign alone would increase the diagnostic accuracy.

Pedicle involvement in tuberculous spondylitis and pyogenic spondylitis: Comparative magnetic resonance imaging study

AimMagnetic resonance imaging (MRI) comparison of the pedicle involvement in TB spondylitis and pyogenic spondylitis in relation to degree of spinal deformity, degree of vertebral body and disc damage and paravertebral and epidural abscess formation. Materials and methodsMRIs of 38 patients who had been diagnosed with and treated for spinal infection, 22 patients for TB spondylitis and 16 patients for pyogenic spondylitis were retrospectively evaluated for pedicle involvement, degree of spinal deformity, vertebral body and disc damage and paravertebral and epidural abscess formation. ResultsIncidence of pedicle involvement was highly significant more in TB spondylitis than in pyogenic spondylitis (P value <0.01). Incidence of vertebral body collapse in vertebral bodies with pedicle involvement was equal in both groups, however more than 50% vertebral body collapse only reported in TB spondylitis (P value=0.0001). Kyphotic deformity was reported only in TB spondylitis. There was no significant difference in disc damage, paravertebral or epidural abscess formation between both groups. ConclusionPedicle involvement is a common MRI finding in TB spondylitis, and significantly less common in pyogenic spondylitis. Kyphotic deformity and advanced degree of vertebral body collapse might play a significant role in pedicle involvement in cases of spinal infection.

Novel magnetic resonance imaging scoring system for diagnosis of spinal tuberculosis: A preliminary report

Background:There exists a lot of ambiguity in the preoperative diagnosis of the various vertebral lesions. Mostly in these patients tuberculosis of spine (TB) is suspected due to endemicity of the disease in the Indian subcontinent. However, no definite guidelines are available to diagnose tuberculous (TB) vertebral lesions in the current literature.Study Design:This prospective study was conducted in the Department of Neurosurgery, Nizam's Institute of Medical Sciences, from August 2009 to March 2012.Aim of the Study:To formulate non invasive methods to diagnose tuberculous vertebral lesions confidently so that the dependency on histopathologic diagnosis can be reduced.Material and Methods:Spinal MRI images of 45 patients suspected of having tuberculosis aetiology were included in the study prospectively.Results:A total of 64 patients were analysed and 19 patients were excluded due to lack of regular follow up or histological proof. The patients were divided into two groups; those with TB of the spine and those with some other condition affecting the spine (non TB spine) based on the final diagnosis. Of the 45 patients males were 30 (66.6%) and females were 15 (33.3%). There was no significant difference in the mean age of presentation. For TB patients this was 41 ± 15.56 years and in Non TB was 43 ± 18.27 years. All patients presented with backache in either group. There was epiphyseal involvement (100%), disc height reduction (71.42%) and pedicle destruction (42.82%) in plain X-rays in the TB group. Lumbar spine was the most common affected region in our study (26.31% in non TB and 34.6% in TB group of patients). Significant P value and the Odds Ratio was found for T1 hypo intensity, T2 hyper intensity, epiphyseal involvement, disc involvement, pedicle involvement, anterior subligamentous extension, paraspinal extension and no spinous process involvement (eight parameters). The eight parameters were tested among both the groups and it was noted that scores ≥ 6 favored a tuberculous pathology whereas ≤4 were suggestive of non tuberculous etiology.Conclusions:The eight point MRI criteria of the vertebral lesions are likely to enhance the diagnostic ability of tuberculous and non tuberculous pathologies thereby reducing the dependency on histopathologic diagnosis or invasive method for early initiation of therapy.